糖尿病伴血脂异与常患者的社区治疗策略.pptVIP

* LDL-C是个重要危险因素, 但HDL-C,SBP, HbA1c同样是心血管危险预测的重要因素. * 我国建议 * * 2006年BMJ上一篇关于同时入选糖尿病和非糖尿病患者降脂研究荟萃分析显示, 降脂研究(绝大部分是他汀研究)可以显著降低糖尿病和非糖尿病患者的心血管风险. 而糖尿病患者无论在一级预防还是二级预防中获益更多. The evidence that lipid lowering drug treatment (especially statins) significantly reduce cardiovascular risk in diabetic and non-diabetic patients is strong and suggests that diabetic patients benefit more, in both primary and secondary prevention. * UKPDS clearly demonstrated that in addition to important glucose control for reducing microvascular complications, LDL-C is a primary target for reducing CHD risk in patients with diabetes. The effect of a unit increment in key risk factors (1?mmol/L for LDL-C, 0.1?mmol/L in HDL-C, 10?mmHg in systolic blood pressure [SBP], and 1% in HbA1c) on CHD risk was also determined. For each increment of 1?mmol/L in LDL-C, there was a 1.57-fold (57%) increased risk of CHD. For each positive increment of 0.1?mmol/L in HDL-C, there was a 0.15-fold (15%) decrease in risk. For each increment of 10?mmHg in SBP, there was a 1.15-fold (15%) risk increase, and for each increment of 1% in HbA1c, there was a 1.11-fold (11%) increase in risk.20 This analysis supports the view that elevated LDL-C is the strongest determinant of CHD risk in patients with type 2 diabetes. Ref 20, p 826, C2, ?3, L1 % increase= risk – 1.00 ? 100 * * 辛伐他汀可以显著减少单纯糖尿病患者或糖尿病合并心血管疾病患者的主要血管事件 * HDL颗粒的功能异质性 ApoAI作为HDL的主要组成蛋白, 在RCT中起了很大作用. ApoAI能诱发ABCA1和卵磷脂胆固醇酰基转移酶的活性, 也是HDL分解代谢(cubilin受体和B链ATP合酶)和胆固醇脂选择性摄取中涉及的膜联受体(SR-B1)的配体. ApoAII存在于部分HDL中.在动物模型中可能有致动脉粥样硬化性.只含有ApoAI(Lp AI)的HDL颗粒主要是HDL2. 与Lp AI+II的HDL相比, HDL2是外周细胞ATP结合盒转运体A1(ABCA1)的游离胆固醇更有效的受体, 也是肝脏细胞SR-B1素胆固醇脂的更有效受体 * 尽管已经把糖尿病作为冠心病的等危因素，但是仍然需要一些前瞻性试验数据来强调在糖尿病患者中控制CVD风险的重要性。 目前，关于他汀药物在预防糖尿病患者心血管病的作用方面，只有一些长期大规模临床试验的亚组分析数据。这些试验数据显示，在降低心血管病风险方面，他汀类药物对糖尿病患者的疗效至少和对CHD患者的疗效一样。 除了心脏保护试验（HPS）之外，在这些试验中只有一小部分糖尿病患者的试验数据用于评估分析。因此目前需要大规模的试验，来充分评估他汀类药物对糖尿病患者可能存在的临床获益，尤其是在一级预防中的临床获益。 Heart Protection Study Collaborative Group. MRC/BHF Heart Protection St