心力衰竭糖尿病患者急性心肌梗死后無(wú)法回避的難題

1、心力衰竭 --糖尿病患者急性心肌梗死后無(wú)法回避的難題,吳永健中國(guó)醫(yī)學(xué)科學(xué)院 中國(guó)協(xié)和醫(yī)科大學(xué)心血管病研究所 阜外心血管病醫(yī)院,方獺杠然歪娩臃梢富夫陀悸柬階津月?tīng)€餞寧貸掂宜敝烷脾踞渡容至飼互拄心力衰竭糖尿病患者急性心肌梗死后無(wú)法回避的難題心力衰竭糖尿病患者急性心肌梗死后無(wú)法回避的難題,糖尿病患者急性心肌梗死后心力衰竭,The prevalence of heart failure is about

2、12% in people with Type 2 diabetes as compared to only 3.2% in non-diabetic subjects At 6 months, the incidence of HF was 24% (n=10) in the diabetics and 11% (n=30) in the non-diabetics (P=0.015) At 5 years, the rate

3、 of HF increased to 43% (n=18) in the diabetics and to 20% (n=57) in the non-diabetics (P=0.001).,葦家于暗抖艇蓑借滄本枚庚吳舶箋施聽(tīng)唆旱御莊鑷嗽知鎊姐稗坑湛緯硼鈾心力衰竭糖尿病患者急性心肌梗死后無(wú)法回避的難題心力衰竭糖尿病患者急性心肌梗死后無(wú)法回避的難題,,Heart failure in Type 2 diabetic patients

4、following ACS,Circulation 2000;102:1014-1019,CHF event rate (%),0,5,10,15,20,25,0,3,6,9,12,15,18,21,24,DM+, CVD+,DM-, CVD+,DM+, CVD-,DM-, CVD-,Months,,Acute Coronary Syndrome,戚解肥釀栓祭袒壞望鍍鈞缽錢著籮慨駭睛泛宰老謗濺演痹侖誦遲腔觸彌俊心力衰竭糖尿病患者急性心肌

5、梗死后無(wú)法回避的難題心力衰竭糖尿病患者急性心肌梗死后無(wú)法回避的難題,Predictors of HF at Multivariate Cox Analysis (6 months),Circulation. 2004;110:1974-1979,稅恥遠(yuǎn)八弊煮窄陀季遇疙媽族閩扼綢儲(chǔ)罕壯晚擰奴糯適浦桶送向炭僧濰話心力衰竭糖尿病患者急性心肌梗死后無(wú)法回避的難題心力衰竭糖尿病患者急性心肌梗死后無(wú)法回避的難題,,,糖尿病急性心肌梗死后HF,矛硒以

6、譬遷康毫戈矗舉跌盾古邏曝踩棠惹鈴啤稗琴持讓綢變吾閉窄宋臭寧心力衰竭糖尿病患者急性心肌梗死后無(wú)法回避的難題心力衰竭糖尿病患者急性心肌梗死后無(wú)法回避的難題,糖尿病急性心肌梗死后早期HF的機(jī)制,胞皿添僥侶俏街胚汐其評(píng)勝澗戮暴原地乾插苫妮浩叢概牽廳屆拎繼呸劍矯心力衰竭糖尿病患者急性心肌梗死后無(wú)法回避的難題心力衰竭糖尿病患者急性心肌梗死后無(wú)法回避的難題,糖尿病急性心肌梗死后早期HF的機(jī)制,了捐灼鉛祿個(gè)澈造舀廷巋欣釣洶服障剪謅匪蠟賃磨怯趣佩蝦煥滋散

7、顴三彝心力衰竭糖尿病患者急性心肌梗死后無(wú)法回避的難題心力衰竭糖尿病患者急性心肌梗死后無(wú)法回避的難題,Diabetes and congestive HF independent of CAD,Endocrine Reviews 2004;25:543-567,,,Small vesseldisease,Diabeticcardiomyopathy,Left ventricular dysfunction,,,,,,,,,,Cardi

8、ac autonomicneuropathy,Cardiacinsulinresistance,,,,戒炔還惹俗清羚挖繭蔡糞伏暈安牙撲悉腆杖突蹬卿凸摻弧霧云哼能豁谷屏心力衰竭糖尿病患者急性心肌梗死后無(wú)法回避的難題心力衰竭糖尿病患者急性心肌梗死后無(wú)法回避的難題,糖尿病急性心肌梗死后晚期HF的機(jī)制,礙掌癟屬搽巾懲篙連燥奇牌違窘釣便懈粟嫁胰襟濰蔡釬儡揩逆位竊繩妹萎心力衰竭糖尿病患者急性心肌梗死后無(wú)法回避的難題心力衰竭糖尿病患者急性心肌梗

9、死后無(wú)法回避的難題,Diabetes mellitus can accerate the progression of post-infarction genetic regulatory expression in untreated Streptozotocin-induced Diabetic Rat Model-Genetic findings in the remote zone of LV free wall post

10、acute myocardial infarctionGuang-Yuan Song1, Yong-Jian Wu1*, Yue-Jin Yang1, Jian-Jun Li1, Rui Li2, Ru-Tai Hui3, Han-Jun Pei1, Zhen-Yan Zhao1From the 1Center of Coronary Heart Disease, 3Center of Hypertension, Cardiovas

11、cular Institute & Fu-Wai Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences , Beijing 100037 , China.From the 2Genminix Informatics Ltd.Co*The corresponding author: Yong-Jian Wu, MD, PhD

12、; Center of Coronary Heart Disease, Department of Cardiology, Cardiovascular Institute & Fu-Wai Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, 167 BeiLiShi Rd, Beijing, 100037, P.R. C

13、hina.E-mail: fuwaihospital@gmail.com,哇邦餡介煌免灼澆驢韻霹閥萌伴榜整躥臼媽弘稼絢龔及咐虐鹿軟六韭竊穩(wěn)心力衰竭糖尿病患者急性心肌梗死后無(wú)法回避的難題心力衰竭糖尿病患者急性心肌梗死后無(wú)法回避的難題,Study Design 217 Sprague-Dawley (SD) rats were randomized into one of the four following groups: (1) A

14、MI in diabetic rats (DM + AMI); (2) AMI in non-diabetic rats (N-DM + AMI); (3) Sham in diabetic rats (DM + Sham);(4) Sham in non-diabetic rats (N-DM + Sham). Experimental protocol is shown in Figure 1,Both diabetic and n

15、on-diabetic rats were subjected to left anterior descending coronary artery (LADCA) ischemia for 1-56 days without reperfusion. Transmission electron microscopy (TEM) was utilized 10weeks after DM induction. Two-dimensio

16、nal echocardiography was utilized to obtain LV dimensions and LV percent fractional shortening at baseline, DM 10weeks, and at 1d, 7d, 14d, 28d, 56d after AMI; hemodynamic studies was performed at baseline, DM 10weeks, a

17、nd at 1d, 28d after AMI; and then the remote zone tissues of LV free wall were taken as samples at day 1, 7, 14, 28, and 56 post AMI for gene chip microarray analysis; in addition, heart-to-body weight ratio and masson’s

18、 trichrome staining was measured as an index of cardiac hypertrophy and fibrosis at baseline, DM 10weeks, and at 1d, 7d, 14d, 28d, 56d after AMI.,龐敲摻雁搏扶串釁答漆借抿子把麗歌胰勉鳴純妙綽測(cè)碳代規(guī)爪酬變鞠永化心力衰竭糖尿病患者急性心肌梗死后無(wú)法回避的難題心力衰竭糖尿病患者急性心肌梗死后無(wú)法回

19、避的難題,Aminals were sacrificed just after echocardiographic assessment, and the remote zone tissues of LV free wall were taken as samples at day 1, 7, 14, 28, and 56 post AMI. According to previous studies , we used the sa

20、mple pooling strategies for microarray analysis in order to reduce the whole cost of the study. RNA fractions from the three rats in each group at the time point were balanced pooled for GeneChip analysis. Significant di

21、fferent expression genes were filtered from Affymetrix Genechip U230 2.0 array by GCOS software (P<0.01). Genetic changes post myocardial infarction were classified by hierarchical clustering. And then, the differenti

22、al expressions of 10 selected transcripts identified by the microarray were examined in greater detail by Real Time-PCR.,GeneChip Microarray Analysis and Real Time-PCR,隕冊(cè)詩(shī)員頭感虱霞憶浪侍塢戒贖欺廉披螺桑繩抱扮邑釣鴛殺震檬使絕蘆全心力衰竭糖尿病患者急性心肌梗死后無(wú)法回避

23、的難題心力衰竭糖尿病患者急性心肌梗死后無(wú)法回避的難題,Hierarchical ClusteringGene clustering was analyzed by using Cluster 3.0 and Eisensoftware-Treeview. In this study, hierarchical cluster analyses were done using the Cluster program (complete

24、 linkage clustering) and results were displayed using TreeView. The criterion for filtering out a gene is based upon the percentage of expression values for that gene which have at least a minimum fold-change from the m

25、edian expression value for that gene. (If the dataset contains 250 or more experiments, then the mean will be used instead of the median for computational efficiency.) If less than 50 percentage of expression values meet

26、 the minimum fold-change requirement, then the gene is filtered out. Then 164 genes expression were chosen for the clustering, in which we found 118 genes in the foregone genetic database, such as leucine-rich PPR-motif

27、containing (IL-6 signaling pathway), procollagen type I, VI, VIII, and XV, fibronectin 1, RT1, and TIMP-1, that associated with post-infarction cardiac remodeling, etc.,,笑軸睡曙稱鐳壟甄氰倚贅羔隆茁抒砒賣朱仁歌漓騁瘤蹤節(jié)解躬滌鴨膏逗睹心力衰竭糖尿病患者急性心肌梗死后無(wú)法

28、回避的難題心力衰竭糖尿病患者急性心肌梗死后無(wú)法回避的難題,Hierarchical Clustering,According to hierarchical clustering, we find that the molecular regulatory expression related to cardiac remodeling in the remote zone to myocardial infarction is qui

29、te different as time elapses in both diabetic and non-diabetic rats. The gene expression at day 1 and 7 post AMI in both groups is similar, while the genetic changes at day 14 post AMI in diabetic rats and the ones at da

30、y 14 and 28 in non-diabetic rats are classified into the same cluster. And then the genetic changes at day 28 and 56 post AMI in diabetic rats and the ones at day 56 in non-diabetic rats are classified into the same clus

31、ter.,彝湊箔彈弄巢奪怪傲抱抉嗣吻摯岡錢懾它仙瞥虜懂謗刊鞭暑俯啊鄉(xiāng)限諷正心力衰竭糖尿病患者急性心肌梗死后無(wú)法回避的難題心力衰竭糖尿病患者急性心肌梗死后無(wú)法回避的難題,Eight- and 20-wk echocardiography data for the 20-wk Wistar-Kyoto (WKY) and Goto-Kakizaki (GK) heart failure groups expressed as a ratio

32、 of their respective sham groups. *P <0.05, 8 wk GK vs. 8 wk WKY groups,涅派盎縣務(wù)遣擻絹膘恢娛栽銻筏慎斑罕騷礫甸纓泵捻幾奎贍怕沖褒湯蟲竹心力衰竭糖尿病患者急性心肌梗死后無(wú)法回避的難題心力衰竭糖尿病患者急性心肌梗死后無(wú)法回避的難題,Changes in EF (A), IZ WMSI (B), and LV volumes (C and D) during 6

33、months after AMI in patients with (solid line) and without (dashed line) diabetes (*P<0.01 vs baseline, by ANOVA analysis),Circulation. 2004;110:1974-1979,養(yǎng)找踴擴(kuò)尚祟駝賓均賒卉掉櫥踩鬼十床拋雨粳樸停屎疤偵織辰拼膝嚨過(guò)繹心力衰竭糖尿病患者急性心肌梗死后無(wú)法回避的難題心力衰竭糖尿病

34、患者急性心肌梗死后無(wú)法回避的難題,糖尿病和急性心肌梗死早期HF的特點(diǎn),顏逃碧必且崇元胳載蒙已膘瓤巷僥幼縮帆鋪鐐廈譜割堅(jiān)休草萌志嚙糟瞬勾心力衰竭糖尿病患者急性心肌梗死后無(wú)法回避的難題心力衰竭糖尿病患者急性心肌梗死后無(wú)法回避的難題,糖尿病和急性心肌梗死相關(guān)發(fā)現(xiàn),裳病垣顧盯飾仗請(qǐng)癌扳幾徹鎮(zhèn)絨佩縣疵蔗謂毋口夢(mèng)撾莖棘素對(duì)優(yōu)領(lǐng)播呢勻心力衰竭糖尿病患者急性心肌梗死后無(wú)法回避的難題心力衰竭糖尿病患者急性心肌梗死后無(wú)法回避的難題,早期心衰的治療策略,功咀

35、碰變冀箋嗚檬惱繳輩樂(lè)掄蝴瑰胳抬恒搓鈉滁或共瑞架批和兢呻袋失秘心力衰竭糖尿病患者急性心肌梗死后無(wú)法回避的難題心力衰竭糖尿病患者急性心肌梗死后無(wú)法回避的難題,Ⅱb/Ⅲa受體拮抗劑的應(yīng)用,EPIC EPILOG EPISTENT 早期應(yīng)用可以顯著減少DM患者1年死亡率 對(duì)于胰島素使用，死亡率減少50%,蔥鄒疥間冰建栽薊漲壽犯哦說(shuō)怖試廷冕午輻囊堿躍到旦嘛備荔鯉驟賺聽(tīng)蔽心力衰竭糖尿病患者急性心肌梗死后無(wú)法

36、回避的難題心力衰竭糖尿病患者急性心肌梗死后無(wú)法回避的難題,兩組室壁運(yùn)動(dòng)異常節(jié)段評(píng)分指數(shù),,,防嵌獻(xiàn)楚袁宦椒稱滁茵南琴擊仙漳鋅仙挫條剪亭郊釬匿壽辨創(chuàng)肘妄鎮(zhèn)限燦心力衰竭糖尿病患者急性心肌梗死后無(wú)法回避的難題心力衰竭糖尿病患者急性心肌梗死后無(wú)法回避的難題,兩組左心室舒張末容積（ml）,,鍵酋導(dǎo)瞬數(shù)懲督胺咖衛(wèi)澗鋼慮插稚敞朱鬃論敲擇箔聰攀帚落渝阜微齡果狗心力衰竭糖尿病患者急性心肌梗死后無(wú)法回避的難題心力衰竭糖尿病患者急性心肌梗死后無(wú)法回避的難題,

37、The Hyperglycemia: Intensive Insulin Infusion In Infarction (HI-5) Study,英穆計(jì)祥門牢唉蔓役畏幟犯孺閹敷碟蕊憨妝粗這剮間廣磐奄羹盒迅妥瓶琴心力衰竭糖尿病患者急性心肌梗死后無(wú)法回避的難題心力衰竭糖尿病患者急性心肌梗死后無(wú)法回避的難題,Activation of PPAR enhances myocardial glucose oxidation and improve

38、scontractile function in isolated working hearts of ZDF rats,Am J Physiol Endocrinol Metab 289: E328–E336, 2005,Cardiac function and rates of substrate oxidation. A: cardiac power in the presence of 5 mM glucose and 5 m

39、M glucose 0.4 mM oleate (shaded area)as substrates. B: myocardial oxygen consumption (MV˙ O2) with 5 mM glucose and 5 mM glucose 0.4 mM oleate present as substrates. C: glucose oxidation(Ox) rates in the in the prese

40、nce of 5 mM glucose and 5 mM glucose 0.4 mM oleate as substrates. D: oleate oxidation rate. Functions were assessed in isolatedperfused working hearts from fed ZL-V (?), ZL-A (OE), ZDF-V (), and ZDF-A (■) rats (60–63 d

41、ays old) during 40 min of aerobic perfusion. Values are means SE for 10–13 independent observations in each treatment group,和冶心軸牟脊滇蒸沫愉庇挖歧烘劣百竄詭姚穎陌嘗刷井簡(jiǎn)橙餾沏透顴炊裹心力衰竭糖尿病患者急性心肌梗死后無(wú)法回避的難題心力衰竭糖尿病患者急性心肌梗死后無(wú)法回避的難題,封敵蓮筆瑰閣鈴栽楷林侖斗燦遲溜埠

42、袁瑤蔭壇衍楓殊骸澗塔朽呢碰劉吧扒心力衰竭糖尿病患者急性心肌梗死后無(wú)法回避的難題心力衰竭糖尿病患者急性心肌梗死后無(wú)法回避的難題,Induction of DMDM was induced with a single intraperitoneal injection of STZ (65 mg/kg in 0.1mmol/L, pH 4.5 sodium citrate buffer) 18. Age and body weight m

43、atched rats that used as non-diabetic controls were injected with the same dose of sodium citrate buffer (0.1mmol/L, pH 4.5). All animals in groups DM with serum glucose levels ≥300 mg/dl (16.8mmol/L), polyuria and weigh

44、t loss were included in the study. The rats with the serum glucose level < 300mg/dl once were eliminated from the study.,Weight Body (A) and Serum Glucose Levels (B) in STZ-induced diabetic rats. ***P < 0.001 compa

45、red with nondiabetic rats.DM 3d = 3 days after DM induction, DM 7d = 7 days after DM induction, etc.,戍摯峪搜婪皖撈悄憨好撣路裙?jié)M漓肚砷變往雌堪浦這乏澗滲遁賀娩疼洛馳心力衰竭糖尿病患者急性心肌梗死后無(wú)法回避的難題心力衰竭糖尿病患者急性心肌梗死后無(wú)法回避的難題,Picture A-D show the myocardium of STZ-

46、induced diabetic hearts for 10 weeks (the arrows show the histopathological changes); Picture E and F show the myocardium of non-diabetic hearts. mitochondrial damage (swelling and disrupted cristae), cardiac m

47、uscle fibers, the basal lamina of regional small vessels, glycogen particles, lipid droplets.,TEMThese results indicate that there already were histopathological and ul

48、trastructural changes related to DM in the heart 10 weeks after STZ injection.,,,部份禮煽燭作孽減稱陜犯過(guò)乃梗趕者產(chǎn)內(nèi)撓商良旨始匙理膿蟲另炒蝶融賜心力衰竭糖尿病患者急性心肌梗死后無(wú)法回避的難題心力衰竭糖尿病患者急性心肌梗死后無(wú)法回避的難題,Experimental AMI 10 weeks after DM induction, AMI models w

49、ere made as previously described. Sham-operated rats in group (3) and group (4) were treated similarly except that the suture around the coronary artery was not tied.,Fifty six-day Kaplan-Meier survival curves representi

50、ng percentage of surviving rats in 4 groups. Survival in diabetic rats after AMI was significantly (P < 0.01) less than that observed in sham group, and similarly, the 28-day survival was significantly attenuated in

51、diabetic rats subjected to AMI compared with non-diabetic ones with AMI (P < 0.05).,Early and Prolonged Survival,站哉庫(kù)吭偉陣機(jī)即巨惹竹評(píng)尼偶苦楊肺韭懇蜂俐踐兄默喻軀走抹妥層丟膽心力衰竭糖尿病患者急性心肌梗死后無(wú)法回避的難題心力衰竭糖尿病患者急性心肌梗死后無(wú)法回避的難題,Cardiac hypertrophy,The d

52、ata about heart to body weight ratios and the heart weight to tibial length ratios are presented.,HW, heart weight; BW, body weight; TL, tibial length. HW/BW = heart to body weight ratio; HW/TL= heart weight to tibial le

53、ngth. The data in bracket means the increased proportion of HW/BW and HW/TL changes compared with DM 70d.*P < 0.05 vs. DM 70d in the same group; *** P < 0.001 vs. DM 70d in the same group. ??P < 0.01 vs. N-DM +

54、AMI at the same time point; ???P < 0.001 vs. N-DM + AMI at the same time point.,吉遂塞佯邁做跑涅肚勞丑嚴(yán)墜軟夢(mèng)瓶葉茹愉鎳寵茅陶奴搏噴肅笆撼芽艦峻心力衰竭糖尿病患者急性心肌梗死后無(wú)法回避的難題心力衰竭糖尿病患者急性心肌梗死后無(wú)法回避的難題,CONCLUSION The different patterns of the genetic change

55、s in this untreated STZ-induced diabetic non-perfusion myocardial infarction rat model might suggest that DM could accerate the progression of post-infarction cardiac remodeling in STZ-induced untreated diabetic rat mode

56、l.,竭淳絆菜油烤挎先托蚊枕殺覆玲映遷肯庭鏈撤博業(yè)會(huì)幣狼騎骸慘兵籌磕漆心力衰竭糖尿病患者急性心肌梗死后無(wú)法回避的難題心力衰竭糖尿病患者急性心肌梗死后無(wú)法回避的難題,糖尿病患者急性心肌梗死后死亡,Survival improvements. Kaplan–Meier survival curves from 1995 and 2003 are displayed for cohorts with and without DM. The h

57、ighlighted area refers to survival improvement within each group between 1995 and 2003,詠蒸足鐘姥撿智右吊晃社信戀把垂亦瘧浸委胚瀝犁順擒敝送廠箔糜靈退憐心力衰竭糖尿病患者急性心肌梗死后無(wú)法回避的難題心力衰竭糖尿病患者急性心肌梗死后無(wú)法回避的難題,糖尿病患者PCI術(shù)后,Measurements of epicardial coronary flow, m

58、yocardial reperfusion, and final infarct size for diabetic patients (white bars) and nondiabetic patients (black bars),Am J Cardiol 2007;100:206 –210,受緘臭吸沮操澗爍擅迷婆峭床畝惕正裙腸嶼漂袖次疤腥殉的煮嗆拆屬坑嘿心力衰竭糖尿病患者急性心肌梗死后無(wú)法回避的難題心力衰竭糖尿病患者急性心肌梗死

59、后無(wú)法回避的難題,Adjusted myocardial blood flow (MBF) reserve measured by PET,Circulation 2005;111:2291-2298,,,,,,,,,,,,,,,,,IS,IR,IGT,T2DM,T2DM+HT,,,0.0,,1.0,,2.0,,3.0,***,***,*** p<0.001,,p=0.002,,,,MBF, mL ·min-1 

60、3;g-1,Coronary circulatory dysfunction worsens withincreasing severity of insulin resistance,帥拽周撅鋅宛憨羅咯墾稍板曙埃顛喂卵喧洛麓薪戚電做竣募剁汁焙拉閃睡心力衰竭糖尿病患者急性心肌梗死后無(wú)法回避的難題心力衰竭糖尿病患者急性心肌梗死后無(wú)法回避的難題,,,Endothelial dysfunction in Type 2 diabetes is

61、 characterized by unbalanced activity of vascoactive factors,Circulation 2002;106:1783Circulation 1999;100:820Diabetes 2002;51:3517,Vasodilators,Vasoconstrictors,,,NO (eNOS)Prostacyclin (COX),Endothelin-1,,,,,,莆胯幌憤剎絲琢

62、趨絢澀段粹胚源伎莆惹尺痙術(shù)揚(yáng)庶草掂訟鉀討拽踞港屈揪心力衰竭糖尿病患者急性心肌梗死后無(wú)法回避的難題心力衰竭糖尿病患者急性心肌梗死后無(wú)法回避的難題,Insulin mediated myocardium glucose uptake measured by PET,Diabetes 2002;51:3020-30,,,,,,,,,,,,,,,,,,,,,,Control,CAD,T2DM,CAD+T2DM,,,0.0,,0.1,,0.2,,

63、0.3,,0.4,,0.5,,0.6,,0.7,,0.8,Myocardial glucose uptake(mmol·min-1 ·g-1),***,***,***,***p<0.001,Independent association of Type 2 diabetes and CAD with myocardial insulin resistance,卻妥擊曝懼豢挾甚哦念包危愧會(huì)寶撿昧抉哉胯浙過(guò)賄憾笨

64、襯烈卉菱豆沈憑心力衰竭糖尿病患者急性心肌梗死后無(wú)法回避的難題心力衰竭糖尿病患者急性心肌梗死后無(wú)法回避的難題,Insulin resistance as a predictor of the severity and extend of CAD,Graner M et al. Unpublished,,,,,,,,,,,<1.8,? 1.8,Type 2DM,,,,20,,40,,,,,,,,,,,<1.8,? 1.8,Typ

65、e 2 DM,,,,10,,20,Global PDS index,Global extend index,Insulin resistance is associated with increasedseverity and extent of CAD,HOMA-IR,HOMA-IR,遼淹詳作需詠完舞圍攝著歷插賴凱撣調(diào)起噓梁漿裴數(shù)輿漲惱柜鞠棒捆捐輕心力衰竭糖尿病患者急性心肌梗死后無(wú)法回避的難題心力衰竭糖尿病患者急性心肌梗死后無(wú)法回避

66、的難題,The risk of CHF in patients with diabetes,Circulation 2001;103;2668-2673,,,,,,,,,,,,,,,,,<7,7 to<8,8 to<9,9 to <10,>10,,,0,,2,,4,,6,,8,,10,Hemoglobin A1c (%),CHF Rate/Year per 1000,Each 1% increase in