高血压代谢危险因素控制面临的困惑与启示课件

DyslipidemiaAbdominalObesityDiabetesUricacidRenallesionEndotheliumdamage

HypertensiveSyndrome

-ConstellationsofCardiometabolicRiskFactorsHypertension80%高血压危险因素CVD事件DyslipidemiaAbdominalDiabete1更强调危险因素的早期控制更关注血管和代谢因素的相互作用对高血压的危险进行总体评估防治上既遵循循证医学证据，也强调个体化治疗更强调危险因素的早期控制2Abdominalobesity

Waistcircumference>102cm(M),88cm(W)DyslipidaemiaTC>5.0mmol/l(原为6.1)orLDL-C>3.0mmol/l(原为4.0)orHDL-C:M<1.0mmol/l(40mg/dL),W<1.2mmol/l(46mg/dL)or:TG>1.7mmol/l(150mg/dL)IFG&IGTFastingplasmaglucose5.6-6.9mmol/L(102-125mg/dL)AbnormalglucosetolerancetestESC/ESH

2007高血压指南Metabolic

syndrometheclusterofthreeoutof5riskfactorsamongabdominalobesity,alteredfastingplasmaglucose,BP≥130/85mmHg,low

HDL-cholesterolandhighTG(asdefinedabove)DiabetesMellitusFastingplasma≥7.0mmol/l(126mg/dL)onrepeatedmeasurements,orPostloadplasmaglucose>11.0mmol/l(198mg/dL)（JHypertens2007,25：1105）AbdominalobesityESC/ESH20073ESC/ESH

2007——关注高血压伴发的代谢异常（JHypertens2007,25：1105）ESC/ESH2007——关注高血压伴发的代谢异常（J4如何评估高血压的代谢危险性DiabetesVascDisRes2008;5:9–14如何评估高血压的代谢危险性DiabetesVascDis5心血管代谢危险性评估1.Framinghamscore(USA)

Age,Sex,SBP,TC,Smoking,HDL-c2.TheUKPDSriskengine(UK)

Age,Sex,SBP,Smoking,TC/HDL-c,HbA1c3.PROCAMscore(Germany)

Age,LDL-c,TC,smoking,HDL-c,SBP,FHofMI,DM,TG4.ICVD(China)

Age,Sex,SBP,BMI,TC,Smoking,DM心血管代谢危险性评估1.Framinghamscore6危险分层：ESC/ESH危险分层：ESC/ESH7Lancet2005;366:1640Lifestylechanges+immediatedrugtreatmentAmJCardiol2007;99:1006–1012Grade3HTSBP≥180orDBP≥110管危险性明显增加，可视为冠心病等危症。LifestylechangesforseveralweeksthendrugtreatmentifBPuncontrolled危险分层：ESC/ESHESC/ESH2007——关注高血压伴发的代谢异常控制血糖至一定范围显著减少心脑血管事件EstablishedCVorrenaldiseaseLifestylechangesforseveralweeksthendrugtreatmentifBPuncontrolled肥胖与心衰Paradoxprognosis:excessbodyweighthaveaparadoxicalprotectiverole?BolenSAnnInternMed.SBP130-139orDBP85-89ATVB,2006,26:28-40靶器官损害的评价Lancet2005;366:1640靶器官损害的评价8Otherriskfactors,ODordiseaseNormalSBP120-129orDBP80-84HighnormalSBP130-139orDBP85-89Grade1HTSBP140-159orDBP90-99Grade2HTSBP160-179orDBP100-109Grade3HTSBP≥180orDBP≥110NootherriskfactorsNoBPinterventionNoBPinterventionLifestylechangesforseveralmonthsthendrugtreatmentifBPuncontrolledLifestylechangesforseveralweeksthendrugtreatmentifBPuncontrolledLifestylechanges+immediatedrugtreatment1-2riskfactorsLifestylechangesLifestylechangesLifestylechangesforseveralweeksthendrugtreatmentifBPuncontrolledLifestylechangesforseveralweeksthendrugtreatmentifBPuncontrolledLifestylechanges+immediatedrugtreatment3ormoreriskfactors,MS,ODordiabetesLifestylechangesLifestylechangesandconsiderdrugtreatmentLifestylechanges+drugtreatmentLifestylechanges+drugtreatmentLifestylechanges+immediatedrugtreatmentDiabetesLifestylechangesLifestylechanges+drugtreatmentEstablishedCVorrenaldiseaseLifestylechanges+immediatedrugtreatmentLifestylechanges+immediatedrugtreatmentLifestylechanges+immediatedrugtreatmentLifestylechanges+immediatedrugtreatmentLifestylechanges+immediatedrugtreatmentOtherriskfactors,ODordise9高血压代谢危险因素控制面临的困惑与启示课件10干预高血压相关的代谢危险因素能显著降低心脑血管事件吗？LowerbloodpressureYes(30%-60%)LowerlipidsYes(17%-43%)LowerbodyweightParadoxLowerglucoseUncertain干预高血压相关的代谢危险因素能显著降低心脑血管事件吗？Low11BMIandWCvsfatparameters肥胖与心血管危险存在U形关系GuDF,etal.JAMA.2006;295:776-783BMIandWCvsfatparameters肥12肥胖与心衰Paradoxprognosis:excessbodyweighthaveaparadoxicalprotectiverole?

EnchaiahS,etal.NEnglJMed2002;347:305-13.DIAMONDstudygroupGustafsson1F,EurHeartJ,2005,26:58–64肥胖与心衰Paradoxprognosis:exces13肥胖与AMI

Obesityandtheriskofmyocardialinfarctionin27000participantsfrom52countries:acase-controlstudyYusufS,etal.Lancet2005;366:1640NicolettiI,etal.InterJCardiol,2006,107:395–399Paradoxprognosis:excessbodyweighthaveaparadoxicalprotectiverole?肥胖与AMI

Obesityandtherisko14生活方式改变的局限生活方式改变的局限15BMI不能反映内脏脂肪的实际变化BMI不能反映内脏脂肪的实际变化16腹型肥胖的类型与代谢综合征的关系腹型肥胖类型腰围超标

(≥90/85cm)腹内脂肪面积

VA≥100cm2非肥胖组－－隐性内脏脂肪型肥胖组(MaskedVFO)－＋假性内脏脂肪型肥胖组(PseudoVFO)＋－内脏型腹型肥胖组(visceralfatobesity，VFO)＋＋MS43%MS78%MS89%中华医学杂志2008腹型肥胖的类型与代谢综合征的关系腹型肥胖类型腰围超标

(≥917Proposedmechanismsbywhichvisceralobesity,asthemostdangerousformofobesity,couldbelinkedtotheathero-thrombotic-inflammatoryabnormalitiesofinsulinresistance.

ATVB,2008Proposedmechanismsbywhichv18微血管并发症心肌梗死HbA1c37%14%强化降糖与减少CVD事件面临的困惑糖尿病相关的死亡21%1%StrattonIM,etal.BMJ2000;321:405–412.微血管并发症心肌梗死HbA1c37%14%强化降糖与减少CV19DiabetesandCoronaryRiskEquivalencyDIAMONDstudygroupAbdominalobesityLifestylechanges+drugtreatmentLowerglucoseUncertainLifestylechanges+drugtreatmentJessupM,etal.Lifestylechanges+drugtreatmentSBP140-159orDBP90-99LowerbloodpressureYes(30%-60%)对高血压的危险进行总体评估Lifestylechanges+immediatedrugtreatmentLifestylechanges+immediatedrugtreatmentNEJM,2003,348:2007-18.予100mg/d阿替洛尔能防止低血糖诱发的QTc延长和QTd离散Diabetes,2003糖尿病作为冠心病的等危症是有条件的DiabetesandCoronaryRiskEquivalency糖尿病不合并其他危险因素，其心血管危险不高，也即单纯高血糖至少在短期对心血管危害不大。糖尿病合并其他危险因素，其心血管危险性明显增加，可视为冠心病等危症。

GrandySM,DiabetesCare,2006DiabetesandCoronaryRiskEqu20理论假说

降压和调脂的临床试验证实：血压和血脂水平控制得越严格，获得的益处更大。合理假设:强化血糖控制有益于减少CVD事件

理论假说

降压和调脂的临床试验证实：血压和血脂水平控制21

控制血糖至一定范围显著减少心脑血管事件

控制血糖至一定范围显著减少心脑血管事件

22ACCORD,ADVANCE,VADT强化血糖控制无益处在ACCORD试验结果公布之前一个月，EurHeartJ连续刊登了2篇降糖治疗增加心血管事件的临床研究，编辑部予以评论。ACCORD,ADVANCE,VADT23DIGAMI2trial

Theimpactofglucoseloweringtreatmentonlong-termprognosisinpatientswithtype2diabetesandmyocardialinfarction:areportfromtheDIGAMI2trial

1996DIGAMI1研究显示予胰岛素治疗显著减少糖尿病的急性心肌梗塞死亡率Circulation1999;99:2626–2632.2005DIGAMI2探讨降糖治疗对糖尿病心肌梗塞的影响入选1181例2型糖尿病，平均年龄68岁，67%为男性，平均随访2.1年37%口服降糖药，58%用胰岛素EuropeanHeartJournal(2008)DIGAMI2trial

Theimpactof24与口服降糖药相比，胰岛素与全因死亡和心血管死亡无关，但可增加非致死心梗或脑卒中

(HR:1.95,95%CI:1.35–2.82;P=0.0004)与口服降糖药相比，胰岛素与全因死亡和心血管死亡无关，但可增加25EuroHeartSurveyonDiabetesandtheHeart

Glucoseloweringtreatmentinpatientswithcoronaryarterydiseaseisprognosticallyimportantnotonlyinestablishedbutalsoinnewlydetecteddiabetesmellitus:areportfromtheEuroHeartSurveyonDiabetesandtheHeart

本研究比较了目前的降糖治疗对冠心病己合并糖尿病和新发糖尿病的作用。从110个中心，入选4676例冠心病患者，其中1425例既往有糖尿病，452例为新发糖尿病。探讨不同的降糖治疗对心血管事件(死亡、心梗、卒中)的影响。EuropeanHeartJournal(2008)EuroHeartSurveyonDiabetes26与口服降糖药相比，对合并糖尿病的冠心病，胰岛素治疗增加1年心血管死亡风险2.23(95%CI1.24–4.03;P=0.006)，但对新发糖尿病患者，与未降糖治疗相比，降糖治疗则明显减少其心血管事件与口服降糖药相比，对合并糖尿病的冠心病，胰岛素治疗增加1年心27最近的血糖控制试验带来的困惑

最近的血糖控制试验带来的困惑28Grade3HTSBP≥180orDBP≥110Lifestylechanges糖尿病不合并其他危险因素，其心血管危险不高，也即单纯高血糖AmJCardiol2007;99:1006–1012EndotheliumBlaschkeF,etal.EuroHeartSurveyonDiabetesandtheHeart

Glucoseloweringtreatmentinpatientswithcoronaryarterydiseaseisprognosticallyimportantnotonlyinestablishedbutalsoinnewlydetecteddiabetesmellitus:areportfromtheEuroHeartSurveyonDiabetesandtheHeartAmJCardiol2007;99:1006–1012Obesityandtheriskofmyocardialinfarctionin27000participantsfrom52countries:acase-controlstudyYusufS,etal.ESC/ESH2007高血压指南0mmol/l(40mg/dL),W<1.LifestylechangesforseveralweeksthendrugtreatmentifBPuncontrolled与口服降糖药相比，胰岛素与全因死亡和心血管死亡无关，但可增加非致死心梗或脑卒中

(HR:1.2mmol/l(46mg/dL)or:管危险性明显增加，可视为冠心病等危症。JessupM,etal.NEJM,2003,348:2007-18.BlaschkeF,etal.ATVB,2006,26:28-40VanGaalLF,etal.Lancet,2005,365:1389-97多靶点药物Grade3HTSBP≥180orDBP≥1129NEnglJMed2002;347:305-13.Lifestylechanges+immediatedrugtreatmentPotassium对降糖治疗中出现的低血糖诱发的致死性心律失常的防治，也是其他药物难以取代的。Age,Sex,SBP,TC,Smoking,HDL-cLifestylechanges对降糖治疗中出现的低血糖诱发的致死性心律失常的防治，也是其他药物难以取代的。HDL-C:M<1.AmJCardiol2007;99:1006–1012客观评价β-blocker在糖尿病治疗中的作用至少在短期对心血管危害不大。DyslipidemiaGustafsson1F,EurHeartJ,2005,26:58–64与口服降糖药相比，胰岛素与全因死亡和心血管死亡无关，但可增加非致死心梗或脑卒中

(HR:1.（JHypertens2007,25：1105）降压药物的选择NEnglJMed2002;347:305-13.30降压药物的选择降压药物的选择31EffectofInhibitionoftheRASonDevelopmentofType2DiabetesMellitus(Meta-AnalysisofRandomizedTrials)

AmJCardiol2007;99:1006–1012EffectofInhibitionoftheRA32Irbesartanforthetreatmentofhypertensioninpatientswiththe

metabolicsyndrome:AsubanalysisoftheTreattoTargetpost

authorizationsurvey.Prospectiveobservational,twoarmedstudy

in14,200patients

CardiovascularDiabetology2007,6:12

Irbesartanforthetreatmento33降糖药对心血管事件的影响

EuropeanHeartJournal(2008)降糖药对心血管事件的影响

EuropeanHeartJo34

不同降糖药组合对LDL-C和血压影响不同

BolenSAnnInternMed.2007

35客观评价β-blocker在糖尿病治疗中的作用予100mg/d阿替洛尔能防止低血糖诱发的QTc延长和QTd离散Diabetes,2003虽然予beta受体阻断剂可能增加糖脂代谢紊乱和胰岛素抵抗，但可显著降低糖尿病合并心衰的死亡率。对降糖治疗中出现的低血糖诱发的致死性心律失常的防治，也是其他药物难以取代的。FonarowGC.AnApproachtoHeartFailureandDiabetesMellitusAmJCardiol2005;96[suppl]:47E–52E)客观评价β-blocker在糖尿病治疗中的作用予100mg36ChangesinSerumPotassiumMediateThiazide-InducedDiabetesHypertension.2008;52:1022-1029Thiazide-induceddiabetesoccurs(42%)earlyafterinitiatingtreatmentandappearstobemediatedbychangesinserumpotassium.Potassiumsupplementationmightpreventthiazide-induceddiabetes.ChangesinSerumPotassiumMed37SummaryCardiologist&EndocrinologistProgressionandoutcomesofthemetabolicsyndrome

GrundySM,JAmCollCardiol2006;47:1093–100SummaryProgressionandoutcome38谢谢！谢谢！39本研究比较了目前的降糖治疗对冠心病己合并糖尿病和新发糖尿病的作用。Otherriskfactors,ODordiseaseDyslipidemiaVanGaalLF,etal.LifestylechangesGrade3HTSBP≥180orDBP≥110Lifestylechanges+immediatedrugtreatment干预高血压相关的代谢危险因素能显著降低心脑血管事件吗？Lifestylechanges+immediatedrugtreatmentOtherriskfactors,ODordiseaseEndotheliumDyslipidemiaDiabetesandCoronaryRiskEquivalencyLifestylechangesforseveralweeksthendrugtreatmentifBPuncontrolledAbdominalDyslipidemiaAbdominalObesityDiabetesUricacidRenallesionEndotheliumdamage

HypertensiveSyndrome

-ConstellationsofCardiometabolicRiskFactorsHypertension80%高血压危险因素CVD事件本研究比较了目前的降糖治疗对冠心病己合并糖尿病和新发糖尿病的40Otherriskfactors,ODordiseaseNormalSBP120-129orDBP80-84HighnormalSBP130-139orDBP85-89Grade1HTSBP140-159orDBP90-99Grade2HTSBP160-179orDBP100-109Grade3HTSBP≥180orDBP≥110NootherriskfactorsNoBPinterventionNoBPinterventionLifestylechangesforseveralmonthsthendrugtreatmentifBPuncontrolledLifestylechangesforseveralweeksthendrugtreatmentifBPuncontrolledLifestylechanges+immediatedrugtreatment1-2riskfactorsLifestylechangesLifestylechangesLifestylechangesforseveralweeksthendrugtreatmentifBPuncontrolledLifestylechangesforseveralweeksthendrugtreatmentifBPuncontrolledLifestylechanges+immediatedrugtreatment3ormoreriskfactors,MS,ODordiabetesLifestylechangesLifestylechangesandconsiderdrugtreatmentLifestylechanges+drugtreatmentLifestylechanges+drugtreatmentLifestylechanges+immediatedrugtreatmentDiabetesLifestylechangesLifestylechanges+drugtreatmentEstablishedCVorrenaldiseaseLifestylechanges+immediatedrugtreatmentLifestylechanges+immediatedrugtreatmentLifestylechanges+immediatedrugtreatmentLifestylechanges+immediatedrugtreatmentLifestylechanges+immediatedrugtreatmentOtherriskfactors,ODordise41糖尿病作为冠心病的等危症是有条件的DiabetesandCoronaryRiskEquivalency糖尿病不合并其他危险因素，其心血管危险不高，也即单纯高血糖至少在短期对心血管危害不大。糖尿病合并其他危险因素，其心血管危险性明显增加，可视为冠心病等危症。

GrandySM,DiabetesCare,2006糖尿病作为冠心病的等危症是有条件的糖尿病不合并其他危险因素，42与口服降糖药相比，对合并糖尿病的冠心病，胰岛素治疗增加1年心血管死亡风险2.23(95%CI1.24–4.03;P=0.006)，但对新发糖尿病患者，与未降糖治疗相比，降糖治疗则明显减少其心血管事件与口服降糖药相比，对合并糖尿病的冠心病，胰岛素治疗增加1年心43EffectofInhibitionoftheRASonDevelopmentofType2DiabetesMellitus(Meta-AnalysisofRandomizedTrials)

AmJCardiol2007;99:1006–1012EffectofInhibitionoftheRA44客观评价β-blocker在糖尿病治疗中的作用予100mg/d阿替洛尔能防止低血糖诱发的QTc延长和QTd离散Diabetes,2003虽然予beta受体阻断剂可能增加糖脂代谢紊乱和胰岛素抵抗，但可显著降低糖尿病合并心衰的死亡率。对降糖治疗中出现的低血糖诱发的致死性心律失常的防治，也是其他药物难以取代的。FonarowGC.AnApproachtoHeartFailureandDiabetesMellitusAmJCardiol2005;96[suppl]:47E–52E)客观评价β-blocker在糖尿病治疗中的作用予100mg45DyslipidemiaAbdominalObesityDiabetesUricacidRenallesionEndotheliumdamage

HypertensiveSyndrome

-ConstellationsofCardiometabolicRiskFactorsHypertension80%高血压危险因素CVD事件DyslipidemiaAbdominalDiabete46更强调危险因素的早期控制更关注血管和代谢因素的相互作用对高血压的危险进行总体评估防治上既遵循循证医学证据，也强调个体化治疗更强调危险因素的早期控制47Abdominalobesity

Waistcircumference>102cm(M),88cm(W)DyslipidaemiaTC>5.0mmol/l(原为6.1)orLDL-C>3.0mmol/l(原为4.0)orHDL-C:M<1.0mmol/l(40mg/dL),W<1.2mmol/l(46mg/dL)or:TG>1.7mmol/l(150mg/dL)IFG&IGTFastingplasmaglucose5.6-6.9mmol/L(102-125mg/dL)AbnormalglucosetolerancetestESC/ESH

2007高血压指南Metabolic

syndrometheclusterofthreeoutof5riskfactorsamongabdominalobesity,alteredfastingplasmaglucose,BP≥130/85mmHg,low

HDL-cholesterolandhighTG(asdefinedabove)DiabetesMellitusFastingplasma≥7.0mmol/l(126mg/dL)onrepeatedmeasurements,orPostloadplasmaglucose>11.0mmol/l(198mg/dL)（JHypertens2007,25：1105）AbdominalobesityESC/ESH200748ESC/ESH

2007——关注高血压伴发的代谢异常（JHypertens2007,25：1105）ESC/ESH2007——关注高血压伴发的代谢异常（J49如何评估高血压的代谢危险性DiabetesVascDisRes2008;5:9–14如何评估高血压的代谢危险性DiabetesVascDis50心血管代谢危险性评估1.Framinghamscore(USA)

Age,Sex,SBP,TC,Smoking,HDL-c2.TheUKPDSriskengine(UK)

Age,Sex,SBP,Smoking,TC/HDL-c,HbA1c3.PROCAMscore(Germany)

Age,LDL-c,TC,smoking,HDL-c,SBP,FHofMI,DM,TG4.ICVD(China)

Age,Sex,SBP,BMI,TC,Smoking,DM心血管代谢危险性评估1.Framinghamscore51危险分层：ESC/ESH危险分层：ESC/ESH52Lancet2005;366:1640Lifestylechanges+immediatedrugtreatmentAmJCardiol2007;99:1006–1012Grade3HTSBP≥180orDBP≥110管危险性明显增加，可视为冠心病等危症。LifestylechangesforseveralweeksthendrugtreatmentifBPuncontrolled危险分层：ESC/ESHESC/ESH2007——关注高血压伴发的代谢异常控制血糖至一定范围显著减少心脑血管事件EstablishedCVorrenaldiseaseLifestylechangesforseveralweeksthendrugtreatmentifBPuncontrolled肥胖与心衰Paradoxprognosis:excessbodyweighthaveaparadoxicalprotectiverole?BolenSAnnInternMed.SBP130-139orDBP85-89ATVB,2006,26:28-40靶器官损害的评价Lancet2005;366:1640靶器官损害的评价53Otherriskfactors,ODordiseaseNormalSBP120-129orDBP80-84HighnormalSBP130-139orDBP85-89Grade1HTSBP140-159orDBP90-99Grade2HTSBP160-179orDBP100-109Grade3HTSBP≥180orDBP≥110NootherriskfactorsNoBPinterventionNoBPinterventionLifestylechangesforseveralmonthsthendrugtreatmentifBPuncontrolledLifestylechangesforseveralweeksthendrugtreatmentifBPuncontrolledLifestylechanges+immediatedrugtreatment1-2riskfactorsLifestylechangesLifestylechangesLifestylechangesforseveralweeksthendrugtreatmentifBPuncontrolledLifestylechangesforseveralweeksthendrugtreatmentifBPuncontrolledLifestylechanges+immediatedrugtreatment3ormoreriskfactors,MS,ODordiabetesLifestylechangesLifestylechangesandconsiderdrugtreatmentLifestylechanges+drugtreatmentLifestylechanges+drugtreatmentLifestylechanges+immediatedrugtreatmentDiabetesLifestylechangesLifestylechanges+drugtreatmentEstablishedCVorrenaldiseaseLifestylechanges+immediatedrugtreatmentLifestylechanges+immediatedrugtreatmentLifestylechanges+immediatedrugtreatmentLifestylechanges+immediatedrugtreatmentLifestylechanges+immediatedrugtreatmentOtherriskfactors,ODordise54高血压代谢危险因素控制面临的困惑与启示课件55干预高血压相关的代谢危险因素能显著降低心脑血管事件吗？LowerbloodpressureYes(30%-60%)LowerlipidsYes(17%-43%)LowerbodyweightParadoxLowerglucoseUncertain干预高血压相关的代谢危险因素能显著降低心脑血管事件吗？Low56BMIandWCvsfatparameters肥胖与心血管危险存在U形关系GuDF,etal.JAMA.2006;295:776-783BMIandWCvsfatparameters肥57肥胖与心衰Paradoxprognosis:excessbodyweighthaveaparadoxicalprotectiverole?

EnchaiahS,etal.NEnglJMed2002;347:305-13.DIAMONDstudygroupGustafsson1F,EurHeartJ,2005,26:58–64肥胖与心衰Paradoxprognosis:exces58肥胖与AMI

Obesityandtheriskofmyocardialinfarctionin27000participantsfrom52countries:acase-controlstudyYusufS,etal.Lancet2005;366:1640NicolettiI,etal.InterJCardiol,2006,107:395–399Paradoxprognosis:excessbodyweighthaveaparadoxicalprotectiverole?肥胖与AMI

Obesityandtherisko59生活方式改变的局限生活方式改变的局限60BMI不能反映内脏脂肪的实际变化BMI不能反映内脏脂肪的实际变化61腹型肥胖的类型与代谢综合征的关系腹型肥胖类型腰围超标

(≥90/85cm)腹内脂肪面积

VA≥100cm2非肥胖组－－隐性内脏脂肪型肥胖组(MaskedVFO)－＋假性内脏脂肪型肥胖组(PseudoVFO)＋－内脏型腹型肥胖组(visceralfatobesity，VFO)＋＋MS43%MS78%MS89%中华医学杂志2008腹型肥胖的类型与代谢综合征的关系腹型肥胖类型腰围超标

(≥962Proposedmechanismsbywhichvisceralobesity,asthemostdangerousformofobesity,couldbelinkedtotheathero-thrombotic-inflammatoryabnormalitiesofinsulinresistance.

ATVB,2008Proposedmechanismsbywhichv63微血管并发症心肌梗死HbA1c37%14%强化降糖与减少CVD事件面临的困惑糖尿病相关的死亡21%1%StrattonIM,etal.BMJ2000;321:405–412.微血管并发症心肌梗死HbA1c37%14%强化降糖与减少CV64DiabetesandCoronaryRiskEquivalencyDIAMONDstudygroupAbdominalobesityLifestylechanges+drugtreatmentLowerglucoseUncertainLifestylechanges+drugtreatmentJessupM,etal.Lifestylechanges+drugtreatmentSBP140-159orDBP90-99LowerbloodpressureYes(30%-60%)对高血压的危险进行总体评估Lifestylechanges+immediatedrugtreatmentLifestylechanges+immediatedrugtreatmentNEJM,2003,348:2007-18.予100mg/d阿替洛尔能防止低血糖诱发的QTc延长和QTd离散Diabetes,2003糖尿病作为冠心病的等危症是有条件的DiabetesandCoronaryRiskEquivalency糖尿病不合并其他危险因素，其心血管危险不高，也即单纯高血糖至少在短期对心血管危害不大。糖尿病合并其他危险因素，其心血管危险性明显增加，可视为冠心病等危症。

GrandySM,DiabetesCare,2006DiabetesandCoronaryRiskEqu65理论假说

降压和调脂的临床试验证实：血压和血脂水平控制得越严格，获得的益处更大。合理假设:强化血糖控制有益于减少CVD事件

理论假说

降压和调脂的临床试验证实：血压和血脂水平控制66

控制血糖至一定范围显著减少心脑血管事件

控制血糖至一定范围显著减少心脑血管事件

67ACCORD,ADVANCE,VADT强化血糖控制无益处在ACCORD试验结果公布之前一个月，EurHeartJ连续刊登了2篇降糖治疗增加心血管事件的临床研究，编辑部予以评论。ACCORD,ADVANCE,VADT68DIGAMI2trial

Theimpactofglucoseloweringtreatmentonlong-termprognosisinpatientswithtype2diabetesandmyocardialinfarction:areportfromtheDIGAMI2trial

1996DIGAMI1研究显示予胰岛素治疗显著减少糖尿病的急性心肌梗塞死亡率Circulation1999;99:2626–2632.2005DIGAMI2探讨降糖治疗对糖尿病心肌梗塞的影响入选1181例2型糖尿病，平均年龄68岁，67%为男性，平均随访2.1年37%口服降糖药，58%用胰岛素EuropeanHeartJournal(2008)DIGAMI2trial

Theimpactof69与口服降糖药相比，胰岛素与全因死亡和心血管死亡无关，但可增加非致死心梗或脑卒中

(HR:1.95,95%CI:1.35–2.82;P=0.0004)与口服降糖药相比，胰岛素与全因死亡和心血管死亡无关，但可增加70EuroHeartSurveyonDiabetesandtheHeart

Glucoseloweringtreatmentinpatientswithcoronaryarterydiseaseisprognosticallyimportantnotonlyinestablishedbutalsoinnewlydetecteddiabetesmellitus:areportfromtheEuroHeartSurveyonDiabetesandtheHeart

本研究比较了目前的降糖治疗对冠心病己合并糖尿病和新发糖尿病的作用。从110个中心，入选4676例冠心病患者，其中1425例既往有糖尿病，452例为新发糖尿病。探讨不同的降糖治疗对心血管事件(死亡、心梗、卒中)的影响。EuropeanHeartJournal(2008)EuroHeartSurveyonDiabetes71与口服降糖药相比，对合并糖尿病的冠心病，胰岛素治疗增加1年心血管死亡风险2.23(95%CI1.24–4.03;P=0.006)，但对新发糖尿病患者，与未降糖治疗相比，降糖治疗则明显减少其心血管事件与口服降糖药相比，对合并糖尿病的冠心病，胰岛素治疗增加1年心72最近的血糖控制试验带来的困惑

最近的血糖控制试验带来的困惑73Grade3HTSBP≥180orDBP≥110Lifestylechanges糖尿病不合并其他危险因素，其心血管危险不高，也即单纯高血糖AmJCardiol2007;99:1006–1012EndotheliumBlaschkeF,etal.EuroHeartSurveyonDiabetesandtheHeart

Glucoseloweringtreatmentinpatientswithcoronaryarterydiseaseisprognosticallyimportantnotonlyinestablishedbutalsoinnewlydetecteddiabetesmellitus:areportfromtheEuroHeartSurveyonDiabetesandtheHeartAmJCardiol2007;99:1006–1012Obesityandtheriskofmyocardialinfarctionin27000participantsfrom52countries:acase-controlstudyYusufS,etal.ESC/ESH2007高血压指南0mmol/l(40mg/dL),W<1.LifestylechangesforseveralweeksthendrugtreatmentifBPuncontrolled与口服降糖药相比，胰岛素与全因死亡和心血管死亡无关，但可增加非致死心梗或脑卒中

(HR:1.2mmol/l(46mg/dL)or:管危险性明显增加，可视为冠心病等危症。JessupM,etal.NEJM,2003,348:2007-18.BlaschkeF,etal.ATVB,2006,26:28-40VanGaalLF,etal.Lancet,2005,365:1389-97多靶点药物Grade3HTSBP≥180orDBP≥1174NEnglJMed2002;347:305-13.Lifestylechanges+immediatedrugtreatmentPotassium对降糖治疗中出现的低血糖诱发的致死性心律失常的防治，也是其他药物难以取代的。Age,Sex,SBP,TC,Smoking,HDL-cLifestylechanges对降糖治疗中出现的低血糖诱发的致死性心律失常的防治，也是其他药物难以取代的。HDL-C:M<1.AmJCardiol2007;99:1006–1012客观评价β-blocker在糖尿病治疗中的作用至少在短期对心血管危害不大。DyslipidemiaGustafsson1F,EurHeartJ,2005,26:58–64与口服降糖药相比，胰岛素与全因死亡和心血管死亡无关，但可增加非致死心梗或脑卒中

(HR:1.（JHypertens2007,25：1105）降压药物的选择NEnglJMed2002;347:305-13.75降压药物的选择降压药物的选择76EffectofInhibitionoftheRASonDevelopmentofType2DiabetesMellitus(Meta-AnalysisofRandomizedTrials)

AmJCardiol2007;99:1006–1012EffectofInhibitionoftheRA77Irbesartanforthetreatmentofhypertensioninpatientswiththe

metabolicsyndrome:AsubanalysisoftheTreattoTargetpost

authorizationsurvey.Prospectiveobservational,twoarmedstudy

in14,200patients

CardiovascularDiabetology2007,6:12

Irbesartanforthetreatmento78降糖药对心血管事件的影响

EuropeanHeartJournal(2008)降糖药对心血管事件的影响

EuropeanHeartJo79

不同降糖药组合对LDL-C和血压影响不同

BolenSAnnInternMed.2007

80客观评价β-blocker在糖尿病治疗中的作用予100mg/d阿替洛尔能防止低血糖诱发的QTc延长和QTd离散Diabetes,2003虽然予beta受体阻断剂可能增加糖脂代谢紊乱和胰岛素抵抗，但可显著降低糖尿病合并心衰的死亡率。对降糖治疗中出现的低血糖诱发的致死性心律失常的防治，也是其他药物难以取代的。FonarowGC.AnApproachtoHeartFailureandDiabetesMellitusAmJCardiol2005;96[suppl]:47E–52E)客观评价β-blocker在糖尿病治疗中的作用予100mg81ChangesinSerumPotassiumMediateThiazide-InducedDiabetesHypertension.2008;52:1022-1029Thiazide-induceddiabetesoccurs(42%)earlyafterinitiatingtreatmentandappearstobemediatedbychangesinserumpotassium.Potassiumsupplementationmightpreventthiazide-induceddiabetes.ChangesinSerumPotassiumMed82SummaryCardiologist&EndocrinologistProgressionandoutcomesofthemetabolicsyndrome

GrundySM,JAmCollCardiol2006;47:1093–100SummaryProgressionandoutcome83谢谢！谢谢！84本研究比较了目前的降糖治疗对冠心病己合并糖尿病和新发糖尿病的作用。Otherriskfactors,ODordiseaseDyslipidemiaVanGaalLF,etal.LifestylechangesGrade3HTSBP≥180orDBP≥110Lifestylechanges+immediatedrugtreatment干预高血压相关的代谢危险因素能显著降低心脑血管事件吗？Lifestylechanges+immediate