糖尿病并發(fā)急性冠脈綜合征的治療

1、糖尿病合并急性冠脈綜合征的治療,謝 紅,文獻(xiàn)閱讀報(bào)告,報(bào)告內(nèi)容,文獻(xiàn)來源,文獻(xiàn)內(nèi)容簡介,文獻(xiàn)分析與評論,結(jié)論與啟示,4,1,2,3,一、文獻(xiàn)來源,,2007冠心病患者合并高血糖診治的中國專家共識,中國醫(yī)師協(xié)會心血管內(nèi)科醫(yī)師分 會/中國醫(yī)師協(xié)會循證醫(yī)學(xué)專業(yè)委員會.夏城東,殷惠軍,陳可冀.糖尿病防治的策略轉(zhuǎn)變——從關(guān)注糖化血紅蛋白到著眼心血管事件[J].醫(yī)學(xué)與哲學(xué)(臨床決策論壇版),2009,30（4）,4-7. F

2、rederick Feit, Steven V. Manoukian, Ramin Ebrahimi,et.Safety and Efficacy of Bivalirudin Monotherapy in Patients With Diabetes Mellitus and Acute Coronary Syndromes. Journal of the American College of Cardiology, 200

3、8,51（17）,1645-1652.Giovanni Paolo TalaricoM, Marta BrancatiM, Francesco Burzotta, et. Glycoprotein IIB/IIIA inhibitor to reduce postpercutaneous coronary intervention myonecrosis and improve coronary flow in diabetics

4、: the ‘ OPTIMIZE-IT’ pilot randomized study.Journal of Cardiovascular Medicine, 2009,10(3),245-262.,文獻(xiàn)1 糖尿病是冠心病的等危癥,,,,糖尿病患者患心血管疾病的危險(xiǎn)是無糖尿病者的2~4倍。無心肌梗死病史的糖尿病患者在未來8~10年發(fā)生心肌梗死的危險(xiǎn)高達(dá)20%,約等同于已患心肌梗死者再發(fā)心肌梗死的危險(xiǎn)。而曾發(fā)生心肌梗死的糖尿病患者未

5、來再發(fā)心肌梗死的危險(xiǎn)超過40%。,2007冠心病患者合并高血糖診治的中國專家共識,中國醫(yī)師協(xié)會心血管內(nèi)科醫(yī)師分會/中國醫(yī)師協(xié)會循證醫(yī)學(xué)專業(yè)委員會..,文獻(xiàn)1 冠心病高血糖處理原則,,,,控制目標(biāo)：接近6.1mmol/l，<10mmol/l，靜脈應(yīng)用胰島素控制血糖，循序漸進(jìn)，劑量個(gè)體化和血糖監(jiān)測，避免低血糖發(fā)生,穩(wěn)定型冠心病患者,急性冠脈綜合征患者,控制目標(biāo)：FPG 5.0-7.2mmol/l ， PPG<

6、10mmol/l，必要時(shí)應(yīng)用胰島素治療,2007冠心病患者合并高血糖診治的中國專家共識,中國醫(yī)師協(xié)會心血管內(nèi)科醫(yī)師分會/中國醫(yī)師協(xié)會循證醫(yī)學(xué)專業(yè)委員會..,文獻(xiàn)2 以血糖為中心轉(zhuǎn)向以防治心血管事件為中心的多危險(xiǎn)因素綜合防治,,,,UKPDS有關(guān)2型糖尿病冠心病危險(xiǎn)因素的分析顯示：T2DM患者冠心病危險(xiǎn)因素按重要性依次為LDL-Ch、HDL-Ch、SBP、HbA1c與吸煙。DCCT觀察發(fā)現(xiàn)T1DM HbA1c較常規(guī)治療組明顯下降

7、，微血管病變和神經(jīng)病變終點(diǎn)的風(fēng)險(xiǎn)顯著降低，大血管與心血管事件的風(fēng)險(xiǎn)降低并無計(jì)學(xué)意義。2007年歐洲心臟病學(xué)會和歐洲糖尿病研究協(xié)會制定診療指南，并指出多種危險(xiǎn)因素干預(yù)更有利于糖尿病和心血管疾病的治療，并提出了明確的糖尿病合并心血管疾病患者的干預(yù)目標(biāo)。Steno-2研究顯示：全面控制血壓、血脂、血糖等多種危險(xiǎn)因素，可顯著改善合并微量蛋白尿T2DM患者的預(yù)后，使死亡危險(xiǎn)顯著降低57%，任一心血管事件危險(xiǎn)顯著降低59%。,夏城東,殷惠軍

8、,陳可冀.糖尿病防治的策略轉(zhuǎn)變——從關(guān)注糖化血紅蛋白到著眼心血管事件[J].醫(yī)學(xué)與哲學(xué)（臨床決策論壇版）,2009,30（4）,4-7.,文獻(xiàn)2 糖尿病血糖控制 應(yīng)早期、長程、持續(xù)、穩(wěn)定,,2008年歐洲心臟病學(xué)年會報(bào)道Monteiro等對1053例急性冠脈綜合征患者研究發(fā)現(xiàn)，在糖尿病和非糖尿病患者中血糖變異幅度高者，ST段抬高心肌梗死發(fā)生率也越高，并且血糖變異幅度與壞死和炎癥因子標(biāo)志物、左室射血分?jǐn)?shù)、肌酐清除率相關(guān)。VADT項(xiàng)目S

9、vensson等對713例糖尿病合并急性冠脈事件患者調(diào)查發(fā)現(xiàn)，入院時(shí)的高血糖與住院期間發(fā)生的低血糖均與2年后全因死亡風(fēng)險(xiǎn)增加獨(dú)立相關(guān)，說明避免急性冠脈事件中的低血糖和高血糖同等重要。DCCT/EDIC、UKPDS研究發(fā)現(xiàn)早期強(qiáng)化降糖治療對糖尿病心血管并發(fā)癥具有長期的后續(xù)效應(yīng)。,夏城東,殷惠軍,陳可冀.糖尿病防治的策略轉(zhuǎn)變——從關(guān)注糖化血紅蛋白到著眼心血管事件[J].醫(yī)學(xué)與哲學(xué)（臨床決策論壇版）,2009,30（4）,4-7.,文獻(xiàn)3

10、糖蛋白IIB/IIIA抑制劑減少糖尿病患者經(jīng)皮冠脈干預(yù)治療(PCIs)肌壞死和改善冠脈血流,,,,文獻(xiàn)3糖蛋白IIB/IIIA抑制劑減少糖尿病患者經(jīng)皮冠脈干預(yù)治療(PCIs)肌壞死和改善冠脈血流,Methods randomized consecutive stable diabetic patients, undergoing elective PCI, to tirofiban or placebo groups; High

11、-dose bolus (25mg/kg per 3 min) of tirofiban administered before PCI followed by 8 h continuous infusion (0.15mg/kg per min). Postprocedural myonecrosis was assessed prospectively by measurement of cardiac troponin T

12、(cTnT) at 6 and 24 h after PCI. The primary endpoints were post-PCI coronary flow estimated by corrected thrombolysis in myocardial infarction frame count and post- PCI myocardial infarction. Platelet aggregation was me

13、asured by platelet function analyser-100 values.,,Giovanni Paolo TalaricoM,et.Journal of Cardiovascular Medicine, 2009,10（3）, 245-262.,,,,Giovanni Paolo TalaricoM,et.Journal of Cardiovascular Medicine, 2009,10（3）, 245-26

14、2.,,文獻(xiàn)3 結(jié)果（一）,文獻(xiàn)3 結(jié)果二,,,文獻(xiàn)3 結(jié)果三,,文獻(xiàn)3 結(jié)果四,,文獻(xiàn)3 結(jié)論,Conclusions the administration pre-PCI of HBD tirofiban, in stable diabetic patients undergoing elective PCI, was associated with a marked reduction of platelet aggreg

15、ation；not associated with a significant improvement in the risk of bleeding (with the prevalent radial approach)； which did not translate to a lower incidence of post-PCI myocardial necrosis nor to better myocardial pe

16、rfusion as compared with placebo.,文獻(xiàn)四 比伐盧定單藥治療在糖尿病和急性冠脈綜合征患者的安全性和有效性,MethodsWe evaluated the impact of diabetes on 30-day net adverse clinical outcomes (composite ischemia [death, myocardial infarction, or unplanned i

17、schemic revascularization] or major bleeding), overall and by antithrombotic strategy.,Frederick Feit, Steven V. Manoukian, Ramin Ebrahimi,et.Safety and Efficacy of Bivalirudin Monotherapy in Patients With Diabetes Me

18、llitus and Acute Coronary Syndromes. Journal of the American College of Cardiology, 2008,51（17）,1645-1652.,Groups:Diabetic patients, Nondiabetic patientsSubgroups:Heparin plus GPI, Bivalliudin plus GPI, Bivallirudin mon

19、otherapy,文獻(xiàn)4 結(jié)果一,文獻(xiàn)4 結(jié)果二,,ConclusionsDiabetic patients with ACS managed invasively have higher rates of composite ischemia and major bleeding.Compared with treatment with heparin plus GPI, bivalirudin monotherapy

20、provides similar protection from ischemic events with less major bleeding, resulting in a significant reduction in net adverse clinical outcomes.,文獻(xiàn)4 結(jié)論,文獻(xiàn)結(jié)論與啟示,1、糖尿病合并急性冠脈綜合征要把血糖控制在6.1mmol/l，不超過10mmol/l，注意監(jiān)測血糖，避免發(fā)生低血糖。