心血管疾病和事件同糖尿病的关联.ppt

单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。,预计,2030,年我国糖尿病患者将超过,42,300,000,人,SARAH WILD,Global Prevalence of Diabetes,，,Diabetes Care 2004;27:10471053,糖尿病,（,Mio,）,20.8,17.7,8.4,6.8,5.2,42.3,30.3,21.3,8.9,13.9,31.7,79.4,0,10,20,30,40,50,60,70,80,90,印度,中国,美国,印尼,日本,巴基斯坦,2000,年,2030,年,中国糖尿病发病率,全世界有一亿八千万糖尿病患者，,接近九千万在中国,糖尿病发病率,%,（,20-74,岁）,*,*Estimated based on 2008 survey data,Pan,XR;Yang,WY;Li,GW;Liu,J.Prevalence of diabetes and its risk factors in China,1994.National Diabetes Prevention and Control Co-Operative Group.Diabetes Care.1997;20:16649,世界,WY Yang:Prevalence of Diabetes among Men and Women in China.N Engl J Med 2010;362:1090-101.,2,Major Cardiovascular Risk Factors,Cigarette smoking,Elevated blood pressure,Elevated serum total(and LDL)cholesterol,Low serum HDL cholesterol,Diabetes mellitus,Advancing age,3,视网膜病变,导致劳动成年人失明的,主要原因,1,糖尿病肾病,导致终末期肾病的主要原因,2,神经,/,血管病变,/,糖尿病足,导致非创伤性截肢,的主要原因,5,心血管事件,75,糖尿病患者死于,心血管疾病,（如心衰，心梗等）,4,脑血管,糖尿病患者卒中风险,增加,1.2-1.8,倍,3,1.Fong DS et al.,Diabetes Care 2003;26(Suppl.1):S99-S102,2.Molitch ME et al.,Diabetes Care 2003;26(Suppl.1):S94-S98,3.Kannel WB et al.,Am Heart J 1990;120:672-676,4.Gray RP&Yudkin JS.In Textbook of Diabetes 1997,5.Mayfield JA et al.,Diabetes Care 2003;26(Suppl.1):S78-S79,微血管病变,大血管病变,高血糖导致的血管损害,高血糖,氧化应激,多元醇及醛糖,还原酶途径产物增加,糖基化终末产物增加,蛋白激酶,C,及,核因子,B,的活化,糖毒性产生,基因表达改变 蛋白质功能改变,细胞损害及功能异常,Sheetz M,et al.JAMA 2002;288:2579,99.Ceriello A.Diabetes 2005;54:17.,代谢综合征,胰岛素抵抗,餐后高血糖,内皮细胞功能异常,氧化应激,-,细胞功能缺失,心血管疾病,2,型糖尿病,Ceriello A,et al.Arterioscler Thromb Vasc Biol 2004;22:816,23.,共同土壤学说,HR for coronary heart disease by long-term average concentrations of fasting blood glucose concentration,total(and non-HDL)cholesterol,and systolic blood pressure,Lancet,2010;375:221522,Hazard ratios(HRs)for vascular outcomes in people with versus those without diabetes,Lancet,2010;375:221522,2001,年中国,T2DM,住院患者调查,患病率（）,心血管疾病是我国糖尿病患者发病率和致死率最高、危害最大的慢性并发症,中国糖尿病防治指南,34.2,17.1,12.6,5.2,0,5,10,15,20,25,30,35,40,高血压,心血管疾病,脑血管疾病,下肢血管病,糖尿病与心血管疾病（,CVD,）关系密切，犹如硬币的正反面。糖尿病已被列为冠心病等危症，而许多冠心病患者同时患有糖尿病或处于糖尿病前期。,糖尿病是危及心脏的疾病,-,防治并发症是治疗糖尿病的目,标,糖尿病病人的死亡率是非糖尿病病人的两倍,大血管并发症：是微血管并发症的三倍,心血管病,占,75%,死因，并缩短寿命,10,年,(UKPDS),脑血管病,外周血管病,微血管并发症：,视网膜病,肾病,神经病,11,严格血糖控制降低糖尿病并发症的风险,DCCT Research Group.,N Engl J Med,.1993;329:977-986.,Ohkubo Y,et al.,Diabetes Res Clin Pract,.1995;28:103-117.,UKPDS 33:,Lancet,1998;352,837-853.,Stratton IM et al.BMJ.2000;321:405-412.,A1c,Retinopathy,Nephropathy,Neuropathy,CV disease,Type 1,DCCT,1,9 7%,63%,54%,60%,41%*,Type 2,Kumamoto,2,9 7%,69%,70%,-,52%*,Type 2,UKPDS,3,8 7%,17-21%,24-33%,-,16%*,*,Not statistically significant due to small number of events.,Showed statistical significance in subsequent epidemiologic analysis,4,A1C,%,6.4 vs.7.5*,6.4 vs.7.3*,6.9 vs.8.4*,总死亡率,%,5.0 vs.4.0*,8.9 vs.9.6,NA,心血管病死亡率,%,2.6 vs.1.8*,4.5 vs.5.2,2.1 vs.1.7,Nonfatal MI,%,3.6 vs.4.6*,2.7 vs.2.8,6.1 vs.6.3,Nonfatal stroke,%,1.3 vs.1.2,3.8 vs.3.8,2.0 vs.3.1,New or worsening nephropathy,%,NA,4.1 vs.5.2*,NA,Major/severe hypoglycemia,%,10.5 vs.3.5*,2.7 vs.1.5*,21.1 vs.9.7*,Weight gain,kg,3.5 vs.0.4*,0.0 vs.-1.0*,NA,ACCORD,ADVANCE,VADT,Major Cardiovascular Risk Factors,Cigarette smoking,Elevated blood pressure,Elevated serum total(and LDL)cholesterol,Low serum HDL cholesterol,Diabetes mellitus,Advancing age,14,A little bit of BP Reductions More Benefits,Meta-analysis of 61 prospective,observational studies,1 million adults,12.7 million person-years,7,Lewington S et al.,Lancet,2002;360:1903-1913,.,2 mm Hg decrease in mean SBP,10%reduction in risk of stroke mortality,7%reduction in risk of IHD mortality,15,Any,diabetes-,related,end point,Diabetes-,related,death,Stroke,Microvascular,end points,-12%,(,P,0.0001),-10%,(,P,=0.34),-25%,(,P,0.01),-25%,(,P,0.005),-32%,(,P,=0.019),-44%,(,P,=0.013),-37%,(,P,=0.009),Proper Control of Glucose and BP Improves Ou,tcomes,Microvascular,end points,Any,diabetes-,related,end point,Diabetes-,related,death,UKPDS Group 38.,BMJ.,1998;317:703,713.,UKPDS Group 33.,Lancet.,1998;352:837,853.,Glucose control,BP control,(144/82 vs 154/87 mm Hg),0,-10,-50,-20,-30,-40,16,Mei,M.Weber,2009 CCMR Symposium,2009,年,欧洲心脏病学会（,ESC,）和欧洲糖尿病研究学会（,ESAD,）联合发表了糖尿病、糖尿病前期与心血管疾病指南，制定了冠心病合并糖尿病诊疗流,程。,合并高血压的糖尿病患者心血管危险显著增加，降压治疗可有效降低危险，血压控制目标值为,130/80mmHg,。,为了理想控制血压，合并高血压糖尿病患者通常需联用数种降压药物，其中应包括抑制肾素,-,血管紧张素,-,醛固酮系统（,RAS,）药物。筛查微量白蛋白尿，并采用血管紧张素转换酶抑制剂（,ACEI,）和血管紧张素,受体抑制剂（,ARB,）等充分降压，可降低,1,型和,2,型糖尿病患者的微血管与大血管并发症发病率。,Major Cardiovascular Risk Factors,Cigarette smoking,Elevated blood pressure,Elevated serum total(and LDL)cholesterol,Low serum HDL cholesterol,Diabetes mellitus,Advancing age,19,Risk Ratios for Coronary Heart Disease,Ischemic Stroke,or Nonvascular Death by Quantile of Usual Lp(a)Level,JAMA.2009;302(4):412-423,6/18/2010,21,6/18/2010,22,2009,年,欧洲心脏病学会（,ESC,）和欧洲糖尿病研究学会（,ESAD,）联合发表了糖尿病、糖尿病前期与心血管疾病指南，制定了冠心病合并糖尿病诊疗流,程。,无论基线,LDL-C,水平如何，合并,CVD,的糖尿病患者均应开始他汀治疗，,LDL-C,目标值应,1.8,2.0 mmol/L,（,70,77 mg/dl,）。无,CVD,的,2,型糖尿病成人患者若总胆固醇,3.5 mmol/L,（,135 mg/dl,）应考虑他汀治疗，其目标为,LDL-C,降低,30%,40%,。,由于高,CVD,危险会伴随终生，建议所有年龄超过,40,岁的,1,型糖尿病患者应考虑他汀治疗。,18,39,岁的糖尿病患者（,1,型或,2,型）如果存在其他危险因素（如肾脏病变、血糖控制不佳、视网膜病变、高血压、高胆固醇血症、代谢综合征或早发血管疾病家族史）应考虑他汀治疗。,糖尿病患者如果他汀治疗后,LDL-C,达标但甘油三酯,2 mmol/L,（,177 mg/dl,），应加大他汀剂量，某些患者可考虑加用依折麦布、烟酸或贝特类药物。,Reduction in CHD Calculated by Framingham Algorithms in Hypertension,Nominal*Optimal*,Control of BP alone 19%37%,Control of lipids alone 27%62%,Control of BP+lipids 38%76%,*BP 45,*BP 60,Lopez,Franklin,Tang 9:436-443,24,Controlling 3Bs is Necessary,Controlling,Blood Pressure,Blood Glucose,and Blood Lipid,All 3Bs,Is Necessary for Effective Prevention of Cardiovascular Diseases in Diabetic Pat,全面管理和治疗策略,早期血糖干预,全面血压控制,血脂控制,三科协作共同掌控“三高”,谢谢！,