控制糖尿病患者心血管危险的干预治疗策略课件

1、控制糖尿病患者心血管危险控制糖尿病患者心血管危险的干预治疗策略的干预治疗策略 糖尿病与心血管危险糖尿病与心血管危险 影响心血管危险的因素影响心血管危险的因素 综合控制的理论与实践综合控制的理论与实践Countries With Highest Numbers of EstimatedCases of Diabetes for 2000 and 2030RankingCountryPeople with diabetes(millions)CountryPeople with diabetes(millions)200020301India31.7India79.42China20.8China

2、42.33U.S.17.7U.S.30.34Indonesia8.4Indonesia21.35Japan6.8Pakistan13.96Pakistan5.2Brazil11.37Russian Federation4.6Bangladesh11.18Brazil4.6Japan8.99Italy4.3Pinecones7.810Bangladesh3.2Egypt16.7Total: 177 million366 MILLION BY 2030Type 2 diabetes and CHD7-Year Incidence of Fatal/Nonfatal MI (East West St

3、udy) Incidence During Follow-up (%)(n=69)Nondiabetics with prior MINondiabetics with no prior MIDiabetics with prior MIDiabetics with no prior MI18.8Haffner SM et al. N Engl J Med 1998;339:229-234.(n=1304)(n=169)(n=890)3.00.57.83.23.545.020.2Events per100 person-yr:P0.001p0.001Type 2 diabetes and St

4、roke7-Year Incidence of Fatal/Nonfatal Stroke (East West Study)Incidence During Follow-up (%)(n=69)Nondiabetics with prior MINondiabetics with no prior MIDiabetics with prior MIDiabetics with no prior MI7.2Haffner SM et al. N Engl J Med 1998;339:229-234.(n=1304) (n=169)(n=890)1.20.33.41.61.919.510.3

5、Events per100 person-yr:P=0.01p0.001Prevalence of CHD by the Metabolic Syndrome and Diabetes in the NHANES Population Age 50+Alexander C et al. Diabetes 2003;52:1210-121425%20%15%10%5%0%No MS/No DM8.7%13.9%7.5%19.2%MS/No DMDM/No MSDM/MS% of population = 54.2%28.7%2.3%14.8%CHD Prevalence1.00.90.80.70

6、.60.00246810Follow-up, years# at risk174214099062828935No metabolic syndromeMetabolic syndromelog-rank = 45.4 p0.001Event-free survivalSchillaci G. JACC. 2004; 43:1817-1822代谢综合征与心血管危险代谢综合征与心血管危险Ml and Microvascular End Points: Incidence byMean Systolic BP and HbA1c ConcentrationMlMicrovascular and p

7、ointsMlMicrovascular and points50403020100806040200Adjusted incidence per 1000 person-yr (%)110 120130 140 150160170567891011Updated mean systolic BP (mmHg)Updated mean HbA1c concentration (%)Adjusted incidence per 1000 person-yr (%)Adler Al et al. BMJ 2000;321:412-419Stration IM et al. BMJ 2000;321

8、:405-412MetS和和DM患者血脂异常特征患者血脂异常特征 游离脂肪酸 TG HDL-C VLDL-C 小而密LDL颗粒 氧化LDL-C 餐后高脂血症MaleGender-adjustedFemaleReduced risk with small, dense LDL0.1Relative risk for myocardial infarction110Increased risk with small, dense LDLSmall, dense LDL increases cardiovascular riskUKPDS Stepwise Selection of Risk Fac

9、tors* in Patients with Type 2 Diabetes LDL-CHDL-CHemoglobin A1cSystolic Blood PressureSmoking0.0001 0.0001 0.0022 0.00650.056Coronary Artery Disease (n=280)FirstSecondThirdFourthFifth*Adjusted for age and sex.Turner RC et al. BMJ 1998;316:823-828.Mangaging overweight in type 2 diabeticsEffective wei

10、ght management is the first step in treating type 2 diabetesLean MEJ et al., Diabet Med, 1990;7:228-233Good glycemic control is not enoughUKPDSGOOD GLYCEMIC CONTROLMICROVASCULAR COMPLICATIONSSignificant reductionsMACROVASCULAR COMPLICATIONSNo significant effectPROACTIVE StudySept. 2005, 欧洲糖尿病会议欧洲糖尿病

11、会议 Pioglitazone vs PlaceboACCORD StudyAction to Control Cardiovascular risk in DiabetesPrisant LM. J Clin Pharmacol 2004; 44(4):423-430HbA1c: 6.0% vs 7.0-7.9% 糖尿病患者降压治疗临床试验糖尿病患者降压治疗临床试验 SHEP ALLHAT SYST-EUR HOPE CAPPP HOT NORDIL RENAAL STOP-2 PRIME INSIGHT LIFE UKPDS Major cardiovascular events (per

12、 100 patients-years) in all treated hypertensive and in hypertensive patients with diabetes in relation to target blood pressures of 90. 85, and 80 mm Hg. 302520151050 80 85 90 90 85 80P=0.50 for trendP=0.005 for trendAll hypertensive patients(n=18790)Hypertensive with diabetes(n=1501)Target blood p

13、ressure groupsMajor cardiovascular events/1000 patients-yearsHOT Study: Results in Patients with DMEffect of Intensive vs Moderate Antihypertensive Treatmenton Stroke Incidence in Diabetic NormotensivesIntensiveModerateAchieved BP (mmHg)128/75137/81Stroke (%)1.75.4P = 0.03Schrier et al., Kidney Int

14、2002; 61:1086CHD Prevention Trials with Statins in Diabetic Subjects Subgroup Analyses Primary PreventionAFCAPS/TexCAPSSecondary PreventionCARE4SLIPID4S-ExtendedLovastatinPravastatinSimvastatinPravastatinSimvastatin43%25% (p=0.05)55% (p=0.002)19%42% (p=0.001)37%23%32%25%32%239586202782483Adapted fro

15、m Downs JR et al. JAMA 1998;279:1615-1622; Goldberg RB et al. Circulation 1998;98:2513-2519; Pyrl K et al. Diabetes Care 1997;20:614-620; The Long-Term Intervention with Pravastatin in Ischaemic Disease (LIPID) Study Group. N Engl J Med 1998;339:1349-1357; Haffner SM et al. Arch Intern Med 1999;159:

16、2661-2667.Trials with Fibrates in Patients with DiabetesStudyEffectp-valueCommentFIELD StudyFenofibrate Intervention and Event Lowering in DiabetesMazzone T. Am J Cardiol 2004;93:27C-31C糖尿病患者心血管危险因素的控制目标糖尿病患者心血管危险因素的控制目标 减轻体重 降糖: HbA1c 7.0% 降压: 130/80 调脂: LDL-C 1.81 mmol/LSteno-2 StudyMultifactorial

17、 Intervention and Cardiovascular Disease in Patients with Type 2 DiabetesGrade P, et al. N ENGL J MED 2003;348:383-393Steno-2: Intensive TherapyNEJM 2000; 342:905-912Basic Intervention脂肪摄入30%饱和脂肪酸摄入10%运动 3035次/wACEI or ARB多种维生素AspirinPharmacology Intervention降糖降糖 metformin gliclazide metformin + gli

18、clazide降压降压 thiazide ACEI or ARB + CCB -blocker降脂降脂 statinsSteno-2: Treatment GoalsVariable Conventional Intensive Therapy TherapySBP (mmHg) 140 130 DBP (mmHg) 85 80 Hba1c (%) 6.5 6.5TC (mg/dl) 190 175 TG (mg/dl) 150 150Steno-2 Change in Clinical Variables at the End of the StudyVariable Conventional Intensive p Therapy TherapySBP