控制糖尿病患者心血管危险的干预治疗策略.ppt

控制糖尿病患者心血管危险的干预治疗策略,糖尿病与心血管危险影响心血管危险的因素综合控制的理论与实践,CountriesWithHighestNumbersofEstimatedCasesofDiabetesfor2000and2030,Ranking,Country,Peoplewithdiabetes(millions),Country,Peoplewithdiabetes(millions),2000,2030,1India31.7India79.42China20.8China42.33U.S.17.7U.S.30.34Indonesia8.4Indonesia21.35Japan6.8Pakistan13.96Pakistan5.2Brazil11.37RussianFederation4.6Bangladesh11.18Brazil4.6Japan8.99Italy4.3Pinecones7.810Bangladesh3.2Egypt16.7,Total:177million,366MILLIONBY2030,Type2diabetesandCHD7-YearIncidenceofFatal/NonfatalMI(EastWestStudy),IncidenceDuringFollow-up(%),(n=69),NondiabeticswithpriorMINondiabeticswithnopriorMIDiabeticswithpriorMIDiabeticswithnopriorMI,18.8,HaffnerSMetal.NEnglJMed1998;339:229-234.,(n=1304),(n=169),(n=890),3.0,0.5,7.8,3.2,3.5,45.0,20.2,Eventsper100person-yr:,P<0.001,p<0.001,Type2diabetesandStroke7-YearIncidenceofFatal/NonfatalStroke(EastWestStudy),IncidenceDuringFollow-up(%),(n=69),NondiabeticswithpriorMINondiabeticswithnopriorMIDiabeticswithpriorMIDiabeticswithnopriorMI,7.2,HaffnerSMetal.NEnglJMed1998;339:229-234.,(n=1304),(n=169),(n=890),1.2,0.3,3.4,1.6,1.9,19.5,10.3,Eventsper100person-yr:,P=0.01,p<0.001,PrevalenceofCHDbytheMetabolicSyndromeandDiabetesintheNHANESPopulationAge50+,AlexanderCetal.Diabetes2003;52:1210-1214,25%,20%,15%,10%,5%,0%,NoMS/NoDM,8.7%,13.9%,7.5%,19.2%,MS/NoDM,DM/NoMS,DM/MS,%ofpopulation=54.2%28.7%2.3%14.8%,CHDPrevalence,SchillaciG.JACC.2004;43:1817-1822,代谢综合征与心血管危险,MlandMicrovascularEndPoints:IncidencebyMeanSystolicBPandHbA1cConcentration,Ml,Microvascularandpoints,Ml,Microvascularandpoints,50,40,30,20,10,0,80,60,40,20,0,Adjustedincidenceper1000person-yr(%),110,120,130,140,150,160,170,5,6,7,8,9,10,11,UpdatedmeansystolicBP(mmHg),UpdatedmeanHbA1cconcentration(%),Adjustedincidenceper1000person-yr(%),AdlerAletal.BMJ2000;321:412-419,StrationIMetal.BMJ2000;321:405-412,MetS和DM患者血脂异常特征,游离脂肪酸TGHDL-CVLDL-C小而密LDL颗粒氧化LDL-C餐后高脂血症,Male,Gender-adjusted,Female,Reducedriskwithsmall,denseLDL,0.1,Relativeriskformyocardialinfarction,1,10,Increasedriskwithsmall,denseLDL,Small,denseLDLincreasescardiovascularrisk,UKPDSStepwiseSelectionofRiskFactors*inPatientswithType2Diabetes,VariableLDL-CHDL-CHemoglobinA1cSystolicBloodPressureSmoking,PValue<0.00010.00010.00220.00650.056,CoronaryArteryDisease(n=280),PositioninModelFirstSecondThirdFourthFifth,*Adjustedforageandsex.TurnerRCetal.BMJ1998;316:823-828.,Mangagingoverweightintype2diabetics,Effectiveweightmanagementisthefirststepintreatingtype2diabetes,Weightloss(kg)infirst12months,LeanMEJetal.,DiabetMed,1990;7:228-233,Goodglycemiccontrolisnotenough,UKPDS,GOODGLYCEMICCONTROL,MICROVASCULARCOMPLICATIONSSignificantreductions,MACROVASCULARCOMPLICATIONSNosignificanteffect,PROACTIVEStudy,Sept.2005,欧洲糖尿病会议,PioglitazonevsPlacebo,ACCORDStudyActiontoControlCardiovascularriskinDiabetes,PrisantLM.JClinPharmacol2004;44(4):423-430,HbA1c:6.0%vs7.0-7.9%,糖尿病患者降压治疗临床试验,SHEPALLHATSYST-EURHOPECAPPPHOTNORDILRENAALSTOP-2PRIMEINSIGHTLIFEUKPDS,Majorcardiovascularevents(per100patients-years)inalltreatedhypertensiveandinhypertensivepatientswithdiabetesinrelationtotargetbloodpressuresof90.85,and80mmHg.,HOTStudy:ResultsinPatientswithDM,EffectofIntensivevsModerateAntihypertensiveTreatmentonStrokeIncidenceinDiabeticNormotensives,IntensiveModerateAchievedBP(mmHg)128/75137/81Stroke(%)1.75.4,Schrieretal.,KidneyInt2002;61:1086,CHDPreventionTrialswithStatinsinDiabeticSubjectsSubgroupAnalyses,PrimaryPreventionAFCAPS/TexCAPSSecondaryPreventionCARE4SLIPID4S-Extended,CHDRiskReduction(overall),Drug,No.,LovastatinPravastatinSimvastatinPravastatinSimvastatin,43%25%(p=0.05)55%(p=0.002)19%42%(p=0.001),37%23%32%25%32%,239586202782483,CHDRiskReduction(diabetes),Study,AdaptedfromDownsJRetal.JAMA1998;279:1615-1622;GoldbergRBetal.Circulation1998;98:2513-2519;PyrlKetal.DiabetesCare1997;20:614-620;TheLong-TermInterventionwithPravastatininIschaemicDisease(LIPID)StudyGroup.NEnglJMed1998;339:1349-1357;HaffnerSMetal.ArchInternMed1999;159:2661-2667.,TrialswithFibratesinPatientswithDiabetes,FIELDStudyFenofibrateInterventionandEventLoweringinDiabetes,MazzoneT.AmJCardiol2004;93:27C-31C,糖尿病患者心血管危险因素的控制目标,减轻体重降糖:HbA1c7.0%降压:130/80调脂:LDL-C1.81mmol/L,Steno-2StudyMultifactorialInterventionandCardiovascularDiseaseinPatientswithType2Diabetes,GradeP,etal.NENGLJMED2003;348:383-393,Steno-2:IntensiveTherapy,NEJM2000;342:905-912,BasicIntervention,脂肪摄入30%饱和脂肪酸摄入10%运动3035次/wACEIorARB多种维生素Aspirin,PharmacologyIntervention,降糖metformingliclazidemetformin+gliclazide降压thiazideACEIorARB+CCB-blocker降脂statins,Steno-2:TreatmentGoals,VariableConventionalIntensiveTherapyTherapySBP(mmHg)140130DBP(mmHg)8580Hba1c(%)6.56.5TC(mg/dl)190175TG(mg/dl)150150,Steno-2ChangeinClinicalVariablesattheEndoftheStudy,VariableConventionalIntensivepTherapyTherapySBP(mmHg)-33-1420.001DBP(mmHg)-82-1220.006Carbohydrates(%)4.80.99.30.90.001,FPG(mg/dl)-1811-5280.001HbA1c(%)0.20.3-0.50.20.001TC(mg/dl)-37-5040.001LDL-C(mg/dl)-136-4750.001TG(mg/dl)943-41140.015,Steno-2Study:CompositeEndPoint,GradePetal.NEnglJMed2003;348:383-393,Primarycompositeendpoint(%),60,50,40,30,20,10,0,0,12,24,36,48,60,72,84,96,Monthsoffollow-up,Hazardratio=0.47(95%Cl0.24,0.73)P=0.008,ConventionalTherapy,Intensivetherapy,小结,T2DM患者有多重心血管危险因素集聚，是心血管高危人群。T2DM治疗的主要目标应该转移到预防或延缓心血管病事件。在改善生活行为的同时，积极有效地实施降压、降脂和降糖综合措施，是控制糖尿病患者心血管危险的主要治疗策略。,