DyslipidemiaAbdominalObesityDiabetesUricacidRenallesionEndotheliumdamage

HypertensiveSyndrome

-ConstellationsofCardiometabolicRiskFactorsHypertension80%高血壓危險因素CVD事件DyslipidemiaAbdominalDiabete1更強調危險因素的早期控制更關注血管和代謝因素的相互作用對高血壓的危險進行總體評估防治上既遵循循證醫學證據，也強調個體化治療更強調危險因素的早期控制2Abdominalobesity

Waistcircumference>102cm(M),88cm(W)DyslipidaemiaTC>5.0mmol/l(原為6.1)orLDL-C>3.0mmol/l(原為4.0)orHDL-C:M<1.0mmol/l(40mg/dL),W<1.2mmol/l(46mg/dL)or:TG>1.7mmol/l(150mg/dL)IFG&IGTFastingplasmaglucose5.6-6.9mmol/L(102-125mg/dL)AbnormalglucosetolerancetestESC/ESH

2007高血壓指南Metabolic

syndrometheclusterofthreeoutof5riskfactorsamongabdominalobesity,alteredfastingplasmaglucose,BP≥130/85mmHg,low

HDL-cholesterolandhighTG(asdefinedabove)DiabetesMellitusFastingplasma≥7.0mmol/l(126mg/dL)onrepeatedmeasurements,orPostloadplasmaglucose>11.0mmol/l(198mg/dL)（JHypertens2007,25：1105）AbdominalobesityESC/ESH20073ESC/ESH

2007——關注高血壓伴發的代謝異常（JHypertens2007,25：1105）ESC/ESH2007——關注高血壓伴發的代謝異常（J4如何評估高血壓的代謝危險性DiabetesVascDisRes2008;5:9–14如何評估高血壓的代謝危險性DiabetesVascDis5心血管代謝危險性評估1.Framinghamscore(USA)

Age,Sex,SBP,TC,Smoking,HDL-c2.TheUKPDSriskengine(UK)

Age,Sex,SBP,Smoking,TC/HDL-c,HbA1c3.PROCAMscore(Germany)

Age,LDL-c,TC,smoking,HDL-c,SBP,FHofMI,DM,TG4.ICVD(China)

Age,Sex,SBP,BMI,TC,Smoking,DM心血管代謝危險性評估1.Framinghamscore6危險分層：ESC/ESH危險分層：ESC/ESH7Lancet2005;366:1640Lifestylechanges+immediatedrugtreatmentAmJCardiol2007;99:1006–1012Grade3HTSBP≥180orDBP≥110管危險性明顯增加，可視為冠心病等危癥。LifestylechangesforseveralweeksthendrugtreatmentifBPuncontrolled危險分層：ESC/ESHESC/ESH2007——關注高血壓伴發的代謝異常控制血糖至一定范圍顯著減少心腦血管事件EstablishedCVorrenaldiseaseLifestylechangesforseveralweeksthendrugtreatmentifBPuncontrolled肥胖與心衰Paradoxprognosis:excessbodyweighthaveaparadoxicalprotectiverole?BolenSAnnInternMed.SBP130-139orDBP85-89ATVB,2006,26:28-40靶器官損害的評價Lancet2005;366:1640靶器官損害的評價8Otherriskfactors,ODordiseaseNormalSBP120-129orDBP80-84HighnormalSBP130-139orDBP85-89Grade1HTSBP140-159orDBP90-99Grade2HTSBP160-179orDBP100-109Grade3HTSBP≥180orDBP≥110NootherriskfactorsNoBPinterventionNoBPinterventionLifestylechangesforseveralmonthsthendrugtreatmentifBPuncontrolledLifestylechangesforseveralweeksthendrugtreatmentifBPuncontrolledLifestylechanges+immediatedrugtreatment1-2riskfactorsLifestylechangesLifestylechangesLifestylechangesforseveralweeksthendrugtreatmentifBPuncontrolledLifestylechangesforseveralweeksthendrugtreatmentifBPuncontrolledLifestylechanges+immediatedrugtreatment3ormoreriskfactors,MS,ODordiabetesLifestylechangesLifestylechangesandconsiderdrugtreatmentLifestylechanges+drugtreatmentLifestylechanges+drugtreatmentLifestylechanges+immediatedrugtreatmentDiabetesLifestylechangesLifestylechanges+drugtreatmentEstablishedCVorrenaldiseaseLifestylechanges+immediatedrugtreatmentLifestylechanges+immediatedrugtreatmentLifestylechanges+immediatedrugtreatmentLifestylechanges+immediatedrugtreatmentLifestylechanges+immediatedrugtreatmentOtherriskfactors,ODordise9高血壓代謝危險因素控制面臨的困惑與啟示課件10干預高血壓相關的代謝危險因素能顯著降低心腦血管事件嗎？LowerbloodpressureYes(30%-60%)LowerlipidsYes(17%-43%)LowerbodyweightParadoxLowerglucoseUncertain干預高血壓相關的代謝危險因素能顯著降低心腦血管事件嗎？Low11BMIandWCvsfatparameters肥胖與心血管危險存在U形關系GuDF,etal.JAMA.2006;295:776-783BMIandWCvsfatparameters肥12肥胖與心衰Paradoxprognosis:excessbodyweighthaveaparadoxicalprotectiverole?

EnchaiahS,etal.NEnglJMed2002;347:305-13.DIAMONDstudygroupGustafsson1F,EurHeartJ,2005,26:58–64肥胖與心衰Paradoxprognosis:exces13肥胖與AMI

Obesityandtheriskofmyocardialinfarctionin27000participantsfrom52countries:acase-controlstudyYusufS,etal.Lancet2005;366:1640NicolettiI,etal.InterJCardiol,2006,107:395–399Paradoxprognosis:excessbodyweighthaveaparadoxicalprotectiverole?肥胖與AMI

Obesityandtherisko14生活方式改變的局限生活方式改變的局限15BMI不能反映內臟脂肪的實際變化BMI不能反映內臟脂肪的實際變化16腹型肥胖的類型與代謝綜合征的關系腹型肥胖類型腰圍超標

(≥90/85cm)腹內脂肪面積

VA≥100cm2非肥胖組－－隱性內臟脂肪型肥胖組(MaskedVFO)－＋假性內臟脂肪型肥胖組(PseudoVFO)＋－內臟型腹型肥胖組(visceralfatobesity，VFO)＋＋MS43%MS78%MS89%中華醫學雜志2008腹型肥胖的類型與代謝綜合征的關系腹型肥胖類型腰圍超標

(≥917Proposedmechanismsbywhichvisceralobesity,asthemostdangerousformofobesity,couldbelinkedtotheathero-thrombotic-inflammatoryabnormalitiesofinsulinresistance.

ATVB,2008Proposedmechanismsbywhichv18微血管并發癥心肌梗死HbA1c37%14%強化降糖與減少CVD事件面臨的困惑糖尿病相關的死亡21%1%StrattonIM,etal.BMJ2000;321:405–412.微血管并發癥心肌梗死HbA1c37%14%強化降糖與減少CV19DiabetesandCoronaryRiskEquivalencyDIAMONDstudygroupAbdominalobesityLifestylechanges+drugtreatmentLowerglucoseUncertainLifestylechanges+drugtreatmentJessupM,etal.Lifestylechanges+drugtreatmentSBP140-159orDBP90-99LowerbloodpressureYes(30%-60%)對高血壓的危險進行總體評估Lifestylechanges+immediatedrugtreatmentLifestylechanges+immediatedrugtreatmentNEJM,2003,348:2007-18.予100mg/d阿替洛爾能防止低血糖誘發的QTc延長和QTd離散Diabetes,2003糖尿病作為冠心病的等危癥是有條件的DiabetesandCoronaryRiskEquivalency糖尿病不合并其他危險因素，其心血管危險不高，也即單純高血糖至少在短期對心血管危害不大。糖尿病合并其他危險因素，其心血管危險性明顯增加，可視為冠心病等危癥。

GrandySM,DiabetesCare,2006DiabetesandCoronaryRiskEqu20理論假說

降壓和調脂的臨床試驗證實：血壓和血脂水平控制得越嚴格，獲得的益處更大。合理假設:強化血糖控制有益于減少CVD事件

理論假說

降壓和調脂的臨床試驗證實：血壓和血脂水平控制21

控制血糖至一定范圍顯著減少心腦血管事件

控制血糖至一定范圍顯著減少心腦血管事件

22ACCORD,ADVANCE,VADT強化血糖控制無益處在ACCORD試驗結果公布之前一個月，EurHeartJ連續刊登了2篇降糖治療增加心血管事件的臨床研究，編輯部予以評論。ACCORD,ADVANCE,VADT23DIGAMI2trial

Theimpactofglucoseloweringtreatmentonlong-termprognosisinpatientswithtype2diabetesandmyocardialinfarction:areportfromtheDIGAMI2trial

1996DIGAMI1研究顯示予胰島素治療顯著減少糖尿病的急性心肌梗塞死亡率Circulation1999;99:2626–2632.2005DIGAMI2探討降糖治療對糖尿病心肌梗塞的影響入選1181例2型糖尿病，平均年齡68歲，67%為男性，平均隨訪2.1年37%口服降糖藥，58%用胰島素EuropeanHeartJournal(2008)DIGAMI2trial

Theimpactof24與口服降糖藥相比，胰島素與全因死亡和心血管死亡無關，但可增加非致死心?；蚰X卒中

(HR:1.95,95%CI:1.35–2.82;P=0.0004)與口服降糖藥相比，胰島素與全因死亡和心血管死亡無關，但可增加25EuroHeartSurveyonDiabetesandtheHeart

Glucoseloweringtreatmentinpatientswithcoronaryarterydiseaseisprognosticallyimportantnotonlyinestablishedbutalsoinnewlydetecteddiabetesmellitus:areportfromtheEuroHeartSurveyonDiabetesandtheHeart

本研究比較了目前的降糖治療對冠心病己合并糖尿病和新發糖尿病的作用。從110個中心，入選4676例冠心病患者，其中1425例既往有糖尿病，452例為新發糖尿病。探討不同的降糖治療對心血管事件(死亡、心梗、卒中)的影響。EuropeanHeartJournal(2008)EuroHeartSurveyonDiabetes26與口服降糖藥相比，對合并糖尿病的冠心病，胰島素治療增加1年心血管死亡風險2.23(95%CI1.24–4.03;P=0.006)，但對新發糖尿病患者，與未降糖治療相比，降糖治療則明顯減少其心血管事件與口服降糖藥相比，對合并糖尿病的冠心病，胰島素治療增加1年心27最近的血糖控制試驗帶來的困惑

最近的血糖控制試驗帶來的困惑28Grade3HTSBP≥180orDBP≥110Lifestylechanges糖尿病不合并其他危險因素，其心血管危險不高，也即單純高血糖AmJCardiol2007;99:1006–1012EndotheliumBlaschkeF,etal.EuroHeartSurveyonDiabetesandtheHeart

Glucoseloweringtreatmentinpatientswithcoronaryarterydiseaseisprognosticallyimportantnotonlyinestablishedbutalsoinnewlydetecteddiabetesmellitus:areportfromtheEuroHeartSurveyonDiabetesandtheHeartAmJCardiol2007;99:1006–1012Obesityandtheriskofmyocardialinfarctionin27000participantsfrom52countries:acase-controlstudyYusufS,etal.ESC/ESH2007高血壓指南0mmol/l(40mg/dL),W<1.LifestylechangesforseveralweeksthendrugtreatmentifBPuncontrolled與口服降糖藥相比，胰島素與全因死亡和心血管死亡無關，但可增加非致死心?；蚰X卒中

(HR:1.2mmol/l(46mg/dL)or:管危險性明顯增加，可視為冠心病等危癥。JessupM,etal.NEJM,2003,348:2007-18.BlaschkeF,etal.ATVB,2006,26:28-40VanGaalLF,etal.Lancet,2005,365:1389-97多靶點藥物Grade3HTSBP≥180orDBP≥1129NEnglJMed2002;347:305-13.Lifestylechanges+immediatedrugtreatmentPotassium對降糖治療中出現的低血糖誘發的致死性心律失常的防治，也是其他藥物難以取代的。Age,Sex,SBP,TC,Smoking,HDL-cLifestylechanges對降糖治療中出現的低血糖誘發的致死性心律失常的防治，也是其他藥物難以取代的。HDL-C:M<1.AmJCardiol2007;99:1006–1012客觀評價β-blocker在糖尿病治療中的作用至少在短期對心血管危害不大。DyslipidemiaGustafsson1F,EurHeartJ,2005,26:58–64與口服降糖藥相比，胰島素與全因死亡和心血管死亡無關，但可增加非致死心?；蚰X卒中

(HR:1.（JHypertens2007,25：1105）降壓藥物的選擇NEnglJMed2002;347:305-13.30降壓藥物的選擇降壓藥物的選擇31EffectofInhibitionoftheRASonDevelopmentofType2DiabetesMellitus(Meta-AnalysisofRandomizedTrials)

AmJCardiol2007;99:1006–1012EffectofInhibitionoftheRA32Irbesartanforthetreatmentofhypertensioninpatientswiththe

metabolicsyndrome:AsubanalysisoftheTreattoTargetpost

authorizationsurvey.Prospectiveobservational,twoarmedstudy

in14,200patients

CardiovascularDiabetology2007,6:12

Irbesartanforthetreatmento33降糖藥對心血管事件的影響

EuropeanHeartJournal(2008)降糖藥對心血管事件的影響

EuropeanHeartJo34

不同降糖藥組合對LDL-C和血壓影響不同

BolenSAnnInternMed.2007

35客觀評價β-blocker在糖尿病治療中的作用予100mg/d阿替洛爾能防止低血糖誘發的QTc延長和QTd離散Diabetes,2003雖然予beta受體阻斷劑可能增加糖脂代謝紊亂和胰島素抵抗，但可顯著降低糖尿病合并心衰的死亡率。對降糖治療中出現的低血糖誘發的致死性心律失常的防治，也是其他藥物難以取代的。FonarowGC.AnApproachtoHeartFailureandDiabetesMellitusAmJCardiol2005;96[suppl]:47E–52E)客觀評價β-blocker在糖尿病治療中的作用予100mg36ChangesinSerumPotassiumMediateThiazide-InducedDiabetesHypertension.2008;52:1022-1029Thiazide-induceddiabetesoccurs(42%)earlyafterinitiatingtreatmentandappearstobemediatedbychangesinserumpotassium.Potassiumsupplementationmightpreventthiazide-induceddiabetes.ChangesinSerumPotassiumMed37SummaryCardiologist&EndocrinologistProgressionandoutcomesofthemetabolicsyndrome

GrundySM,JAmCollCardiol2006;47:1093–100SummaryProgressionandoutcome38謝謝！謝謝！39本研究比較了目前的降糖治療對冠心病己合并糖尿病和新發糖尿病的作用。Otherriskfactors,ODordiseaseDyslipidemiaVanGaalLF,etal.LifestylechangesGrade3HTSBP≥180orDBP≥110Lifestylechanges+immediatedrugtreatment干預高血壓相關的代謝危險因素能顯著降低心腦血管事件嗎？Lifestylechanges+immediatedrugtreatmentOtherriskfactors,ODordiseaseEndotheliumDyslipidemiaDiabetesandCoronaryRiskEquivalencyLifestylechangesforseveralweeksthendrugtreatmentifBPuncontrolledAbdominalDyslipidemiaAbdominalObesityDiabetesUricacidRenallesionEndotheliumdamage

HypertensiveSyndrome

-ConstellationsofCardiometabolicRiskFactorsHypertension80%高血壓危險因素CVD事件本研究比較了目前的降糖治療對冠心病己合并糖尿病和新發糖尿病的40Otherriskfactors,ODordiseaseNormalSBP120-129orDBP80-84HighnormalSBP130-139orDBP85-89Grade1HTSBP140-159orDBP90-99Grade2HTSBP160-179orDBP100-109Grade3HTSBP≥180orDBP≥110NootherriskfactorsNoBPinterventionNoBPinterventionLifestylechangesforseveralmonthsthendrugtreatmentifBPuncontrolledLifestylechangesforseveralweeksthendrugtreatmentifBPuncontrolledLifestylechanges+immediatedrugtreatment1-2riskfactorsLifestylechangesLifestylechangesLifestylechangesforseveralweeksthendrugtreatmentifBPuncontrolledLifestylechangesforseveralweeksthendrugtreatmentifBPuncontrolledLifestylechanges+immediatedrugtreatment3ormoreriskfactors,MS,ODordiabetesLifestylechangesLifestylechangesandconsiderdrugtreatmentLifestylechanges+drugtreatmentLifestylechanges+drugtreatmentLifestylechanges+immediatedrugtreatmentDiabetesLifestylechangesLifestylechanges+drugtreatmentEstablishedCVorrenaldiseaseLifestylechanges+immediatedrugtreatmentLifestylechanges+immediatedrugtreatmentLifestylechanges+immediatedrugtreatmentLifestylechanges+immediatedrugtreatmentLifestylechanges+immediatedrugtreatmentOtherriskfactors,ODordise41糖尿病作為冠心病的等危癥是有條件的DiabetesandCoronaryRiskEquivalency糖尿病不合并其他危險因素，其心血管危險不高，也即單純高血糖至少在短期對心血管危害不大。糖尿病合并其他危險因素，其心血管危險性明顯增加，可視為冠心病等危癥。

GrandySM,DiabetesCare,2006糖尿病作為冠心病的等危癥是有條件的糖尿病不合并其他危險因素，42與口服降糖藥相比，對合并糖尿病的冠心病，胰島素治療增加1年心血管死亡風險2.23(95%CI1.24–4.03;P=0.006)，但對新發糖尿病患者，與未降糖治療相比，降糖治療則明顯減少其心血管事件與口服降糖藥相比，對合并糖尿病的冠心病，胰島素治療增加1年心43EffectofInhibitionoftheRASonDevelopmentofType2DiabetesMellitus(Meta-AnalysisofRandomizedTrials)

AmJCardiol2007;99:1006–1012EffectofInhibitionoftheRA44客觀評價β-blocker在糖尿病治療中的作用予100mg/d阿替洛爾能防止低血糖誘發的QTc延長和QTd離散Diabetes,2003雖然予beta受體阻斷劑可能增加糖脂代謝紊亂和胰島素抵抗，但可顯著降低糖尿病合并心衰的死亡率。對降糖治療中出現的低血糖誘發的致死性心律失常的防治，也是其他藥物難以取代的。FonarowGC.AnApproachtoHeartFailureandDiabetesMellitusAmJCardiol2005;96[suppl]:47E–52E)客觀評價β-blocker在糖尿病治療中的作用予100mg45DyslipidemiaAbdominalObesityDiabetesUricacidRenallesionEndotheliumdamage

HypertensiveSyndrome

-ConstellationsofCardiometabolicRiskFactorsHypertension80%高血壓危險因素CVD事件DyslipidemiaAbdominalDiabete46更強調危險因素的早期控制更關注血管和代謝因素的相互作用對高血壓的危險進行總體評估防治上既遵循循證醫學證據，也強調個體化治療更強調危險因素的早期控制47Abdominalobesity

Waistcircumference>102cm(M),88cm(W)DyslipidaemiaTC>5.0mmol/l(原為6.1)orLDL-C>3.0mmol/l(原為4.0)orHDL-C:M<1.0mmol/l(40mg/dL),W<1.2mmol/l(46mg/dL)or:TG>1.7mmol/l(150mg/dL)IFG&IGTFastingplasmaglucose5.6-6.9mmol/L(102-125mg/dL)AbnormalglucosetolerancetestESC/ESH

2007高血壓指南Metabolic

syndrometheclusterofthreeoutof5riskfactorsamongabdominalobesity,alteredfastingplasmaglucose,BP≥130/85mmHg,low

HDL-cholesterolandhighTG(asdefinedabove)DiabetesMellitusFastingplasma≥7.0mmol/l(126mg/dL)onrepeatedmeasurements,orPostloadplasmaglucose>11.0mmol/l(198mg/dL)（JHypertens2007,25：1105）AbdominalobesityESC/ESH200748ESC/ESH

2007——關注高血壓伴發的代謝異常（JHypertens2007,25：1105）ESC/ESH2007——關注高血壓伴發的代謝異常（J49如何評估高血壓的代謝危險性DiabetesVascDisRes2008;5:9–14如何評估高血壓的代謝危險性DiabetesVascDis50心血管代謝危險性評估1.Framinghamscore(USA)

Age,Sex,SBP,TC,Smoking,HDL-c2.TheUKPDSriskengine(UK)

Age,Sex,SBP,Smoking,TC/HDL-c,HbA1c3.PROCAMscore(Germany)

Age,LDL-c,TC,smoking,HDL-c,SBP,FHofMI,DM,TG4.ICVD(China)

Age,Sex,SBP,BMI,TC,Smoking,DM心血管代謝危險性評估1.Framinghamscore51危險分層：ESC/ESH危險分層：ESC/ESH52Lancet2005;366:1640Lifestylechanges+immediatedrugtreatmentAmJCardiol2007;99:1006–1012Grade3HTSBP≥180orDBP≥110管危險性明顯增加，可視為冠心病等危癥。LifestylechangesforseveralweeksthendrugtreatmentifBPuncontrolled危險分層：ESC/ESHESC/ESH2007——關注高血壓伴發的代謝異常控制血糖至一定范圍顯著減少心腦血管事件EstablishedCVorrenaldiseaseLifestylechangesforseveralweeksthendrugtreatmentifBPuncontrolled肥胖與心衰Paradoxprognosis:excessbodyweighthaveaparadoxicalprotectiverole?BolenSAnnInternMed.SBP130-139orDBP85-89ATVB,2006,26:28-40靶器官損害的評價Lancet2005;366:1640靶器官損害的評價53Otherriskfactors,ODordiseaseNormalSBP120-129orDBP80-84HighnormalSBP130-139orDBP85-89Grade1HTSBP140-159orDBP90-99Grade2HTSBP160-179orDBP100-109Grade3HTSBP≥180orDBP≥110NootherriskfactorsNoBPinterventionNoBPinterventionLifestylechangesforseveralmonthsthendrugtreatmentifBPuncontrolledLifestylechangesforseveralweeksthendrugtreatmentifBPuncontrolledLifestylechanges+immediatedrugtreatment1-2riskfactorsLifestylechangesLifestylechangesLifestylechangesforseveralweeksthendrugtreatmentifBPuncontrolledLifestylechangesforseveralweeksthendrugtreatmentifBPuncontrolledLifestylechanges+immediatedrugtreatment3ormoreriskfactors,MS,ODordiabetesLifestylechangesLifestylechangesandconsiderdrugtreatmentLifestylechanges+drugtreatmentLifestylechanges+drugtreatmentLifestylechanges+immediatedrugtreatmentDiabetesLifestylechangesLifestylechanges+drugtreatmentEstablishedCVorrenaldiseaseLifestylechanges+immediatedrugtreatmentLifestylechanges+immediatedrugtreatmentLifestylechanges+immediatedrugtreatmentLifestylechanges+immediatedrugtreatmentLifestylechanges+immediatedrugtreatmentOtherriskfactors,ODordise54高血壓代謝危險因素控制面臨的困惑與啟示課件55干預高血壓相關的代謝危險因素能顯著降低心腦血管事件嗎？LowerbloodpressureYes(30%-60%)LowerlipidsYes(17%-43%)LowerbodyweightParadoxLowerglucoseUncertain干預高血壓相關的代謝危險因素能顯著降低心腦血管事件嗎？Low56BMIandWCvsfatparameters肥胖與心血管危險存在U形關系GuDF,etal.JAMA.2006;295:776-783BMIandWCvsfatparameters肥57肥胖與心衰Paradoxprognosis:excessbodyweighthaveaparadoxicalprotectiverole?

EnchaiahS,etal.NEnglJMed2002;347:305-13.DIAMONDstudygroupGustafsson1F,EurHeartJ,2005,26:58–64肥胖與心衰Paradoxprognosis:exces58肥胖與AMI

Obesityandtheriskofmyocardialinfarctionin27000participantsfrom52countries:acase-controlstudyYusufS,etal.Lancet2005;366:1640NicolettiI,etal.InterJCardiol,2006,107:395–399Paradoxprognosis:excessbodyweighthaveaparadoxicalprotectiverole?肥胖與AMI

Obesityandtherisko59生活方式改變的局限生活方式改變的局限60BMI不能反映內臟脂肪的實際變化BMI不能反映內臟脂肪的實際變化61腹型肥胖的類型與代謝綜合征的關系腹型肥胖類型腰圍超標

(≥90/85cm)腹內脂肪面積

VA≥100cm2非肥胖組－－隱性內臟脂肪型肥胖組(MaskedVFO)－＋假性內臟脂肪型肥胖組(PseudoVFO)＋－內臟型腹型肥胖組(visceralfatobesity，VFO)＋＋MS43%MS78%MS89%中華醫學雜志2008腹型肥胖的類型與代謝綜合征的關系腹型肥胖類型腰圍超標

(≥962Proposedmechanismsbywhichvisceralobesity,asthemostdangerousformofobesity,couldbelinkedtotheathero-thrombotic-inflammatoryabnormalitiesofinsulinresistance.

ATVB,2008Proposedmechanismsbywhichv63微血管并發癥心肌梗死HbA1c37%14%強化降糖與減少CVD事件面臨的困惑糖尿病相關的死亡21%1%StrattonIM,etal.BMJ2000;321:405–412.微血管并發癥心肌梗死HbA1c37%14%強化降糖與減少CV64DiabetesandCoronaryRiskEquivalencyDIAMONDstudygroupAbdominalobesityLifestylechanges+drugtreatmentLowerglucoseUncertainLifestylechanges+drugtreatmentJessupM,etal.Lifestylechanges+drugtreatmentSBP140-159orDBP90-99LowerbloodpressureYes(30%-60%)對高血壓的危險進行總體評估Lifestylechanges+immediatedrugtreatmentLifestylechanges+immediatedrugtreatmentNEJM,2003,348:2007-18.予100mg/d阿替洛爾能防止低血糖誘發的QTc延長和QTd離散Diabetes,2003糖尿病作為冠心病的等危癥是有條件的DiabetesandCoronaryRiskEquivalency糖尿病不合并其他危險因素，其心血管危險不高，也即單純高血糖至少在短期對心血管危害不大。糖尿病合并其他危險因素，其心血管危險性明顯增加，可視為冠心病等危癥。

GrandySM,DiabetesCare,2006DiabetesandCoronaryRiskEqu65理論假說

降壓和調脂的臨床試驗證實：血壓和血脂水平控制得越嚴格，獲得的益處更大。合理假設:強化血糖控制有益于減少CVD事件

理論假說

降壓和調脂的臨床試驗證實：血壓和血脂水平控制66

控制血糖至一定范圍顯著減少心腦血管事件

控制血糖至一定范圍顯著減少心腦血管事件

67ACCORD,ADVANCE,VADT強化血糖控制無益處在ACCORD試驗結果公布之前一個月，EurHeartJ連續刊登了2篇降糖治療增加心血管事件的臨床研究，編輯部予以評論。ACCORD,ADVANCE,VADT68DIGAMI2trial

Theimpactofglucoseloweringtreatmentonlong-termprognosisinpatientswithtype2diabetesandmyocardialinfarction:areportfromtheDIGAMI2trial

1996DIGAMI1研究顯示予胰島素治療顯著減少糖尿病的急性心肌梗塞死亡率Circulation1999;99:2626–2632.2005DIGAMI2探討降糖治療對糖尿病心肌梗塞的影響入選1181例2型糖尿病，平均年齡68歲，67%為男性，平均隨訪2.1年37%口服降糖藥，58%用胰島素EuropeanHeartJournal(2008)DIGAMI2trial

Theimpactof69與口服降糖藥相比，胰島素與全因死亡和心血管死亡無關，但可增加非致死心梗或腦卒中

(HR:1.95,95%CI:1.35–2.82;P=0.0004)與口服降糖藥相比，胰島素與全因死亡和心血管死亡無關，但可增加70EuroHeartSurveyonDiabetesandtheHeart

Glucoseloweringtreatmentinpatientswithcoronaryarterydiseaseisprognosticallyimportantnotonlyinestablishedbutalsoinnewlydetecteddiabetesmellitus:areportfromtheEuroHeartSurveyonDiabetesandtheHeart

本研究比較了目前的降糖治療對冠心病己合并糖尿病和新發糖尿病的作用。從110個中心，入選4676例冠心病患者，其中1425例既往有糖尿病，452例為新發糖尿病。探討不同的降糖治療對心血管事件(死亡、心梗、卒中)的影響。EuropeanHeartJournal(2008)EuroHeartSurveyonDiabetes71與口服降糖藥相比，對合并糖尿病的冠心病，胰島素治療增加1年心血管死亡風險2.23(95%CI1.24–4.03;P=0.006)，但對新發糖尿病患者，與未降糖治療相比，降糖治療則明顯減少其心血管事件與口服降糖藥相比，對合并糖尿病的冠心病，胰島素治療增加1年心72最近的血糖控制試驗帶來的困惑

最近的血糖控制試驗帶來的困惑73Grade3HTSBP≥180orDBP≥110Lifestylechanges糖尿病不合并其他危險因素，其心血管危險不高，也即單純高血糖AmJCardiol2007;99:1006–1012EndotheliumBlaschkeF,etal.EuroHeartSurveyonDiabetesandtheHeart

Glucoseloweringtreatmentinpatientswithcoronaryarterydiseaseisprognosticallyimportantnotonlyinestablishedbutalsoinnewlydetecteddiabetesmellitus:areportfromtheEuroHeartSurveyonDiabetesandtheHeartAmJCardiol2007;99:1006–1012Obesityandtheriskofmyocardialinfarctionin27000participantsfrom52countries:acase-controlstudyYusufS,etal.ESC/ESH2007高血壓指南0mmol/l(40mg/dL),W<1.LifestylechangesforseveralweeksthendrugtreatmentifBPuncontrolled與口服降糖藥相比，胰島素與全因死亡和心血管死亡無關，但可增加非致死心?；蚰X卒中

(HR:1.2mmol/l(46mg/dL)or:管危險性明顯增加，可視為冠心病等危癥。JessupM,etal.NEJM,2003,348:2007-18.BlaschkeF,etal.ATVB,2006,26:28-40VanGaalLF,etal.Lancet,2005,365:1389-97多靶點藥物Grade3HTSBP≥180orDBP≥1174NEnglJMed2002;347:305-13.Lifestylechanges+immediatedrugtreatmentPotassium對降糖治療中出現的低血糖誘發的致死性心律失常的防治，也是其他藥物難以取代的。Age,Sex,SBP,TC,Smoking,HDL-cLifestylechanges對降糖治療中出現的低血糖誘發的致死性心律失常的防治，也是其他藥物難以取代的。HDL-C:M<1.AmJCardiol2007;99:1006–1012客觀評價β-blocker在糖尿病治療中的作用至少在短期對心血管危害不大。DyslipidemiaGustafsson1F,EurHeartJ,2005,26:58–64與口服降糖藥相比，胰島素與全因死亡和心血管死亡無關，但可增加非致死心?；蚰X卒中

(HR:1.（JHypertens2007,25：1105）降壓藥物的選擇NEnglJMed2002;347:305-13.75降壓藥物的選擇降壓藥物的選擇76EffectofInhibitionoftheRASonDevelopmentofType2DiabetesMellitus(Meta-AnalysisofRandomizedTrials)

AmJCardiol2007;99:1006–1012EffectofInhibitionoftheRA77Irbesartanforthetreatmentofhypertensioninpatientswiththe

metabolicsyndrome:AsubanalysisoftheTreattoTargetpost

authorizationsurvey.Prospectiveobservational,twoarmedstudy

in14,200patients

CardiovascularDiabetology2007,6:12

Irbesartanforthetreatmento78降糖藥對心血管事件的影響

EuropeanHeartJournal(2008)降糖藥對心血管事件的影響

EuropeanHeartJo79

不同降糖藥組合對LDL-C和血壓影響不同

BolenSAnnInternMed.2007

80客觀評價β-blocker在糖尿病治療中的作用予100mg/d阿替洛爾能防止低血糖誘發的QTc延長和QTd離散Diabetes,2003雖然予beta受體阻斷劑可能增加糖脂代謝紊亂和胰島素抵抗，但可顯著降低糖尿病合并心衰的死亡率。對降糖治療中出現的低血糖誘發的致死性心律失常的防治，也是其他藥物難以取代的。FonarowGC.AnApproachtoHeartFailureandDiabetesMellitusAmJCardiol2005;96[suppl]:47E–52E)客觀評價β-blocker在糖尿病治療中的作用予100mg81ChangesinSerumPotassiumMediateThiazide-InducedDiabetesHypertension.2008;52:1022-1029Thiazide-induceddiabetesoccurs(42%)earlyafterinitiatingtreatmentandappearstobemediatedbychangesinserumpotassium.Potassiumsupplementationmightpreventthiazide-induceddiabetes.ChangesinSerumPotassiumMed82SummaryCardiologist&EndocrinologistProgressionandoutcomesofthemetabolicsyndrome

GrundySM,JAmCollCardiol2006;47:1093–100SummaryProgressionandoutcome83謝謝！謝謝！84本研究比較了目前的降糖治療對冠心病己合并糖尿病和新發糖尿病的作用。Otherriskfactors,ODordiseaseDyslipidemiaVanGaalLF,etal.LifestylechangesGrade3HTSBP≥180orDBP≥110Lifestylechanges+immediatedrugtreatment干預高血壓相關的代謝危險因素能顯著降低心腦血管事件嗎？Lifestylechanges+immediate