Diabetologia:糖尿病患者降糖药物使用与新发房颤的关系

2022-06-25 从医路漫漫 MedSci原创

糖尿病和心房颤动(AF)在全球范围内呈上升趋势,并与发病率和死亡率增加相关。糖尿病患者发生房颤的风险增加,但目前有争议的是,糖尿病的治疗方法是否会影响新发房颤的风险。

背景:糖尿病和心房颤动(AF)在全球范围内呈上升趋势,并与发病率和死亡率增加相关。糖尿病患者发生房颤的风险增加,但目前有争议的是,糖尿病的治疗方法是否会影响新发房颤的风险。目前还没有确凿的证据表明,现有的不同降糖方案会加速或减缓新发房颤的发展。同时缺乏分析不同糖尿病药物的大型研究。在一项全国性的纵向队列研究调查了糖尿病的治疗是否与房颤的不同风险相关。

方法:该分析使用了EGB (' Echantillon Généraliste des Bénéficiaires '),包含了法国全国范围内索赔和住院数据约1/97代表性样本。我们确定了所有诊断1型或2型糖尿病患者。在排除了基线时有房颤病史的患者后,建立了一个由2010年至2018年期间就诊的25117名患有糖尿病的成年队列,并跟踪调查到2018年12月新发房颤的发病率(表1)。测量了进入队列后180天内的药物暴露情况,将患者分为两组(无论每种药物暴露或不暴露,以及患者在这180天的随访期间是否有用药变化)。其中二甲双胍36.5%,磺脲类药物32.2%,二肽基肽酶-4抑制剂7.1%,胰高血糖素样肽-1类似物1.6%,胰岛素19.7%。Cox比例风险模型包含表1所示的所有指标,用于确定随访期间与AF风险独立相关的因素和不同口服糖尿病药物,包括使用多种形式的降糖药物的患者。

结果:平均随访4.8±3.5年(中位4.3年,IQR 1.7-7.5年),有3300例新发房颤(年发生率2.7%)。随访期间,这些患者年龄较大,男性居多,大多数心血管和非心血管合并症的患病率高于无房颤患者(表)。多变量分析显示,高龄、男性、心力衰竭、慢性肾脏病和贫血与新发AF的高风险独立相关在糖尿病药物中,磺脲类药物的使用与较低的房颤风险独立相关(HR 0.86;95% CI 0.80, 0.92;p< 0.0001)。相比之下,使用二甲双胍、GLP1类似物、DPP4抑制剂或胰岛素与房颤发生风险较高独立相关,危险比从二甲双胍的1.09到GLP1类似物的2.27不等(表和图)。我们的研究结果为以下假设提供了一些支持:糖尿病患者不同类型的降糖药物之间发生AF的风险存在差异。虽然强化血糖控制对新发房颤的发生率没有明显影响,但糖尿病治疗对房颤风险的影响一直存在争议。最近的一项孟德尔随机研究并未发现2型糖尿病或血糖异常与房颤风险之间的因果关系。这表明,2型糖尿病患者的血糖控制可能不是减轻社区房颤负担的好方法。

相反,在另一项病例对照研究中,使用二甲双胍类或噻唑烷二酮类与较低的AF风险相关,而使用胰岛素则与较高的AF风险相关。我们的纵向分析没有证实二甲双胍的结果,而由于膀胱癌风险增加,噻唑烷二酮自2011年以来就没有在法国使用。据我们所知,磺酰脲类药物较低的房颤发生风险,而GLP1类似物和DPP4抑制剂的调整后房颤发生风险较高,此前没有报道,可能与最近使用不同方法导致分析结果不同。这可能与以下假设相反:降低胰岛素抵抗或导致体重减轻的药物可能与AF发生率降低有关;通过低血糖刺激交感神经系统的药物与AF发生率增加有关。GLP-1类似物治疗的AF发生率相当小,我们的结果应谨慎的进行解释。

表 糖尿病患者随访期间新发房颤风险的基线特征和调整HRs

图 使用不同类别降糖药物和调整风险比的糖尿病患者在随访期间发生新发房颤的风险。事件AF的值以ASN(年率,%)表示。糖尿病,糖尿病

结论:使用不同糖尿病药物的患者发生房颤的长期风险不同。具体而言,磺脲类药物的使用与房颤发生风险较低相关,而其他抗糖尿病药物在随访中与房颤发生风险较高相关。因此,不同的降糖药物特性可能会影响房颤的发生率,这可能会影响糖尿病患者心血管事件的风险。这些发现可能具有临床意义,并强调了进一步研究降糖药物和房颤风险的必要性。

原文出处:

Fauchier G,  Bisson A,  Bodin A,et al.Glucose-lowering drug use and new-onset atrial fibrillation in patients with diabetes mellitus.Diabetologia 2021 Aug 25

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    2022-05-19 docwu2019
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    2021-11-12 湘雅科教

    已拜读,受益匪浅。

    0

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