治疗糖尿病关注低血糖课件.ppt

* * 首先是2008年2月份ACCORD研究降糖分支3.7年中期分析的公布，因其结果显示强化降糖组全因死亡率显著增加而提前终止研究. * * * 2008年ADA年会中公布的ADVANCE研究表明强化降糖可以显著减少微血管并发症(主要是大量白蛋白尿)，而对大血管病变则未显示明显获益 * * * 会上同时公布的VADT研究结果似更令人意外，其大血管和微血管的危险性均未见有显著意义的减少 * * 目前，已经有大量荟萃分析证明血糖肯定跟糖尿病并发症密切相关，尤其是心血管疾病，同时也看到降低血糖可以得到获益。在1型糖尿病的DCCT研究已经证明机体对血糖具有记忆效应。但是2型糖尿病患者的情况是否一致？今年连续发布几个大型的关于改善2型糖尿病患者血糖控制能否减少并发症的前瞻性研究，结果出人意料，尤其是大血管病变的结果出现矛盾结果。ADVANCE、ACCORD、VADT应该为反方，没有发现有统计学差异的心血管获益，而UKPDS为正方，心血管获益不仅存在，而且持续存在。下面我们仔细分析一下几个研究，了解为什么出现这种矛盾的结果？ * * * Circulation. 2008 Feb 26;117（8）:1018-27. Epub 2008 Feb 11. 9.0 BACKGROUND: Hyperglycemia on admission is associated with an increased mortality rate in patients with acute myocardial infarction. Whether metrics that incorporate multiple glucose assessments during acute myocardial infarction hospitalization are better predictors of mortality than admission glucose alone is not well defined. METHODS AND RESULTS: We evaluated 16,871 acute myocardial infarction patients hospitalized from January 2000 to December 2005. Using logistic regression models and C indexes, 3 metrics of glucose control （mean glucose, time-averaged glucose, hyperglycemic index）, each evaluated over 3 time windows （first 24 hours, 48 hours, entire hospitalization）, were compared with admission glucose for their ability to discriminate hospitalization survivors from nonsurvivors. Models were then used to evaluate the relationship between mean glucose and in-hospital mortality. All average glucose metrics performed better than admission glucose. The ability of models to predict mortality improved as the time window increased （C indexes for admission, mean 24 hours, 48 hours, and hospitalization glucose were 0.62, 0.64, 0.66, 0.70; P0.0001）. Statistically significant but small differences in C indexes of mean glucose, time-averaged glucose, and hyperglycemic index were seen. Mortality rates increased with each 10-mg/dL rise in mean glucose or = 120 mg/dL （odds ratio, 1.8; P=0.003 for glucose 120 to 130 mg/dL） and with incremental d