糖尿病心血管疾病的非降脂治疗与临床评价课件.ppt

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 TransplantH

2、olley 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 ischemia or infarctionn Peripheral or carotid occlusive art

3、erial 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 premature CAD -Positive micro/macroalbuminurianHypertensive

4、CardiomyopathynDiabetic CardiomyopathynAutonomic CardiomyopathynRenal InsufficiencynMicrovascular DysfunctionnImplement more aggressive CHD prevention regimennInitiate anti-ischemic medicationsnIdentify patients who would benefit from revascularizationnEducate patients to recognize coronary symptoms

5、020406080100120140160180Kannel 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/1,00024503877591199017415312348367456113No Glucose IntoleranceGlucose IntoleranceNo Gluco

6、se 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 eventsIntensive%Decrease(rate/1000 pt yrs)PConventionalEndpoint

7、sUKPDS 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 diabetes-related endpointDiabetes-related deathsHeart failureStrokeMy

8、ocardial 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-related endpointDiabetes-related deathsAll-cause mortalityMyocardial infarc

9、tionStrokeMicrovascular1.101.271.141.201.121.290.430.280.440.350.740.30UKPDS Group.BMJ 1998;317:713-720.010203040506070PlaceboEvents/1000 Pt-YearsTuomilehto J et al.NEJM 1999;340:677-684.Active RxPlaceboActive RxDiabetic PatientsNondiabetic Patients051015202530Major CV EventsMIEvents/1000 Pt-YearsHa

10、nsson 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;GISSI=Grupo Italiano per lo Studio d

11、ella 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 al.Am J Cardiol 1998;82:20R-22R;Hansson L et al.

12、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-EurHOTUKPDSCAPPP583/47362790/18,131492/46951501/18,7901148572/10,985BeneficialBeneficialBeneficialBeneficialBeneficialBeneficialHope Study Investigators.NEJM 200

13、0;342:145-153.0510152025Placebo%of PatientsRamiprilPlaceboRamiprilDiabetic PatientsNondiabetic PatientsThompson SG.N Engl J Med 1995;332:635-641.01234567FibrinogenLowerMiddleHigherHigherMiddleLowerTotal CholesterolRisk of Coronary Events(%)4/3069/26110/2825/3113/24710/28111/26616/30421/305Harpaz D e

14、t 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(%)DiabetesAntiplatelet TherapyControlNo DiabetesP0.002P0.00001Malmberg K et al.BMJ

15、 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=133n=139n=314n=3060.00.10.20.30.40.5YearsGustafsson I et al.J Am Coll Ca

16、rdiol 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(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(

17、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 Cardiol 1996;28:1661-1669.2.72.12.42.0012345Odds Ratio for 30-Day MortalityDiabetes vs no d

18、iabetes(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-PTCADM-CABGNon DM-CABGNon DM-PTCAFollow-up(years)0.250.180.080.07123450.00.20.40.60.81.00.00.20.

19、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 Cardiol 2000;35:1122-1129.%Survival01345726Years020406080100%Survival01345726020406080100%Survival01345726

20、p=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.%SurvivalYears after Randomization020406080100%Survival020406080100%Survivalp=0.40p=0.71p=0.23CABG(n=194)PTCA(n=198)CABG

21、(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(%)Angiographic 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

22、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 Occlusion()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

23、-79.Months Post PTCA024681012Year19941995199619971997199619951994N305425480288%Stent17.424.941.055.5Lincoff AM et al.N Engl J Med 1999;341:319-327.Days after Randomization05101520Stent+PlaceboStent+AbciximabAngioplasty+Abciximab0309012018060150Incidence of repeated TVR at 6 mos.(%)Days after Randomi

24、zation051015200309012018060150Incidence of repeated TVR at 6 mos.(%)18.4%16.6%8.1%14.6%Stent+PlaceboStent+AbciximabAngioplasty+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

25、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 acute coronary syndromes

26、nuse medications proven to dramatically improve outcomes in acute MI(beta blockers,ACE inhibitors,aspirin,IIb/IIIa platelet inhibitors,statins)nAdditional clinical trials are needed to evaluate cardiovascular therapeutic interventions in diabetic patients,because certain therapies may produce different results in the presence of diabetes演讲完毕，谢谢观看！Thank you for reading!In order to facilitate learning and use,the content of this document can be modified,adjusted and printed at will after downloading.Welcome to download!汇报人：XXX 汇报日期：20XX年10月10日