Circulation:糖尿病合并冠心病,侵入治疗结局是否更佳?

2021-09-27 MedSci原创 MedSci原创

糖尿病是冠心病的等危症。

糖尿病血管病之间存在着密切的内在联系,二者互为高危人群。2001 年美国国家胆固醇教育计划成人治疗指南Ⅲ(NCEP-ATP Ⅲ)指出:糖尿病是冠心病的等危症。2007 年,美国心脏病学院甚至发出了“糖尿病就是心血管病”的呼声。提高对糖尿病患者冠状动脉病变和介入治疗的认识,以及加强经皮冠状动脉介入治疗(PCI)术后对血糖等危险因素的管理,对于最大程度地改善患者的预后具有重要意义。

然而,糖尿病合并慢性冠心病(CCD)患者中,目前还不清楚在药物治疗的基础上增加侵入性管理是否能改善结果。为了明确上述结果,来自纽约大学的专家开展了ISCHEMIA试验,结果发表在Circulation杂志上。

ISCHEMIA试验(ISCHEMIA和ISCHEMIA CKD)将CCD患者随机分为侵入性治疗(药物治疗+血管造影和血管重建)或保守性治疗(单纯药物治疗,如果药物治疗失败,则进行血管重建)。在没有观察到试验的特定效果后,队列被合并。糖尿病的定义是有病史,HbA1c≥6.5%,或使用降糖药物。主要结果是全因死亡或心肌梗死(MI)。使用贝叶斯方法评估了侵入性管理对死亡或MI的影响的异质性,以防止对糖尿病患者与非糖尿病患者以及临床(女性性别和胰岛素使用)和解剖学特征(冠状动脉疾病[CAD]严重程度或左心室功能)的糖尿病亚组的治疗效果的随机高或低估计。

结果在有完整基线数据的5900名参与者中,中位年龄为64岁,四分位数范围(IQR)[57-70],24%为女性,估计肾小球滤过率中位数为80ml/min/1.73m。在2553名(43%)患有糖尿病的参与者中,HBA1c百分比的中位数为7%,30%接受胰岛素治疗。

总的来说,患有糖尿病的参与者的死亡或MI的危险增加了49%(HR 1.49;95% CI:1.31-1.70)。在中位3.1年的随访中,调整后的无事件生存率为0.54,有糖尿病与无糖尿病的患者为0.66--有糖尿病的参与者的无事件生存率绝对下降12%。胰岛素治疗的女性和男性糖尿病患者的调整无事件生存率分别为0.52和0.49。

综上,尽管死亡或MI的风险较高,但与单纯的初始药物治疗相比,CCD患者并没有从常规侵入性管理中获得更多的益处。

 

参考文献:

Outcomes of Participants with Diabetes in the ISCHEMIA Trials. https://doi.org/10.1161/CIRCULATIONAHA.121.054439

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  2. [GetPortalCommentsPageByObjectIdResponse(id=1694910, encodeId=509016949104f, content=<a href='/topic/show?id=ce9b64692d2' target=_blank style='color:#2F92EE;'>#治疗结局#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=40, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=64692, encryptionId=ce9b64692d2, topicName=治疗结局)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=4d1829785524, createdName=zhangjiqing, createdTime=Wed Dec 15 16:00:00 CST 2021, time=2021-12-15, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1207551, encodeId=2b5a120e5518e, content=谢谢分享。很有用, beContent=null, objectType=article, channel=null, level=null, likeNumber=39, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=b4da6463967, createdName=ms6000000942294328, createdTime=Thu Mar 31 14:52:32 CST 2022, time=2022-03-31, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1055980, encodeId=e518105598055, content=学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=65, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=c7995605070, createdName=鸿毳沉舟, createdTime=Wed Sep 29 10:20:33 CST 2021, time=2021-09-29, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1055437, encodeId=0110105543eb0, content=xuexile, beContent=null, objectType=article, channel=null, level=null, likeNumber=68, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=253f5447547, createdName=ms1000001573099445, createdTime=Mon Sep 27 18:14:52 CST 2021, time=2021-09-27, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1055389, encodeId=d0b01055389ed, content=学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=67, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=0d785442816, createdName=ms8000000545763740, createdTime=Mon Sep 27 15:33:12 CST 2021, time=2021-09-27, status=1, ipAttribution=)]
    2022-03-31 ms6000000942294328

    谢谢分享。很有用

    0

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    2021-09-29 鸿毳沉舟

    学习了

    0

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    2021-09-27 ms1000001573099445

    xuexile

    0

  5. [GetPortalCommentsPageByObjectIdResponse(id=1694910, encodeId=509016949104f, content=<a href='/topic/show?id=ce9b64692d2' target=_blank style='color:#2F92EE;'>#治疗结局#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=40, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=64692, encryptionId=ce9b64692d2, topicName=治疗结局)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=4d1829785524, createdName=zhangjiqing, createdTime=Wed Dec 15 16:00:00 CST 2021, time=2021-12-15, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1207551, encodeId=2b5a120e5518e, content=谢谢分享。很有用, beContent=null, objectType=article, channel=null, level=null, likeNumber=39, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=b4da6463967, createdName=ms6000000942294328, createdTime=Thu Mar 31 14:52:32 CST 2022, time=2022-03-31, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1055980, encodeId=e518105598055, content=学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=65, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=c7995605070, createdName=鸿毳沉舟, createdTime=Wed Sep 29 10:20:33 CST 2021, time=2021-09-29, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1055437, encodeId=0110105543eb0, content=xuexile, beContent=null, objectType=article, channel=null, level=null, likeNumber=68, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=253f5447547, createdName=ms1000001573099445, createdTime=Mon Sep 27 18:14:52 CST 2021, time=2021-09-27, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1055389, encodeId=d0b01055389ed, content=学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=67, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=0d785442816, createdName=ms8000000545763740, createdTime=Mon Sep 27 15:33:12 CST 2021, time=2021-09-27, status=1, ipAttribution=)]
    2021-09-27 ms8000000545763740

    学习了

    0

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