心血管疾病与糖调节异常(4)冠心病患者的血糖管理(续3)

糖尿病是冠心病重要的危险因素,并于2004年被美国心脏病学会正式定义为冠心病的等危症.糖尿病可以使冠心痛的发病率增加2～3倍,对于严重的糖尿病患者如果遭遇心肌缺血的打击,其更加容易发生心力衰竭和死亡,一系列研究显示糖尿病患者发生急性心肌梗死后,将有20%～35%合并心力衰竭,相对于非糖尿病患者发生率增加2～4倍.随着研究的深入学术界已经共同认识到冠心病合并糖尿病问题的严重性,而我国临床实践中对于冠心病患者的血糖管理目前也需要统一的认识和规范,治疗的靶点和目标均不统一,本文将就上述问题结合欧美心血管疾病和糖尿病联合指南提出建议.     

他汀类药物在糖尿病心血管疾病防治中的作用

糖尿病是目前危害人类健康的主要疾病之一，大血管疾病并发症是糖尿病患者的主要死因，近80％的糖尿病患者死于心血管疾病。糖尿病人群的心血管病死亡率至少是普通人群的2～3倍。单纯糖尿病患者10年内发生心肌梗死或冠状动脉（冠脉）疾病死亡的危险性与陈旧性心肌梗死患者相当：且糖尿病患者发生急性心肌梗死的近期和远期预后较非糖尿病者差。为此．美国胆固醇教育计划（NCEP）成人治疗组第3次指南（ATPⅢ）中，明确将糖尿病视为冠心病等危症，并主张对糖尿病患者进行积极的降脂治疗。     

糖尿病患者无症状心肌缺血的检出

英国糖尿病（DM）前瞻性研究（UKPDS）及随后的研究发现．DM患者发生心肌梗死与有心肌梗死病史的非DM患者再梗死的机会相当，是冠心病的等危症。DM是引发心血管疾病的强危险因素，Framingham研究随访20年发现，DM患者发生心脑血管疾病（冠心病、间歇跛行、脑梗死）的比例显著高于非DM者。DM血管病变致心血管病及卒中是其主要死因．占总死亡的65％～80％．比非DM者高2～4倍；致心力衰竭（心衰）在男性增加2倍、女性增加5倍^[1]。近年，2型DM已成为我国常见病，且发病率增长迅速，据估计，到2025年我国DM患者将从目前约2千万人猛增到超过4千万人。可见，对2型DM患者的心血管疾病的早期防控势在必行。     

糖尿病合并冠心病患者的介入治疗

糖尿病患者发生冠心病的机会是非糖尿病者的2～3倍，常见的有心脏扩大、心力衰竭、心律失常、心绞痛、心肌梗死等。糖尿病患者中冠心病发病率增高的原因尚不十分清楚，但糖尿病容易引起动脉粥样硬化已被公认。糖尿病患者并发冠心病时，冠心病的某些临床症状出现得较迟或被掩盖，更应引起重视。     

糖尿病离心肌梗死有多远？

1糖尿病患者发生心肌梗死的危险是非糖尿病患者的2～3倍 可能有的患者想知道，相对于非糖尿病人群，糖尿病患者是不是更容易发生心肌梗死呢？实际情况确实如此。多项临床研究资料表明，2型糖尿病患者冠心病的死亡率是普通人群的1．5～3倍。糖尿病患者发生心肌梗死的危险是非糖尿病患者的2～3倍。     

糖尿病患者常见的无症状性心肌缺血

冠心病是糖尿病的主要并发症和死亡原因。据资料显示,糖尿病患者中的冠心病发病率比同年龄、同性别的非糖尿病患者高2倍(男性)至4倍(女性)。约43%～50%的糖尿病患者合并冠心病,且急性心肌梗死时的死亡率比非糖尿病患者高2～3倍。     

糖尿病无症状性心肌缺血的临床特点及诊治原则

冠心病是糖尿病（DM）的重要并发症，约43％～50％的糖尿病患者合并冠心病，合并急性心肌梗死（AMI）的病死率较非糖尿病高2～3倍。而糖尿病合并心肌缺血时以无症状性常见，且AMI、猝死等发生率高。故对糖尿病无症状性心肌缺血（SMI）进行全面了解有重要意义。     

糖尿病患者急性心肌梗死的临床特点

目的　分析糖尿病患者急性心肌梗死的临床特点及临床治疗经验。方法　取糖尿病和非糖尿病各 5 2例合并急性心肌梗死的病人 ,对比分析其临床症状、体征 ,以及并发症等表现。结果　糖尿病组病死率为非糖尿病组的 2 .5 7倍 ,糖尿病组发生心肌梗死时以无痛型为多 ,并发症中心力衰竭、心律失常、猝死等明显高于非糖尿病组。结论　对糖尿病人应严格控制血糖 ,合并心肌梗死时须给予充分的重视和及时处理。     

阿司匹林在糖尿病心血管病变防治中的作用——证据与争议

心血管事件是糖尿病患者主要的致死、致残原因,糖尿病患者心肌梗死和卒中的风险增加2～4倍。在欧美国家,50％以上的2型糖尿病患者死于心血管疾病。在亚洲-太平洋地区,约1／3的糖尿病患者死于心血管疾病。在香港,中老年2型糖尿病患者（平均年龄57岁）在随访5．4年后,4．97％发生了冠心病。糖尿病诊断10年后死亡原因的排序分别是：肿瘤（20％）、冠心病（20％）、终末期肾病（10％）、卒中（10％）。     

综合治疗，全面达标，是预防心血管并发症的关键

大家都知道，糖尿病不可怕，可怕的是其并发症。国外资料表明，60％～80％的糖尿病人死于心血管并发症。糖尿病患者心血管疾病的风险明显增加，冠心病的患病率和病死率、心肌梗死率、中风等的发病率大都是非糖尿病人群的2～4倍。     

Diabetes and heart failure in the post-myocardial infarction patient

Diabetes mellitus, a disease which is increasing in prevalence, is a major risk factor for coronary heart disease. In patients following acute myocardial infarction, the presence of diabetes is a powerful risk factor for the development of heart failure, and this intersection of heart failure and diabetes following myocardial infarction carries substantial risk. The poor prognosis associated with heart failure in diabetic patients following myocardial infarction is likely multifactorial. Aggressive strategies for prevention and treatment of heart failure are crucial to reducing the risk associated with diabetes and heart failure following myocardial infarction. This review summarizes epidemiologic, pathophysiologic, and therapeutic data related to diabetes and heart failure in the post-myocardial infarction setting.     

Rationale for a metabolic approach in diabetic coronary patients

The incidence of ischaemic heart disease and acute myocardial infarction are greater in people with diabetes than in nondiabetic individuals. Heart disease patients with diabetes have a higher incidence of mortality during and following an acute myocardial infarction and a high risk for progression to heart failure post-infarction. The greater occurrence of ischaemic heart disease is partially due to a poorer coronary artery disease risk factor profile in diabetic patients, and, importantly, due to diabetes-induced abnormalities in the myocardium, termed 'diabetic cardiomyopathy'. The main metabolic abnormalities in the diabetic myocardium are impaired carbohydrate metabolism, specifically reduced pyruvate oxidation in the mitochondria and a greater reliance on fatty acids and ketone bodies as fuels. The healthy heart takes up glucose and lactate and converts them to pyruvate; however, in the diabetic heart there is a reduced capacity to oxidize pyruvate, and thus less glucose and lactate uptake. The defective metabolism is due to high circulating free fatty acids and ketone body concentrations in the plasma, resulting in greater acetyl-Co-enzyme A/Co-enzyme A and reduced nicotinamide adenonine dinucleotide/nicotinamide adenonine dinucleotide+ ratios in the mitochondria, and the subsequent inhibition of pyruvate dehydrogenase. Pharmacological inhibition of fatty acid oxidation during ischaemia increases myocardial pyruvate oxidation and provides clinical benefit to patients with stable angina or ischaemic left ventricular dysfunction. Recent clinical trials with trimetazidine, an inhibitor of the fatty acid beta-oxidation enzyme long chain 3-ketoacylthiolase, showed improvement in cardiac function and exercise performance in diabetic patients with ischaemic heart disease, illustrating the effectiveness of this approach in diabetes.     

Depression and risk of heart failure among older persons with isolated systolic hypertension

BACKGROUND: Investigators have shown that depression is associated with an increased risk of coronary heart disease in general and myocardial infarction in particular. However, it is unknown whether depression, independent of its association with myocardial infarction, is a risk factor for heart failure. METHODS: This study examined whether depression was a predictor of incident heart failure among 4538 persons aged 60 years and older with isolated systolic hypertension who were enrolled in the Systolic Hypertension in the Elderly Program (SHEP). Depression was defined as a score of 16 or more at baseline on the Center for Epidemiological Studies Depression Scale (CES-D). The relationship between depression and heart failure was assessed using Cox proportional hazards regression. RESULTS: The average follow-up was 4.5 years. Heart failure developed in 138 (3.2%) of 4317 nondepressed persons and in 18 (8.1%) of 221 depressed persons. After controlling for age; sex; race; history of myocardial infarction, diabetes, or angina; blood pressure; cholesterol levels; electrocardiographic abnormalities; smoking; disability; and SHEP treatment group, depressed persons had more than a 2-fold higher risk of developing heart failure compared with nondepressed persons (hazard ratio, 2.59; 95% confidence interval, 1.57-4.27; P<.001). After additional adjustment for the occurrence of myocardial infarction during follow-up, depressed persons remained at elevated risk of heart failure (hazard ratio, 2.82; 95% confidence interval, 1.71-4.67; P<.001). CONCLUSIONS: Depression is independently associated with a substantial increase in the risk of heart failure among older persons with isolated systolic hypertension. This association does not appear to be mediated by myocardial infarction.     

The risk factors for ischemic heart disease in young adults

We reviewed the histories and laboratory data of 67 young patients with ischemic heart disease under the age of 40 years. Twenty-three cases were associated with hypercholesterolemia. Of these, 10 were of the familial type. Twenty patients had hypertension, while 14 were diabetics and 13 were heavy smokers. It is noteworthy that 13 of 17 patients with multi-vessel disease and hypercholesterolemia. Significant atherosclerotic coronary stenosis was demonstrated in 51 cases. The incidences of hypercholesterolemia, hypertension and diabetes mellitus in these 51 patients were not only significantly higher than those in age-matched normal health subjects and young patients with non-ischemic heart disease, but also higher than those in patients with ischemic heart disease over the age of 40 years. The results indicated that hypercholesterolemia is the most important risk factor for ischemic heart disease in young patients, although the three previously accepted risk factors (hypertension, diabetes mellitus and cigarette smoking) were all associated with the development of the disease. We could not find any obvious risk factor in 18 young patients with ischemic heart disease, including 12 cases of myocardial infarction. Myocardial infarction in the absence of any obvious risk factor occurred during strenuous physical exercise in 5 patients and following excessive alcohol consumption in 4.     

职业紧张与心肌梗死的相关性研究

目的探讨职业紧张与心肌梗死的相关性。方法共调查260例患者,其中心肌梗死164例,非冠心病96例。利用付出-回报失衡问卷评价患者的职业紧张水平,同时收集患者其他冠心病危险因素,结合临床表现和冠状动脉造影结果明确患者冠心病的诊断。采用病例对照研究方法,进行多因素分析。结果高外在付出、高付出-回报失衡、高内在投入均增加心肌梗死的患病危险,调整年龄、性别、高血压病、高脂血症、糖尿病、早发冠心病家族史、吸烟、体质量指数、教育程度和婚姻等混杂因素后的OR值分别为2.4(95%CI 1.2~5.2)、2.8(95%CI 1.3~6.1)2、.7(95%CI 1.2~5.8),若高付出-回报失衡和高内在投入同时存在时,调整后OR为4.9(95%CI 1.7~14.2)。职业紧张对心肌梗死的影响存在剂量反应关系,职业紧张程度越高,心肌梗死的患病危险越高。结论职业紧张增加心肌梗死的患病危险,很可能是冠心病一个潜在的重要危险因素。     

Glucose abnormalities and heart failure predict poor prognosis in the population-based Reykjavík Study.

BACKGROUND: The risk of cardiovascular disease increases progressively with increasing blood glucose from levels well below the diabetic threshold. In the Reykjavík Study the relationship between heart failure and abnormal glucose regulation was already apparent at the level of impaired glucose tolerance. The aim of this study was to determine the prognosis of participants with any glucose abnormality and heart failure and to test whether the combination of these conditions may adversely affect the subsequent prognosis. DESIGN: A prospective population-based study. METHODS: Data from the first visit of 19 381 participants were used. Participants were divided into groups according to their glycaemic and heart failure level, and comparisons were made between the groups and disease-free participants serving as a reference group. The risk of mortality and morbidity was calculated with adjustments for main cardiovascular risk factors and ischaemic heart disease. RESULTS: Participants in the reference group were younger, had lower body mass indices and more seldom a history of myocardial infarction compared with diseased groups. Mortality was lowest in the reference group (P<0.0001) increasing to a maximum in participants with the combination of glucose abnormality and heart failure. Prognostically, the mortality risk associated with abnormal glucose regulation was increased but was lower than the risk of diabetes. The risk of a new myocardial infarction was highest in participants with diabetes [hazard ratio (HR) 1.6; 95% confidence interval (CI) 1.3-2.0] or diabetes in combination with heart failure (HR 1.8; CI 1.1-2.7). CONCLUSIONS: Heart failure or glucose abnormalities are related to increased morbidity and mortality. The combination of glucose abnormality and heart failure did, however, not add further to the unfavourable prognosis in the presence of ischaemic heart disease.     

Diabetes mellitus as a risk factor for acute myocardial infarction in Asians and Europeans

Ischaemic heart disease is commoner among immigrants from the Indian subcontinent than among Europeans in the United Kingdom. The excess cannot be accounted for by differences in smoking, blood pressure, or lipid concentrations. There is, however, an increased prevalence of diabetes mellitus in the Asian population. Separate estimates of the relative risk of acute myocardial infarction associated with diabetes from parallel case-control studies were made to compare the importance of diabetes as a risk factor in the two ethnic groups. For Asians the relative risk was 3.3 (95% confidence interval 1.9 to 5.8) and for Europeans 1.3 (1.0 to 1.7). Calculations of population attributable risk indicated that clinical diabetes mellitus accounts for 21% of the incidence of myocardial infarction in Asians but only 3% of the incidence in Europeans. Diabetes mellitus is of sufficient quantitative importance as a risk factor to account for the whole of the observed excess of deaths from ischaemic heart disease among Asians in the United Kingdom.     

Prevalence of Heart Disease Demonstrated in 60 Years of the Arquivos Brasileiros de Cardiologia

Considering the historical and academic relevance of the Brazilian Archives of Cardiology (ABC), as its MEDLINE indexing began in 1950, it was assumed as a hypothesis that the analysis of the publications over the last 60 years could reflect the changing trends of heart disease in Brazil.The study data were collected using a program developed for this purpose, allowing the automatic extraction of information from the MEDLINE database. The study information were collected by searching "Brazilian Archives of Cardiology AND selected parameter in English". Four observational groups were determined: (1) major groups of heart diseases (coronary artery disease, valvular heart disease, congenital heart disease and cardiomyopathies); (2) relevant diseases in clinical practice (cardiac arrhythmias, cor pulmonale, myocardial infarction and congestive heart failure); (3) cardiovascular risk factors (hypertension, diabetes, dyslipidemia and atherosclerosis); and (4) group determined due to the growing trend of publications on congestive heart failure seen in previous groups (congestive heart failure, myocardial infarction, rheumatic heart disease and Chagasic heart disease)All publications within the established groups were described, highlighting the increasing importance of heart failure and diabetes as risk factors. A relatively easy search was carried out, using the computer program developed for literature search covering six decades. Emphasizing the limitations of the study, we suggest the existence of an epidemiological link between cardiac diseases that are prevalent in Brazil and the publications of the Brazilian Archives of Cardiology.     

Diabetes mellitus as a risk factor for acute myocardial infarction in Asians and Europeans.

Ischaemic heart disease is commoner among immigrants from the Indian subcontinent than among Europeans in the United Kingdom. The excess cannot be accounted for by differences in smoking, blood pressure, or lipid concentrations. There is, however, an increased prevalence of diabetes mellitus in the Asian population. Separate estimates of the relative risk of acute myocardial infarction associated with diabetes from parallel case-control studies were made to compare the importance of diabetes as a risk factor in the two ethnic groups. For Asians the relative risk was 3.3 (95% confidence interval 1.9 to 5.8) and for Europeans 1.3 (1.0 to 1.7). Calculations of population attributable risk indicated that clinical diabetes mellitus accounts for 21% of the incidence of myocardial infarction in Asians but only 3% of the incidence in Europeans. Diabetes mellitus is of sufficient quantitative importance as a risk factor to account for the whole of the observed excess of deaths from ischaemic heart disease among Asians in the United Kingdom.     

Heart failure and diabetes: left ventricular systolic function

AIM: Heart failure is the main cause of mortality and morbidity in general population, annual mortality rate is 20%, in spite of pharmacological treatments or other therapies. Cardio-vascular events and diabetes tight correlation is well known, while it is less evaluated diabetes and heart failure correlation is less studied, heart failure as left ventricular systolic function impairment. Cardiovascular disease rate is decreasing, systolic heart failure rate is raising. Our study goal is to evaluate which role diabetes plays in determining systolic heart failure, diagnosed by echocardiographical examination. METHODS: Four hundred and fifty consecutive patients, systolic heart failure prone, diagnosed by left ventricular ejection fraction less than 40%, were included. Exclusion criteria were rheumatic or congenital valve diseases. Mean age was 78.3 years (53-93 years), 286 were women and 164 men. Statistical analysis were performed by parametric t-Student test and not parametric chi2 test. High significant difference was assessed for P<0.05. RESULTS: Seventy six (16.9%) patients were diabetes prone (D), 374 (83.1%) were diabetes free, so not diabetic (ND). Forty three men were D (56.5%), 131 ND (35%). Diabetic mean age was 74.7 years (52-88), not diabetic was 79.3 (53-93). Six D (7.8%) and 21 ND patients (5.6%) were hypercholesterolemia prone. Eight D (10.5%) and 18 ND (10.1%) patients were smokers. Twenty eight D (36.8%) and 107 ND patients (28.6%) were hypertensive. Thirty three D (43.4%) and 88 ND (26.4%) patients were coronary artery disease prone, 3 of 33 (3.9%) D and 28 of 88 (7.4%) ND ischemic patients were myocardial infarction prone. Twenty one D (27.6%) and 106 ND (28.3%) patients were atrial fibrillation prone. There were not statistical significant difference among D and ND patients for following variables: sex, smoke, total cholesterolemia, hypertension and atrial fibrillation. We found an high significant difference for mean age (P<0.005) and coronary artery disease prone patients (P<0.007), but not for myocardial infarction prone subjects (P<0.1). CONCLUSIONS: Diabetes, not depending by other common cardiovascular risk factors, causes systolic heart failure, in prone patients, on an younger age, and in the same time an higher coronary artery disease rate, but not an higher myocardial infarction rate, because the coronary artery disease is often a microvascular one, and it leads to heart failure rather than myocardial necrosis.