糖尿病患者低血糖与心血管疾病的关系

控制血糖是糖尿病治疗的首要目标,但在降糖过程中,难以避免的低血糖会减少降糖益处,甚至增加死亡风险.近年来研究发现,低血糖可以改变心血管系统神经内分泌和电生理、损害血管内皮,进而诱发糖尿病急性心血管事件或加快慢性并发症进程.低血糖的发生会抵消糖尿病患者一生高血糖治疗所带来的益处.现将低血糖与糖尿病患者心血管疾病的关系作一综述.     

糖尿病患者低血糖与心血管疾病的关系

控制血糖是糖尿病治疗的首要目标,但在降糖过程中,难以避免的低血糖会减少降糖益处,甚至增加死亡风险.近年来研究发现,低血糖可以改变心血管系统神经内分泌和电生理、损害血管内皮,进而诱发糖尿病急性心血管事件或加快慢性并发症进程.低血糖的发生会抵消糖尿病患者一生高血糖治疗所带来的益处.现将低血糖与糖尿病患者心血管疾病的关系作一综述.     

几招化解低血糖

应用降糖药物治疗糖尿病，尤其是磺脲类药物或胰岛素，低血糖是最大的威胁。轻度低血糖经进食甜食，可以很快恢复；严重的低血糖，若未能及时正确救治，会给机体带来严重的危害。一次降糖药物或胰岛素使用不当所造成的严重低血糖，可使糖尿病病友严格控制血糖所带来的益处付之东流。严重低血糖导致植物人或致死事件时有发生，切不可掉以轻心。     

低血糖的危害及防范——山东中医药大学附属医院内分泌科主任医师,教授,徐云生

低血糖是糖尿病患者常出现的一个症状,某些降糖药物如胰岛素、胰岛素促泌剂会增加患者发生低血糖的危险.低血糖发作可能导致心血管意外,心肌梗死、心律不齐、心肌缺血和自主神经系统功能异常,因此防范低血糖的发生是糖尿病患者需要注意的重要问题. 首先,来看一下低血糖的表现和危害.一般血糖低于2.8mmol/L即可诊为低血糖.临床上低血糖易反复发生,严重者可发生昏迷,有时可危及生命.其中2型糖尿病低血糖发生率较1型糖尿病低.     

分析强化降糖治疗对2型糖尿病合并冠心病患者不良心血管事件的影响

目的分析强化降糖治疗对2型糖尿病合并冠心病患者不良心血管事件的影响。方法随机选取本院于2013年1月~2016年2月期间收治的60例2型糖尿病合并冠心病患者,以血清平均糖化血红蛋白(HbAlc)水平为依据,分为强化降糖组(HbAlc6.5%)与标准降糖组(6.5%HbAlc7.5%),各30例,经1年随访,观察两组患者不良心血管事件(MACE)发生情况。结果对比不良心血管事件总发生率,强化降糖组显著低于标准降糖组(P0.05)。对比低血糖发生率,强化降糖组显著高于标准糖化组(P0.05)。结论针对2型糖尿病合并冠心病患者,强化降糖,可减少不良心血管事件,但易导致低血糖。     

降糖治疗预防心血管事件:怎样做得更好?

糖尿病与心血管疾病紧密相关,糖尿病患者心血管事件发生率显著增加,而约2/3的冠心病患者存在糖代谢异常,两者应进行双向筛查。降糖治疗可以显著减少微血管并发症,然而糖尿病患者致死、致残的主要原因是大血管并发症,强化血糖控制如何减少糖尿病心血管事件,仍无明确结论。推荐根据患者糖尿病病程、心血管并发症情况及低血糖风险等,设定个体化降糖治疗方案,同时进行生活方式改变,控制血压、血脂、肥胖等多重危险因素,以减少心血管事件。     

老年糖尿病胰岛素强化治疗方案的选择及安全性比较

强化胰岛素治疗是临床常用的控制血糖的方法,但老年糖尿病血糖波动大,低血糖发生率高.而强化降糖会导致低血糖.国内外研究表明~([1,2]),胰岛素类似物与普通人胰岛素比较,可减少发生低血糖的风险,但对于老年糖尿病的应用报道较少.本实验比较四种胰岛素强化降糖的方法,并应用动态血糖监测系统(CGMS)技术,观察老年糖尿病患者强化胰岛素治疗后24 h血糖谱变化和低血糖情况.     

应用动态血糖监测系统评价甘精胰岛素治疗老年糖尿病的优越性

老年糖尿病患者往往血糖控制不佳,严格控制血糖可延缓糖尿病的进程及减少或延缓糖尿病并发症的发生,但强化降糖会导致低血糖,影响患者的生活质量,甚至会危及生命.本实验采用动态血糖监测系统(CGMS),观察老年糖尿病患者应用甘精胰岛素(来得时)治疗24 h血糖变化和低血糖情况.     

胰岛素源性糖尿病低血糖症的临床识别及处理

Cryer在2005年曾讲一句对医生在制定治疗方案时很有影响的话:一次严重的医源性低血糖或因此诱发的心血管事件,可能会抵消一生维持血糖正常范围所带来的益处[2]。尽管略有的过刺激,但确实临床上医源性低血糖的发生,不是我们期望的!1糖尿病低血糖据中国2型糖尿病防治指南解释:糖尿病低血糖是专指糖尿病患者在使用药物治疗过程中发生的     

关注血糖达标与低血糖风险之间的平衡——谈糖尿病合并心血管疾病的降血糖治疗

糖尿病明显增加了心血管疾病的死亡率.出人意料的是更严格的血糖控制在某个大型临床试验中竟然增加了心血管病死亡,其间降糖治疗诱发的低血糖难辞其咎.为了减少低血糖的风险,在今后糖尿病合并心血管病患者的降糖治疗中至少有以下三点应予注意:(1)早期识别低血糖,包括不典型或表现怪异的低血糖;(2)强调血糖达标的个体化;(3)更精心地设计降糖治疗方案,特别要注意避免低血糖的发生.     

Hypoglycemia unawareness

Iatrogenic hypoglycemia is the limiting factor in the glycemic control of diabetes. It causes recurrent symptomatic and sometimes, at least temporally, disabling episodes in most people with type 1 diabetes, as well as in many with advanced type 2 diabetes. Furthermore, iatrogenic hypoglycemia precludes maintenance of euglycemia during the lifetime of a person with diabetes and thus full realization of the well established benefits of glycemic control. In this article I discuss the clinical problem of hypoglycemia in diabetes from the perspective of pathophysiology. First, the syndromes of defective glucose counterregulation and hypoglycemia without warning symptoms (known as hypoglycemia unawareness) are described, followed by the unifying concept of Hypoglycemia-Associated Autonomie Failure (HAAF). The concept of hypoglycemia-associated autonomie failure in diabetes posits that recurrent antecedent hypoglycemia causes both defective glucose counterregulation and hypoglycemia unawareness and thus leads to a vicious cycle of recurrent hypoglycemia and further impairment of glucose counterregulation. The clinical relevance of this phenomenon is now well established, but the mechanisms and mediators remain largely unknown. The short-term avoidance of hypoglycemia reverses hypoglycemia unawareness in most affected patients. The ultimate goal of lifelong maintenance of euglycemia in patients with diabetes remains elusive because of the pharmacokinetic imperfections of all current glucose-lowering therapies and the resulting barrier of hypoglycemia. Nonetheless, it is now possible both to improve the control of glycemia and to reduce the frequency of hypoglycemia in many people with diabetes. These results can be accomplished by recognizing the problem of hypoglycemia applying the principles of aggressive glycemic therapy and reducing the risk factors of hypoglycemia in people with diabetes.     

Hypoglycemia, diabetes, and cardiovascular disease

Cardiovascular disease (CVD) remains the leading cause of death in people with diabetes, and the risk of CVD for adults with diabetes is at least two to four times the risk in adults without diabetes. Complications of diabetes, including not only CVD but also microvascular diseases such as retinopathy and nephropathy, are a major health and financial burden. Diabetes is a disease of glucose intolerance, and so much of the research on complications has focused on the role of hyperglycemia. Clinical trials have clearly demonstrated the role of hyperglycemia in microvascular complications of diabetes, but there appears to be less evidence for as strong of a relationship between hyperglycemia and CVD in people with diabetes. Hypoglycemia has become a more pressing health concern as intensive glycemic control has become the standard of care in diabetes. Clinical trials of intensive glucose lowering in both type 1 and type 2 diabetes populations has resulted in significantly increased hypoglycemia, with no decrease in CVD during the trial period, although several studies have shown a reduction in CVD with extended follow-up. There is evidence that hypoglycemia may adversely affect cardiovascular risk in patients with diabetes, and this is one potential explanation for the lack of CVD prevention in trials of intensive glycemic control. Hypoglycemia causes a cascade of physiologic effects and may induce oxidative stress and cardiac arrhythmias, contribute to sudden cardiac death, and cause ischemic cerebral damage, presenting several potential mechanisms through which acute and chronic episodes of hypoglycemia may increase CVD risk. In this review, we examine the risk factors and prevalence of hypoglycemia in diabetes, review the evidence for an association of both acute and chronic hypoglycemia with CVD in adults with diabetes, and discuss potential mechanisms through which hypoglycemia may adversely affect cardiovascular risk.     

低血糖对心血管疾病预后的影响

糖尿病是心血管疾病的病因之一早已得到共识,在临床上,随着对患者血糖检测和控制不断地加强,低 血糖的发生也在增加,同时低血糖对心血管疾病的影响也引起了更多的关注.本文就低血糖以及血糖的强化控制对心血管疾病预后影响的有关研究进展做一综述,并且对其病理生理机制进行探讨.     

Economic burden of diabetes-related hypoglycemia on patients,payors, and employers

The economic and psychological consequences of diabetes-related hypoglycemic events are multifold and shared across various parties, including patients and their family or caregivers, payors, and employers. Hypoglycemic events contribute to increased morbidity, mortality, and a substantial portion of diabetes economic burden. Both severe and non-severe hypoglycemic episodes contribute to economic and psychological burden, and can have short-term consequences, such as emergency services, hospitalization, clinic visits, and increased use of diabetes supplies. Severe hypoglycemic events also generate additional follow-up costs, and are likely to occur again. Left untreated, hypoglycemia can have long-term consequences including, death, cardiovascular events, and cognitive issues. Costs vary geographically based on the treatment protocols which focus on outpatient treatment versus increased in-patient hospitalization. Certain types of medications are also associated with increased hypoglycemia, which requires closer monitoring of the patient, such as with basal insulin initiation. Some individuals with diabetes may be more vulnerable to hypoglycemia, such as the elderly, postoperative bariatric patients, and adolescent females. Measures to mitigate hypoglycemia are essential to ease the economic burden of these events. Medication management, optimal glucose control, lifestyle modifications and frequent glucose monitoring are some interventions which may help prevent hypoglycemia.     

Plötzlicher Herztod bei Diabetes mellitus

Sudden cardiac death (SCD) represents one of the most frequent causes of death in patients with diabetes. In contrast to patients without diabetes it has not been significantly reduced despite improvements in the treatment of acute myocardial infarction and long-term treatment of cardiovascular diseases as well as diabetes mellitus. Several mechanisms can be responsible for the high incidence of SCD in diabetics: 1. arrhythmogenic effects mediated via cardiac autonomic neuropathy, repolarization disturbances or sympathetic tone activation (hypoglycemia), 2. myocardial ischemia due to atherosclerosis, endothelial dysfunction, platelet aggregation or thrombophilic effects, 3. myocardial disease due to inflammation, fibrosis, associated hypertension or uremia and 4. potassium imbalance due to diabetic nephropathy or hypoglycemia. This review introduces concepts of mechanisms that are responsible for SCD in patients with diabetes. Treatment of patients with diabetes should primarily consider a systematic assessment of any deterioration of this chronic disease and of complications at an early stage. Cardiovascular drug treatment corresponds to that of non-diabetics. In antidiabetic treatment drugs with a low risk of hypoglycemia should be preferred. Treatment with implantable cardioverter defibrillators (ICD) also combined with cardiac resynchronization therapy () demonstrated a high life-saving potential particularly in patients with diabetes.     

低血糖对青年2型糖尿病患者心血管事件的影响

目的：探讨低血糖对青年2型糖尿病患者心血管事件的影响。方法：采用回顾性研究方法,2014年8月到2016年6月选择在我院内分泌科诊治的青年2型糖尿病患者360例,收集所有患者的病历资料与血压样本检测结果,记录低血糖发生情况与调查相关因素,随访心血管事件发生情况。结果：360例患者中发生低血糖20例,发生5.6%。根据2型糖尿病患者是否发生低血糖分为低血糖组(n=20)与对照组(n=340),两组的HDL-C、HbA1c、LDL-C、TG、TC值等对比无明显差异(P>0.05),不过低血糖组的SCr、CRP、CK值等都明显高于对照组(P<0.05)。通过采用Logistic回归分析发现,引起低血糖的主要因素为CRP、病程、CK以及年龄。所有患者随访6个月,低血糖组的不稳定性心绞痛、心力衰竭、靶血管血运重建、猝死等心血管事件发生率为40.0%,明显高于对照组的3.8%(P<0.05)。结论：青年2型糖尿病患者存在低血糖状况,主要发病因素包括年龄、病程、CRP、CK等,可导致心血管事件的增加,在临床上要积极进行预防性控制。     

Is There a Rationale for Insulin Therapy in Pre-Diabetic Individuals?

Type 2 diabetes mellitus is usually preceded by impaired glucose tolerance (IGT) and/or impaired fasting glucose (IFG), which are often referred to as pre-diabetes. Individuals with IGT demonstrate beta-cell dysfunction, insulin resistance, and increased hepatic glucose production; IGT and IFG are risk factors for both diabetes and cardiovascular disease. Type 2 diabetes is associated with micro- and macrovascular complications that lead to excessive mortality and morbidity and the risk of microvascular complications extends to people with pre-diabetes. Maintaining good glycemic control in type 2 diabetes can reduce the risk of developing chronic disease-associated complications. Most individuals who develop type 2 diabetes appear to pass through a stage of IFG or IGT; thus, early intervention (lifestyle and/or pharmacologic) in individuals with pre-diabetes may help prevent cardiovascular disease and the development of type 2 diabetes.The use of exogenous insulin treatment offers the potential to reduce the cardiovascular risk in individuals with type 2 diabetes or pre-diabetes through effective reductions in blood glucose and lipid levels, and in the associated tissue damage resulting from their chronic elevations. However, there are barriers associated with insulin initiation in both type 2 diabetes and pre-diabetes (e.g. hypoglycemia, weight gain, the possible unpredictable action of long-acting insulin, and the need for injections). Insulin glargine, with its flat time-action profile, near 24-hour duration of action, reduced risk of hypoglycemia, and improved glycemic control compared with insulin suspension isophane (neutral protamine hagedorn [NPH] insulin), may help to overcome some of these barriers.Initial results from a small study have indicated the feasibility of treating individuals with pre-diabetes to near-normoglycemia using a regimen of low-dose insulin glargine plus caloric restriction. This is being followed up in the ongoing ORIGIN (Outcomes Reduction with Initial Glargine INtervention) study, which will investigate whether treatment to near-normoglycemia with insulin glargine in individuals with IGT, IFG, or new-onset type 2 diabetes can reduce cardiovascular morbidity and mortality compared with conventional management of these conditions, and whether the rate of progression to type 2 diabetes can be similarly reduced.Further studies are needed to investigate the potential benefits of insulin therapy in individuals with pre-diabetes.     

Association of malignant insulinoma and type 2 diabetes mellitus: a case report

We report a case of recurrent hypoglycemia due to malignant insulinoma in a type 2 diabetic patient correctly controlled for years with the same doses of oral antidiabetic agents. A 79-year-old woman was admitted for recurrent severe hypoglycemia. She had a history of type 2 diabetes since 2000. HbA1c was 7.8% when she reported mild hypoglycemia and 5.8% when recurrent hypoglycemia appeared despite progressive diminution of glicazide. Severe hypoglycemia continued despite interrupting diabetes medications. At admission, results showed inappropriately elevated insulin, C-peptide and proinsulin levels despite significant hypoglycemia. CT scan showed "cystic" nodes in the pancreas and in the liver. Liver biopsy found a well-differentiated neuroendocrine carcinoma with positive staining for chromogranin A and negative staining for insulin. Hypoglycemia improved with diazoxide, lanreotide and dextrose infusion. Liver chemoembolization was planned. Severe edema, dyspnea, hyponatremia, and hypo-osmolarity occurred. The patient's clinical status deteriorated rapidly with severe cardiac, renal and hepatic failure. She died in a few days. Association of diabetes mellitus and insulinoma is extremely rare. Malignant insulinoma survival is less than two years, shorter when hepatic localizations are present at diagnosis. Association of diabetes with insulinoma delays the diagnosis, but does not alter prognosis or favor carcinoma frequency. Lanreotide was inefficient in our patient despite good responses described in the literature. Heart, respiratory and renal failures have been described with diazoxide independently of the doses; this may in part explain the rapid death. Insulinoma should be considered as a cause of unusual and recurrent hypoglycemia in a diabetic patient especially if it persists after interrupting antidiabetic agents.