治療糖尿病只靠控制血糖是不夠的

醫生們可能會忽視其他心血管病危險因數

  2002年6月17日報導─據6月15日,美國糖尿病協會年會上報導的兩項研究的結果顯示,在糖尿病的治療中,醫生們可能能很好的控制血糖,但是在控制或治療其他心血管危險因素方面並沒有加以同樣的重視。

  Minneapolis國際糖尿病研究中心的Richard Bergenstal,和他的同事們寫道:「有一個機會可以使糖尿病人的治療得到改善,並且達到目標的血糖、血脂和血壓水準。只要充分瞭解了內科醫師們是如何優先重視和解釋這些危險因素的,就可以制定出更為有效的策略,使得糖尿病患者可以達到治療的目標,並且減少心血管疾病的負擔。」

  這次為期12個月的,多中心的觀察性研究,是目前首次而且是最大的一次前瞻性研究,來研究內科醫師如何處理主要的心血管危險因素,和這些處理步驟是如何最終影響HbA1c、血壓和LDL膽固醇。

  共募集了2300名最近被診斷為糖尿病的患者,其年齡大於或等於40歲,來自144個地區。其平均年齡為61歲,87%的患者患有II型糖尿病。基礎的治療方法包括70%的患者採用降血糖治療,67%的患者進行了降血壓的治療,44%的患者經行了降血脂的治療。基礎階段,達到HbA1c指標治療目標的患者占到了總數的33.5%,達到了LDL-C治療標準的患者占到了30.4%,而降血壓達到目標的占17.6%。

  作者寫道:「內科醫師將主要的注意力集中在了血糖的控制上,控制血壓或血脂被放在次要的位置上,一般作為次要的或第三位元的治療目標。」

  在另一項報告中,Conn New Haven耶魯大學醫學部的Silvio E. Inzucchi,和他的同事們指出,這些治療的優先次序是錯誤的,因為冠狀動脈疾病是導致第二型糖尿病患者死亡的主要原因。儘管血糖的控制還不確定是否可以降低CAD的發病率,其他的代謝綜合症的特徵,如高血壓、dyslipidemia、體重、和血液高粘稠性,似乎更為重要。

  非症狀性糖尿病缺血性疾病(DIAD)的研究,是一項多中心的,採用Adenosine-Sestamibi灌注造影技術,研究II型糖尿病患者無症狀性心肌缺血的患病率的研究。

  從2000年9月以來,在402名被研究中,有55%的人的ADA HbA1c達到了<7.0%的標準。即使在那些血糖控制比較好的被研究者中,其他心血管危險因素的控制也是相當的不穩定的。

  作者寫道:「在我們的研究人群中,大部分患者似乎正處於良好的糖尿病治療中,但是總體上並沒有控制好冠狀動脈疾病的危險因素。我們強調在控制血糖的以外,還要控制好其他心血管危險因素,是為了強調II型糖尿病對冠狀動脈疾病危險因素顯著影響,這樣做是有必要的。」

When Managing Diabetes, Good Glycemic Control Is Not Enough

Doctors May Ignore Other Cardiovascular Risk Factors

By Laurie Barclay, MD
WebMD Medical News

Reviewed by Gary D. Vogin, MD

June 17, 2002 -- When it comes to managing diabetes, doctors may achieve good glycemic control but have a lower priority for controlling or treating other cardiovascular risk factors, according to two presentations June 15 at the annual American Diabetic Association meeting.

"An opportunity exists to improve treatment rates and goal attainment for glycemic, lipid, and blood pressure control among patients with diabetes," write Richard Bergenstal, from the International Diabetes Center in Minneapolis, and colleagues. "Only by understanding how physicians prioritize and address these risk factors will we be able to develop more effective strategies to reach goals and reduce the burden of cardiovascular disease in diabetes."

This 12-month, multicenter, observational study was one of the first and largest prospective studies to investigate how clinicians approach major cardiovascular risk factors and how this approach ultimately affects HbA1c, blood pressure, and LDL cholesterol.

About 2,300 newly referred or newly diagnosed diabetes patients, aged 40 years and older, were enrolled from 144 sites. Mean age was 61 years, and 87% of patients had type 2 diabetes. Baseline medications included glycemic therapy in 70%, antihypertensives in 67%, and lipid-lowering therapy in 44%. The percentage of patients meeting goal at baseline was 33.5% for HbA1c, 30.4% for LDL-C, and only 17.6% for blood pressure.

"Physicians indicated a primary focus on glycemic control," the authors write. "Controlling blood pressure or lipid levels were lower priorities and commonly listed as secondary or tertiary goals."

In a separate presentation, Silvio E. Inzucchi, from Yale University School of Medicine in New Haven, Conn., and colleagues noted that these priorities are misplaced because coronary artery disease is the major cause of death in patients with type 2 diabetes mellitus. Although glycemic control is not definitely known to reduce the incidence of CAD, other features of the metabolic syndrome, including hypertension, dyslipidemia, body weight, and hypercoagulability, appear to be more important.

The Detection of Ischemia in Asymptomatic Diabetics (DIAD) Study is a multicenter study of the prevalence of silent myocardial ischemia in patients with type 2 diabetes, using Adenosine-Sestamibi perfusion imaging.

Of 402 subjects screened since September 2000, 55% are achieving the ADA HbA1c target of <7.0%. Even in these well-controlled subjects, control of other cardiovascular risk factors was quite variable.

"In our study population, large proportions of patients under seemingly excellent diabetic control are not achieving an optimal overall coronary artery disease risk profile," the authors write. "To impact substantively upon the risk of coronary artery disease in type 2 diabetes, emphasis on managing these other cardiovascular risk factors, in addition to glucose control, is necessary."

© 2002 WebMD Inc. All rights reserved.

    
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