社区2型糖尿病患者心脏自主神经病变发生情况及其分级的影响因素研究

背景　心脏自主神经病变（CAN）是糖尿病的严重并发症之一，可导致无痛性心肌梗死、恶性心律失常甚至心源性猝死，同时可导致患者心血管死亡风险升高约5倍，但目前尚缺乏关于我国社区2型糖尿病患者CAN患病情况的研究报道。目的　探讨社区2型糖尿病患者CAN发生情况及其分级的影响因素。方法　采用Excel表进行随机抽样，从2018-11-01至2018-12-31在北京市西城区什刹海社区卫生服务中心6个站点（爱民街站、鼓楼站、百米站、德内站、西四站、柳荫街站）进行糖尿病足和糖尿病肾病筛查的2 751例2型糖尿病患者中抽取300例作为研究对象，通过面对面问卷调查、详细病史询问和体格检查收集相关临床资料，并采用Ewing试验进行CAN筛查；社区2型糖尿病患者CAN分级的影响因素分析采用有序多分类Logistic回归分析。结果　最终共纳入136例患者，其中无CAN（0级）15例（11.0%），亚临床CAN（1级）38例（28.0%），临床CAN（2级）57例（41.9%），严重CAN（3级）26例（19.1%）。不同CAN分级社区2型糖尿病患者性别、卧位舒张压、吸烟史、高血压发生率、脑血管病发生率、慢性肾脏病发生率、低密度脂蛋白胆固醇（LDL-C）、口服甲钴胺及B族维生素情况比较，差异无统计学意义（P>0.05）；不同CAN分级社区2型糖尿病患者年龄、体质指数、2型糖尿病病程、卧位收缩压、冠心病发生率、周围神经病变发生率、空腹血糖、糖化血红蛋白（HbA1c）、高密度脂蛋白胆固醇（HDL-C）、口服二甲双胍情况比较，差异有统计学意义（P<0.05）。有序多分类Logistic回归分析结果显示，年龄〔OR=6.878，95%CI（3.003，15.753）〕、2型糖尿病病程〔OR=4.422，95%CI（2.048，9.546）〕、周围神经病变〔OR=2.830，95%CI（1.315，6.090）〕是社区2型糖尿病患者CAN分级的影响因素（P<0.05）。结论　社区2型糖尿病患者CAN发生率（61.0%）较高，而年龄、2型糖尿病病程、周围神经病变是社区2型糖尿病患者CAN分级的影响因素，应加以关注。

Prevalence and Factors Associated with Grading of Cardiac Autonomic Neuropathy in Community-dwelling Patients with Type 2 Diabetes Mellitus

Background　As one of serious complications of diabetes mellitus，cardiac autonomic neuropathy（CAN）may lead to painless myocardial infarction，malignant arrhythmias and even sudden cardiac death，and is strongly associated with approximately five-fold increased risk of cardiovascular mortality.However，there are no reports about prevalence of CAN in community-dwelling patients with type 2 diabetes mellitus（T2DM）in China so far.Objective　To investigate the prevalence and factors associated with grading of CAN in community-dwelling patients with T2DM.Methods　Random sampling method using Excel was used to extract 300 from 2 751 T2DM patients who underwent screening for diabetic foot and diabetic nephropathy from November 1 to December 31，2018 in six stations attached to Shichahai Community Health Center，Xicheng District，Beijing，including Aimin Street Station，Gulou Street Station，Baimi Station，Denei Station，Xisi Station，Liuyin Street Station.Face-to-face questionnaire survey，detailed medical history inquiry and physical examination were conducted to collect related clinical data.Ewing test was used to screen CAN.Multinomial and ordinal Logistic regression analyses were used to analyze the influencing factors of CAN grading in community-dwelling patients with T2DM.Results　A total of 136 cases were enrolled at last，including 15（11.0%）without CAN（grade 0），38（28.0%）with subclinical CAN（grade 1），57（41.9%）with clinical CAN（grade 2）and 26（19.1%）with severe CAN（grade 3）.Mean age，BMI，course of T2DM，supine systolic blood pressure，fasting plasma glucose，HbA1c，and HDL-C，prevalence of coronary heart disease and peripheral neuropathy，and percent of users of oral metformin varied significantly across the four groups stratified by CAN grade（P<0.05），while sex ratio，mean supine diastolic blood pressure and LDL-C，percents of ever and current smokers，and users of oral mecobalamin and B vitamins，prevalence of hypertension，cerebrovascular disease and chronic kidney disease did not（P>0.05）.Multinomial and ordinal Logistic regression analyses showed that，age〔OR=6.878，95%CI（3.003，15.753）〕，course of T2DM〔OR=4.422，95%CI（2.048，9.546）〕and peripheral neuropathy〔OR=2.830，95%CI（1.315，6.090）〕were associated with CAN grading in community-dwelling patients with T2DM （P<0.05）.Conclusion　The prevalence of CAN was relatively high（61.0%）in community-dwelling patients with T2DM，factors associated with CAN grading may be age，course of T2DM and peripheral neuropathy，which should be paid attention.