血脂异常相关血管病变的剩留风险

随着糖尿病、肥胖、代谢综合征等代谢性高危因素的流行,心血管疾病的防治工作受到了前所未有的挑战。尽管当前的标准治疗能有效控制LDL-C、血压和血糖,但大血管事件和微血管并发症的剩留风险仍然在大多数患者中持续存在,这类患者的血脂异常表现为:TG升高、HDL-C水平较低,或同时伴随有载脂蛋白B和非HDL-C升高,被称为"致动脉粥样硬化性血脂异常",是导致大血管和微血管剩留风险的重要因素。血脂异常相关的剩留血管风险成了全球面临的共同挑战。     

PCI术后病人心血管剩留风险的影响因素研究

[目的]探索分析经皮冠状动脉介入治疗术后(PCI)心血管剩留风险的影响因素,降低剩留风险,减少PCI术后心血管事件的发生率。[方法]随机抽取某三级甲等医院2011年1月—12月PCI术病人462例,术后2年期间再发心血管事件病人121例,未发生心血管事件病人341例,回顾性研究分析两组资料,探讨PCI术后心血管剩留风险的相关因素。[结果]单因素分析两组在年龄、肥胖、糖尿病、高血压史、血脂异常、吸烟史、冠心病家族史、睡眠质量、负性情绪、定期随诊等方面差异有统计学意义(P0.05);多因素Logistic回归分析显示:糖尿病、高血压史、血脂异常、吸烟史、睡眠质量与PCI术后再发心血管事件有关(P0.05或P0.01)。[结论]为了降低术后心血管剩留风险,应早期警惕影响因素,加强对病人的健康知识宣教,实施综合性护理干预。     

老年冠心病疗养员血脂相关性心血管剩留风险调查分析

目的了解老年冠心病疗养员降脂药物治疗现状及血脂参数水平,评估该人群血脂相关性心血管剩留风险。方法共入选老年冠心病疗养员362例,收集降脂药物治疗情况并测量血清总胆固醇(TC)、三酰甘油(TG)、低密度脂蛋白胆固醇(LDL-C)、高密度脂蛋白胆固醇(HDL-C)等血脂参数,计算脂代谢异常发生率。结果老年冠心病疗养员中,单独服用他汀类药物者345例,单独服用贝特类药物者0例,联合服用他汀类及贝特类药物者17例。高胆固醇血症、高三酰甘油血症、高低密度脂蛋白胆固醇血症、低高密度脂蛋白胆固醇血症的患病率分别是9.94%(36/362)、18.23%(66/362)、5.80%(21/362)、16.57%(60/362)。结论老年冠心病疗养员存在不同程度的脂代谢异常,在关注强化降脂治疗的同时,应加强心血管剩留风险评估并进行干预,尽早、全面地纠正血脂异常,从而最大程度地降低老年冠心病疗养员心血管剩留风险。     

VAP(+)在心血管剩留风险相关血脂异常药物选择上的应用

心血管剩留风险是指在低密度脂蛋白胆固醇(LDL-C)水平通过他汀类药物治疗干预达标后,部分患者仍然面临发生心血管事件的风险。剩留风险与一系列致动脉粥样硬化(AS)的脂质紊乱密切相关,通常以高三酰甘油(TG)成分的脂蛋白(TRLs)上升为主,具体表现为高TG血症、低高密度脂蛋白胆固醇(HDL-C)水平、高脂蛋白残粒(RLP)和高小而密LDL颗粒(sd-LDL-P)水平等。但是,传统的临床实验室血脂项目大多无法直接检测出该型别的血脂异常,导致针对性地调脂用药缺少数据支持。美国VAP(+)血脂全套分析填补了这一空白,该检测方法通过垂直超速离心分离血浆脂蛋白,并使其连续与胆固醇试剂反应,获取每一组分的胆固醇含量、脂蛋白颗粒的型别和浓度。在了解患者剩留风险相关的血脂参数后,临床上有多种个性化的用药方案,包括贝特类、烟酸和胆固醇转移蛋白抑制剂等。已经有大量的临床试验发现这些药物单独或者与他汀类的联合使用与脑血管疾病(CVD)管理密切相关。因此,本文通过简要介绍利用VAP(+)检测剩留风险相关的脂质异常特点,再针对该风险的调脂药物的临床试验研究及应用的进展进行综述。     

他汀时代对高甘油三酯血症再认识

近年来,越来越多的证据表明降低低密度脂蛋白胆固醇可以减少心血管事件的发生,降低死亡率,但不容忽视的是,即使经标准治疗后低密度脂蛋白胆固醇达标,仍然存在发生大血管和微血管事件的风险（即心血管剩留风险）。我国成人高甘油三酯血症患病率高,与心血管疾病剩留风险关系密切,应该引起足够的重视。     

microRNAs:高密度脂蛋白胆固醇干预治疗心血管疾病的新靶标

正《中国心血管病报告2014》指出“心血管病已成为仅次于脑卒中危害我国居民健康的第2大病死原因,冠心病的发病率和病死率呈持续性增长趋势”。这一现状使心血管事件的“剩留风险问题”变得更为突出。“剩留风险问题”是低密度脂蛋白胆固醇(LDL-C)水平控制达标情况下,心血管事件再发生的临床实践问题。强化他汀类药物治疗能够进一步减低心血管事     

小儿血脂异常的临床诊疗

小儿血脂异常又称小儿血脂紊乱,主要是指儿童时期的高脂血症,包括血浆总胆固醇(TC)、甘油三酯(TG)、低密度脂蛋白(LDL-C)的升高,近年来把促进胆固醇从血管内清除的高密度脂蛋白(HDL-C)的减少也视为广义的高脂血症范畴。研究表明,小儿血脂异常与成人动脉粥样硬化(AS)密切相关,高脂血症可导致儿童时期发生血管内皮功能障碍、脂肪条纹和脂质沉积等AS早期病理改变,是成人心脑血管疾病的独立危险因素。此外,高脂血症还可引起糖尿病、脂肪     

2型糖尿病患者糖,脂代谢紊乱与血管并发症关系的临床研究

本文选择我院内分泌科住院的合并有血管并发症的 2型糖尿病患者 5 0例 ,其中大血管并发症 15例 ,微血管并发症 3 5例 ,与同期住院的 5 0例无血管并发症的 2型糖尿病患者进行配对分析。结果显示 :并发微血管组的空腹血糖 (FBG)、餐后 2小时血糖 (2BG) ,糖化血红蛋白 (HBA1C)、甘油三脂 (TG)、胆固醇 (TC)均明显高于无血管并发症组 ,P值分别 <0 0 1和 0 0 5 ;并发大血管组的HBA1C,TG ,TC均明显高于无血管并发症组P< 0 0 5 ,提示 :临床治疗的重点不仅要放在降低血糖上 ,而且不应忽视对血脂异常的治疗 ,这对防止 2型糖尿病变、微血管并发症具有重要的意义。     

MRI检测脂蛋白颗粒大小和浓度可预测女性2型糖尿病的发生

糖尿病患者血脂异常的特点为高密度脂蛋白胆固醇（HDL—C）水平降低和甘油三酯（TG）水平升高。美国Brigham女子医院预防医学系的一项前瞻性研究表明，磁共振波谱（MRS）检测到的脂蛋白颗粒大小及浓度与妇女2型糖尿病的发生风险相关，在校正目前已确定的风险因素（包括HDL—C和TG）后仍显著相关。     

健康体检人群中2型糖尿病血脂异常患者健康管理依从性研究

目的:对2型糖尿病血脂异常患者进行健康管理,对患者依从性的相关因素进行调查分析。方法:对120例2型糖尿病血脂异常患者进行健康管理12个月,观察健康管理前后2型糖尿病血脂异常患者血总胆固醇、甘油三酯、高密度脂蛋白胆固醇、低密度脂蛋白胆固醇的变化和患者依从性。结果:健康管理后患者血总胆固醇、甘油三酯、低密度脂蛋白胆固醇均低于干预前,高密度脂蛋白胆固醇高于干预前(P0.05),患者依从性高于干预前(P0.05)。结论:通过对2型糖尿病血脂异常患者进行健康管理,提高了患者的依从性,从而有效控制和延缓病情及并发症的发生发展。     

Lack of management of cardiovascular risk factors in type 2 diabetic patients

Effective management of diabetic patients includes comprehensive control for not only blood sugar, but also other cardiovascular risk factors. We assessed whether haemoglobin A1c (A1C) concentrations, blood pressure, low density lipoprotein (LDL) cholesterol levels and microalbuminuria were regularly measured in 281 patients with type 2 diabetes who received care for over 1 year in the Department of Family Medicine located in an urban area of Korea. Subsequently, in patients with A1C > 7%; blood pressure >130/80 mmHg; LDL cholesterol levels >100 mg/dl; or microalbuminuria, we evaluated the status of management for those cardiovascular risk factors. Physicians were most likely to measure A1C levels (98.6%), but less likely to measure microalbuminuria (56.2%), LDL cholesterol (73.7%), or blood pressure (74.4%). Patients whose A1C levels were above the goal (78.2%) were likely to receive optimal therapy. In contrast, only 21.1% of patients with uncontrolled blood pressure and 5.3% of patients with LDL cholesterol levels above the target range received optimal management. Of the 36 patients with microalbuminuria or overt proteinuria, 66.7% took angiotensin-converting enzyme inhibitors or angiotensin receptor blockers. Measurement of parameters indicating cardiovascular risk factors in type 2 diabetic patients was not optimal, particularly regular measurements for microalbuminuria and for controlling LDL-cholesterol and blood pressure. These findings indicate a need for greater education of comprehensive cardiovascular management in type 2 diabetic patients and their physicians.     

Impact of diabetes duration and cardiovascular risk factors on mortality in type 2 diabetes: the Hoorn Study

BACKGROUND: Several studies have reported differences in the mortality risk between diabetic subjects detected by screening and known diabetic patients. We studied mortality in relation to diabetes duration, and the contribution of other cardiovascular risk factors to the elevated risk. MATERIALS AND METHODS: Participants were type 2 diabetic subjects (n = 174) of a population-based cohort study. Of these, 95 were diagnosed by screening. Known diabetic subjects were grouped into two categories of diabetes duration, with a median duration of 2.4 and 11.2 years, respectively. We assessed the contribution of classical cardiovascular risk factors (dyslipidaemia, hypertension, and prior myocardial infarction), and of new cardiovascular risk factors (microalbuminuria, von Willebrand factor, sVCAM-1 and C-reactive protein) to the mortality risk during nearly 10 years of follow up. Cox's proportional hazards model was used to study the association of diabetes duration and mortality. RESULTS: The age- and sex-adjusted relative risks of mortality were 2.06 (95% C.I. 1.04-4.10) and 3.19 (1.64-6.20) for the patients with short- and long-term diabetes compared with the screening-detected diabetic subjects, respectively. Adjustment for cardiovascular risk factors resulted in a reduction of mortality risk in both groups: 1.13 (0.51-2.50) and 2.39 (1.18-4.83), respectively. Mortality risk significantly increased with increasing diabetes duration, even after multiple adjustment (P-value for trend ranged from < 0.001-0.018). CONCLUSIONS: Mortality risk increased with increasing diabetes duration. In subjects with short diabetes duration the mortality risk could largely be attributed to other risk factors. In subjects with a longer diabetes duration, however, the elevated mortality risk was independent of these cardiovascular risk factors.     

Bacteriuria and autonomic nerve function in diabetic women

Significant bacteriuria (viable count greater than or equal to 10(5)/ml) was found on single testing in 10% of 400 consecutive diabetic women aged 15-65 yr routinely attending a diabetic clinic. Twenty patients with and 21 without significant bacteriuria were then randomly selected for measurement of cardiovascular autonomic reflexes, bladder ultrasound, and mictiography. There were no significant differences between these two groups in age, duration and type of diabetes, glycosylated hemoglobin, blood urea, and creatinine. Abnormalities of cardiovascular autonomic function were more common in the bacteriuric group (P less than .01). Although the bacteriuric group voided a smaller volume of urine, none had evidence of increased residual bladder volume of urine on ultrasound. Diabetic women with cardiovascular autonomic neuropathy appear to be at increased risk of developing bacteriuria. However, age is probably the most important factor influencing the prevalence of bacteriuria in diabetic and in nondiabetic women.     

Diabetes and atherosclerosis

Atherosclerosis is the most important complication of diabetes and diabetes is an important risk factor for cardiovascular disease. Atherosclerosis develops more rapidly and at an earlier age in diabetic patients than in non-diabetic people. Although a number of cardiovascular risk factors are more common in diabetic than non diabetic people, these do not entirely account for the increased frequency of cardiovascular disease. The identity of the additional factor or factors which result in increased atherosclerosis in diabetes is unknown but attention should be paid to the role of glycated lipoproteins and of hyperinsulinaemia. In treating diabetic patients, attention should be paid to cardiovascular risk factors such as dyslipidaemia and hypertension as well as to the control of blood glucose.     

Coronary heart disease in patients with diabetes mellitus

Diabetes mellitus is a well-recognized risk-factor for coronary artery disease. It is known that diabetic patients have a two-to fourfold increased risk of mortality or morbidity for cardiovascular diseases compared with the general population. Further, many diabetic patients with coronary heart disease have severe diseased coronary arteries: multi-vessel disease and/or severe stenosed vessel(s). In Japan, the prevalence of diabetic patients is rapidly increasing in these days. This article will review the evaluation for risk of coronary heart disease by measuring glucose level, the prognosis of diabetic patients, and the prevention of cardiovascular event in the patients with diabetes mellitus.     

Improving antihypertensive therapy in patients with diabetic nephropathy

Nearly all patients with diabetic nephropathy have comorbid hypertension, which greatly elevates the risk for cardiovascular events. As patients are surviving longer, their risk of progressing to end-stage renal disease is increasing, particularly in patients with type 2 diabetes. Prevention of cardiovascular and renal events in this population requires diligent efforts to control blood pressure, serum glucose, and serum lipids. Improving antihypertensive therapy in patients with diabetic nephropathy relies on the following unified strategies: reducing blood pressure to <130/80 mm Hg, prescribing an agent that blocks the renin-angiotensin system, and designing an antihypertensive regimen that both reduces albuminuria and provides cardiovascular protection. A majority of patients will require three or more antihypertensive agents to achieve these objectives. Appropriate antihypertensive therapy in patients with diabetic nephropathy delays progression of renal disease and leads to substantial cost savings.     

Diabetes and glucose tolerance as risk factors for cardiovascular disease: the Framingham study

This report examines prospectively, in the Framingham cohort, the relation of diabetes and impaired glucose tolerance to each of the cardiovascular sequelae, taking into account age, sex, and associated cardiovascular risk factors. The incidence of cardiovascular disease, as well as the levels of cardiovascular risk factors, were found to be higher in diabetic than in nondiabetic men and women. The relative impact of diabetes on coronary heart disease, peripheral vascular disease, or stroke incidence was the same in men and women, but for cardiovascular mortality and cardiac failure the impact is greater for women. Present evidence suggests that alleviation of associated cardiovascular risk factors is the most promising course in reducing cardiovascular sequelae in diabetic patients.     

Improved survival of diabetic foot ulcer patients 1995-2008: possible impact of aggressive cardiovascular risk management

OBJECTIVE—The purpose of this study was to determine whether a strategy of aggressive cardiovascular risk management reduced the mortality associated with diabetic foot ulceration.RESEARCH DESIGN AND METHODS—After an initial audit of outcomes demonstrating a high mortality rate in 404 diabetic foot ulcer patients with the first ulceration developing between 1995 and 1999, a new aggressive cardiovascular risk policy was introduced as standard practice at the Diabetic Foot Clinic, Royal Infirmary of Edinburgh, in 2001. In the first 3 years of this policy, 251 patients were screened and identified. The audit cycle was then closed by reauditing the 5-year mortality for this second group of foot ulcer patients in 2008.RESULTS—Overall 5-year mortality was reduced from 48.0% in cohort 1 to 26.8% in cohort 2 (P < 0.001). Improvement in survival was seen for both neuroischemic patients (5-year mortality of 58% reduced to 36%; relative reduction 38%) and neuropathic patients (36% reduction to 19%; relative reduction 47%) (both P < 0.001). Patients were more likely to die if they were older at the time of ulceration or had type 2 diabetes, renal impairment, or preexisting cardiovascular disease or were already taking aspirin. Prior statin use, current smoker or ex-smoker status, blood pressure, A1C, and total cholesterol were not significantly different between survivors and those who died in the follow-up periods.CONCLUSIONS—Diabetic foot ulcer patients have a high risk of death. Survival has improved over the past 13 years. The adoption of an aggressive cardiovascular risk management policy in diabetic foot ulcer clinics is recommended for these patients.Lower limb amputation in diabetic patients is associated with significant excess mortality (1). Foot ulceration is also believed to be associated with increased deaths due to related cardiovascular disease (2,3). In addition, patients with foot ulceration often have advanced diabetes complications (4). Cardiovascular risk reduction has, over the last 10 years, become a major part of diabetes care, particularly for type 2 diabetic patients. However, it has only been since 2004 that the U.K. General Medical Services contract has made the treatment of cardiovascular risk a renumerated part of diabetes management in primary care (5). This initiative is driven by target A1C, blood pressure, and cholesterol levels rather than absolute or calculated risk as in the past and has increased prescribing of therapies aimed to reduce cardiovascular risk (6). Patients without established risk factors might not receive adequate treatment if their values are not above the target.It is likely that the peripheral arterial disease and microvascular sclerosis associated with diabetic foot ulceration will reflect established arterial disease elsewhere in the body (3). Therefore, cardiovascular risk factor intervention might be expected to be effective in this setting. However, there are no studies of aggressive risk factor modification in patients with diabetic foot ulcer patients to determine whether such a strategy improves survival.     

Microalbuminuria. Implications for micro- and macrovascular disease.

Microalbuminuria is diagnosed when the UAER is greater than 20 but less than 200 micrograms/min. The prevalence of microalbuminuria among diabetic patients is 15-20%. Persistent microalbuminuria in diabetic patients is a risk marker not only of renal disease, but also of proliferative retinopathy and cardiovascular morbidity and mortality. Even among nondiabetic individuals, those with microalbuminuria tend to have an increased cardiovascular morbidity. The established cardiovascular risk factors, such as smoking, elevated plasma cholesterol, fibrinogen, and hypertension, are seen more frequently in diabetic patients with persistent microalbuminuria than in normoalbuminuric diabetic patients of similar age, sex, and diabetes duration. However, these risk factors cannot by themselves explain the cardiovascular overmortality in these patients. In addition, insulin resistance or genetic disposition to hypertension or cardiovascular disease fails to be the missing link. Accumulating evidence suggests a common pathogenetic mechanism for microalbuminuria and premature atherosclerosis (i.e., qualitative alterations of the extracellular matrix, including decreased density and sulfation of HS-PG). Decreased density of HS in the glomeruli may lead to albuminuria and mesangial proliferation. In the intima of large vessel walls, decreased density and/or sulfation of HS may enhance several of the processes involved in premature atherosclerosis. Diabetes affects the composition and structure of the extracellular matrix in many ways and leads to decreased density and sulfation of HS-PG by several mechanisms. Genetic differences in the sulfation of HS and/or genetic defects in the coordinated biosynthesis of HS-PG might contribute to decreased concentration and sulfation of HS-PG in susceptible individuals. It is hoped that susceptibility genes can be identified soon, thereby making prevention of severe late diabetic complications more successful.     

In diabetes, treat hidden heart disease

Both diabetic and prediabetic patients have abnormal vascular reactivity and should be considered to have occult cardiovascular disease. Angiotensin-converting-enzyme (ACE) inhibitors are particularly beneficial in diabetes because they reduce the incidence of both cardiovascular events and diabetes-related complications. In prediabetic patients, ACE inhibitors also reduce the risk of a new diagnosis of type 2 diabetes. Managing hypertension is even more beneficial for diabetic patients than for nondiabetic patients. To further reduce the risk of heart disease in patients with diabetes or prediabetes, dyslipidemia should also be treated aggressively.