糖尿病心血管疾病的非降脂治療與臨床評(píng)價(jià)

1、Koistinen MJ. BMJ 1990;301:92-95. Type 2 Type 1 ControlsNaka M et al. Am Heart J 1992;123:46-53. Type 2 ControlsMiSAD Group. Am J Cardiol 1997;79:134-139. Type 2Rutter MK et al. Am J Cardiol 1999;83:27-31. Type 2 w microalb Type 2 w/o microalbLe A et al. Am J Kidney Dis 1994;24:65-71. Type 1 Renal T

2、ransplantHolley JL et al. Am J Med 1991;90:563-570. Type 1 & 2 Renal Transplant n = 64 n = 72 n = 80 n = 142 n = 149 n = 925 n = 43 n = 43 (thal201) 36% 24% 9% 31% 30% 12.1% 65% 40% 58% 55% 9% 11% 9% 12.1% 5.3% 6.4% 35% 43%n Typical or atypical cardiac symptomsn Resting ECG suggestive of ischemi

3、a or infarctionn Peripheral or carotid occlusive arterial diseasen Sedentary lifestyle or plan to begin a vigorous exercise programn Two or more of the risk factors listed below - Total cholesterol 240 mg/dL, LDL cholesterol 160 mg/dL, or HDL cholesterol 140/90 mmHg - Smoking - Family history of pre

4、mature CAD - Positive micro/macroalbuminurianHypertensive CardiomyopathynDiabetic CardiomyopathynAutonomic CardiomyopathynRenal InsufficiencynMicrovascular DysfunctionnImplement more aggressive CHD prevention regimennInitiate anti-ischemic medicationsnIdentify patients who would benefit from revascu

5、larizationnEducate patients to recognize coronary symptoms020406080100120140160180Kannel WB et al. Am Heart J 1991;121:1268-1273.Age-adjusted CV Event Rate/1,000Systolic BP (mmHg)105135165195020406080100120140160180Systolic BP (mmHg)105135165195Age-adjusted CV Event Rate/1,00024503877591199017415312

6、348367456113No Glucose IntoleranceGlucose IntoleranceNo Glucose IntoleranceGlucose IntoleranceUKPDS Group. Lancet 1998;352:837-853.Any diabetes related*MIStrokePVDMicrovascular40.914.75.61.18.6 4617.4 51.611.40.0290.0520.520.150.0099111625(rate/1000 pt yrs)* Combined microvascular and macrovascular

7、eventsIntensive%Decrease(rate/1000 pt yrs)PConventionalEndpointsUKPDS Group. Lancet 1998;352:837-853.Fatal MI or SDCancerOtherFatal StrokeRenal DiseaseAccidentsPVDHypo- or Hyperglycemia231120744316521(8.4%)(4.4%)(2.9%)(1.6%)(0.6%)(0.2%)(0.07%)(0.04%)(%)N = 2729UKPDS Group. BMJ 1998;317:703-713.Any d

8、iabetes-related endpointDiabetes-related deathsHeart failureStrokeMyocardial infarctionMicrovascular diseaseTight Controln 1,148 Type 2 patientsn Average BP lowered to 144/82 mmHg (controls: 154/87);9-year follow-up243256442137Risk Reduction (%)P value0.00460.0190.00430.013 NS0.0092Any diabetes-rela

9、ted endpointDiabetes-related deathsAll-cause mortalityMyocardial infarctionStrokeMicrovascular1.101.271.141.201.121.290.430.280.440.350.740.30UKPDS Group. BMJ 1998;317:713-720.n9、 人的價(jià)值，在招收誘惑的一瞬間被決定。2022-3-202022-3-20Sunday, March 20, 2022n10、低頭要有勇氣，抬頭要有低氣。2022-3-202022-3-202022-3-203/20/2022 7:11:08

10、 AMn11、人總是珍惜為得到。2022-3-202022-3-202022-3-20Mar-2220-Mar-22n12、人亂于心，不寬余請(qǐng)。2022-3-202022-3-202022-3-20Sunday, March 20, 2022n13、生氣是拿別人做錯(cuò)的事來懲罰自己。2022-3-202022-3-202022-3-202022-3-203/20/2022n14、抱最大的希望，作最大的努力。2022年3月20日星期日2022-3-202022-3-202022-3-20n15、一個(gè)人炫耀什么，說明他內(nèi)心缺少什么。2022年3月2022-3-202022-3-202022-3-20

11、3/20/2022n16、業(yè)余生活要有意義，不要越軌。2022-3-202022-3-20March 20, 2022n17、一個(gè)人即使已登上頂峰，也仍要自強(qiáng)不息。2022-3-202022-3-202022-3-202022-3-20010203040506070PlaceboEvents / 1000 Pt-YearsTuomilehto J et al. NEJM 1999;340: 677-684.Active RxPlaceboActive RxDiabetic PatientsNondiabetic Patients051015202530Major CV EventsMIEven

12、ts / 1000 Pt-YearsHansson L et al. Lancet 1998;351: 1755-1762.CV Mortality90 mmHg (N=501)85 mmHg (N=501)80 mmHg (N=499)Diastolic Targetp0.045p0.016p0.00505101520253090Events / 1000 Pt-YearsHansson L et al. Lancet 1998;351: 1755-1762.8580908580SHEP = Systolic Hypertension in the Elderly Program; GISS

13、I = Grupo Italiano per lo Studio della Sopravvivenza nellInfarto Miocardico; Syst-Eur = Systolic Hypertension in Europe; HOT = Hypertension Optimal Treatment; CAPPP = Captopril Prevention ProjectCurb JD et al. JAMA 1996;276:1886-1892; Zuanetti G et al. Circulation 1997;96:4239-4245; Staessen JA et a

14、l. Am J Cardiol 1998;82:20R-22R; Hansson L et al. Lancet 1998;351:1755-1762;UK Prospective Diabetes Study Group. BMJ 1998;317:703-713; Hansson L et al. Lancet 1999;353:611-616.SHEPGISSI-3Syst-EurHOTUKPDSCAPPP583/47362790/18,131492/46951501/18,7901148572/10,985BeneficialBeneficialBeneficialBeneficial

15、BeneficialBeneficialHope Study Investigators. NEJM 2000;342:145-153.0510152025Placebo% of PatientsRamiprilPlaceboRamiprilDiabetic PatientsNondiabetic PatientsThompson SG. N Engl J Med 1995;332:635-641.01234567FibrinogenLowerMiddleHigherHigherMiddleLowerTotal CholesterolRisk of Coronary Events (%)4/3

16、069/26110/2825/3113/24710/28111/26616/30421/305Harpaz D et al. Am J Med 1998;105:494-499.708090100Survival (%)NodiabetesType 2diabetesTime (Years)0123456No aspirinAspirinOR=0.8 (0.7-0.9)OR=0.7 (0.6-0.8)Antiplatelet Trialists Collaboration. BMJ 1994;308:81-106.0510152025CVD Events (%)DiabetesAntiplat

17、elet TherapyControlNo DiabetesP0.002P0.00001Malmberg K et al. BMJ 1997;314:1512-1515.0.70.60.50.40.30.20.100.70.60.50.40.30.20.10MortalityMortalityTotal CohortNo Insulin Low RiskYears in StudyYears in StudyControlInsulin-glucoseInfusion012345012345Insulin-glucoseInfusionControlp = .0111p = .004n=133

18、n=139n=314n=3060.00.10.20.30.40.5YearsGustafsson I et al. J Am Coll Cardiol 1999;34:83-89.01234Event Rate0.00.10.20.30.40.5Years01234Event RateRelative risk, 0.38P0.001Relative risk, 0.81P = 0.1PlaceboTrandolaprilPlaceboTrandolaprilCardiovascular deathSudden deathReinfarctionProgression in CHF0.56 (

19、0.37-0.85) 0.46 (0.25-0.85)0.55 (0.29-1.07)0.38 (0.21-0.67)0.79 (0.66-0.96) 0.84 (0.63-1.12)0.93 (0.69-1.26)0.81 (0.63-1.04)0.170.090.150.03CI = confidence interval; RR = relative risk.Gustafsson I et al. J Am Coll Cardiol 1999;34:83-89.0.010.010.080.0010.020.230.650.10Woodfield SL et al. J Am Coll

20、Cardiol 1996;28:1661-1669.2.72.12.42.0012345Odds Ratio for 30-Day MortalityDiabetes vs no diabetes(unadjusted)Adjusted for clinical variablesAdjusted for angiographicvariablesAdjusted for clinical &angiographic variablesDetre KM et al. N Engl J Med 2000;342:989-997.0.00.20.40.60.81.00MortalityDM

21、-PTCADM-CABGNon DM-CABGNon DM-PTCAFollow-up (years)0.250.180.080.07123450.00.20.40.60.81.00.00.20.40.60.81.0MortalityFollow-up (years)Years after Q-MIDM-PTCADM-CABGNon DM-CABGNon DM-PTCAMortality012345012345Detre KM et al. N Engl J Med 2000;342:989-997.020406080100BARI Investigators. J Am Coll Cardi

22、ol 2000;35:1122-1129.% Survival01345726Years020406080100% Survival01345726020406080100% Survival01345726p = 0.0425p = 0.7155p = 0.0011CABG (n=914)PTCA (n=915)CABG (n=180)PTCA (n=173)CABG (n=734)PTCA (n=742)84.480.976.455.786.886.4020406080100King SB III et al. J Am Coll Cardiol 2000;35:1116-1121.% S

23、urvivalYears after Randomization020406080100% Survival020406080100% Survivalp = 0.40p = 0.71p = 0.23CABG (n=194)PTCA (n=198)CABG (n=30)PTCA (n=29)CABG (n=164)PTCA (n=169)01345827601345827601345827682.779.302550751000255075100Van Belle E et al. J Am Coll Cardiol 1999;34:476-485.Lesions (%)Angiographi

24、c FU = 6 months62%PTCA Site(s)1 Site2 Sites3 SitesRestenosis(n = 237)Total Occlusion(n = 60)Patients (%)11%25%37%Van Belle E et al. J Am Coll Cardiol 1999;34:476-485.-20-15-10-5051015 in EF (%)p = nsp = nsp = 0.0001(n = 297)(n = 237)(n = 60)Restenosis ()Total Occlusion ()Restenosis (+)Total Occlusio

25、n ()Total Occlusion (+)-1.5+9.5+0.5+9.9-6.2+9.91.000.950.900.850.800.750.700Proportion Free of TVRp = 0.021df = 3, Log-rank TestRankin JM et al. Circulation 1998;98:I-79.Months Post PTCA024681012Year19941995199619971997199619951994N305425480288% Stent17.424.941.055.5Lincoff AM et al. N Engl J Med 19

26、99;341:319-327.Days after Randomization05101520Stent + PlaceboStent + AbciximabAngioplasty + Abciximab0309012018060150Incidence of repeated TVR at 6 mos. (%)Days after Randomization051015200309012018060150Incidence of repeated TVR at 6 mos. (%)18.4%16.6%8.1%14.6%Stent + PlaceboStent + AbciximabAngio

27、plasty + Abciximab9.0%8.8%051015% of PatientsDaysMarso SP et al. Circulation 1999;100:2477-2484.12.7%7.8%6.2%0309012018060150Stent + PlaceboStent + AbciximabPTCA + Abciximabp = 0.029nidentify diabetic patients with particularly high risk for CAD and perform appropriate screening naggressively identify and modify coronary risk factorsnexplore and implement treatment to protect the left ventricle from ischemic injurynmaintain tight but judicious glycemic control in a