小时糖耐量试验的临床意义.ppt

2小时糖耐量试验的临床意义,Finnish Academy Research Fellow 芬兰赫尔辛基大学及 国立公共卫生研究院 北大糖尿病论坛2007年 5 月12日， 北京,乔青 MD, Ph.D,糖尿病诊断试验:历史回顾,糖尿病,症状 尿糖 空腹血糖 糖耐量 (1913年),Jacobsen A. Biochem Z 51:443, 1913,Normal Glucose Homeostasis Daytime Profile (N=12, health; Mean + 95%CI),Owens D ,Zinman B 308:1323-8,5 year cumulative incidence (top) and prevalence (bottom) of retinopathy in relation to tenths of 2hPG, FPG, and HBa1c,现用诊断标准,NDDG1979: FPG=7.8 mmol/l and 75g OGTT at , 1, 1, 2 hours WHO 1980: adopted the NDDG criteria, 2h glucose=11.1 mmol/l after 75g load as “金标准” WHO 1985: slightly modified the WHO 1980 criteria ADA 1997: FPG 7.8 mmol/l to 7.0 mmol/l，Not use OGTT WHO 1999: adopted the FPG 7.0 mmol/l, retained the 2h OGTT WHO/IDF 2006: no changes except for some terms,什么是糖耐量异常?,1. 均值+2标准差 2. 血糖双峰分布,小血管病变 3.大血管病变: 心脑血管及外周血管病变,Dysglycemia Normoglycemia in Acute and Stable CV Disease,Consecutive pts: 2107 in-pts; 2854 out-pt elective CV consults in Europe (71% men; mean age 66),OGTT/old DM in 1587 (75%) acute Eur Ht J 2004;1880,The DECODE Study (http:/www.ktl.fi/decode/index.html) Diabetes Epidemiology: Collaborative analysis Of Diagnostic criteria in Europe,2-hour plasma glucose (mmol/l),7.8,7.811.0,11.1,Total,6.1,6.16.9,21,968,2,020,2,562,893,316,206,24,846,3,119,7.0,276,378,489,1,143,Fasting,plasma,glucose,(mmol/l),Total,24,264,3,833,1,011,29,108,Adapted from DECODE Study Group. Br Med J 1998;317:371375,Classification of individuals - the DECODE Study,Discrepancy of FPG and 2hPG criteria in the DECODA study,Diabetologia 2000; 43: 1470-1475,30-39 40-49 50-59 60-69 70-79 80-89,Prevalence (%) of newly diagnosed DM in DECODE populations,The DECODE group, Diabetes Care 2003; 26: 61-69.,30-39 40-49 50-59 60-69 70-79 80-89,Prevalence (%) of IGT but not IFG increases with age in DECODE population,The DECODE group, Diabetes Care 2003; 26: 61-69.,Hazards ratio for all-cause mortality in subjects without prior history of diabetes,Adj. for age, cohorts, sex, chol, BMI, SBP, smoking,2-hour plasma glucose(mmol/l),Adapted from DECODE Study Group, Lancet 1999;354:617621,All-cause mortality has a linear relationship with 2-hour plasma glucose,DECODE, Diabetes Care 2003; 26: 688-696,CVD mortality by 2-hour plasma glucose,Frequency,Hazard ratio,DECODE, Diabetes Care 26: 688-696,CVD mortality by fasting plasma glucose,Frequency,Hazard ratio,DECODE, Diabetes Care 26: 688-696,Hazard ratio for mortality by FPG categories, the DECODA Study,Model 1: Adjusted for age, sex, cohort, BMI, sysBP, Chol and smoking Model 2: Additional adjustment for 2hPG,DECODA Study Group, Diabetologia 2004; 47: 385-394,Hazard ratio for mortality by 2hPG categories, the DECODA Study,Model 1: Adjusted for age, sex, cohort, BMI, sysBP, Chol and smoking Model 2: Additional adjustment for FPG,DECODA Study Group, Diabetologia 2004; 47: 385-394,Incidence density (no./per 1000 person-years),Qiao et al. Diabetes Care 2003; 26:2910-2914,Hazard ratio (95% CI) by glucose status at baseline and at follow-up,Adjusted for age, sex, WHR, SBP, Chol, HDL and smoking,Qiao et al. Diabetes Care 2003; 26:2910-2914,Effect of intensive glycemic control on the risk for any type of macrovascular events,C Stettler, Am Heart J 2006; 152:27-38,STOP-NIDDM Trial (1),Myocardial infarction Angina Revascularization procedure Cardiovascular death Cerebrovascular event or stroke Peripheral vascular disease Any cardiovascular event,Favours Acarbose,Favours Placebo,Chiasson JL JAMA 2003; 23: 290:486-94,The main changes from baseline to 3 years: AcarbosePlacebo,STOP-NIDDM Trial (3),Body Weight (kg) -1.15 0.26 BMI (kg/m2) -0.60 -0.12 Waist (cm) -0.62 0.17 SysBP (mmHg) -0.97 -0.05 DiasBP (mmHg) -2.8 -1.4 2hPG (mmol/L) -0.63 0.04 Triglycerides (mmol/L) -0.18 -0.04,All p0.01 for the difference between the two groups,Summary,Diabetes diagnosed by either FPG or 2h criteria are risk factor for CVD disease, but 2h criteria identify those who are not diabetic by FPG alone IGT is over IFG with regard to the prediction of the CVD More trials are required to show that intensive treatment of postprandial hyperglycemia can reduce the CVD,RCT Meta-analysis: G Lowering,Type 1 Diabetes Trials,Am Heart J 2006;152:27,Intensive Insulin Rx 353:2643,Participants: 1394 (97% of the original cohort) DCCT participants Outcome: Nonfatal MI or stroke; OR CV death; OR silent MI; OR documented angina; OR revascularization Follow-up: Until 50 conventional pts - CV event 11 yrs post DCCT; 17 yrs altogether GHb Results:,Intensive Insulin Rx 353:2643,Primary CV Composite RRR= 42% (9-63),RRR after adj. for updated GHb until end of DCCT (or CV event during DCCT): 16% (-64 57) P=0.61,Intensive Insulin Rx 353:2643,MI, Stroke, CV Death RRR= 57% (12-79),Chronic G Lowering 290:486,HR 0.51 (0.28-0.95) (i.e. 32/686 vs. 15/682 MI, Angina, Revasc, CV Death, CHF, Stroke, or PVD),Copyright 1994 BMJ Publishing Group Ltd.,McCane, D R et al. BMJ 1994;308:1323-8,ROC curves for prevalence of retinopathy (top) and nephropathy (bottom) for 2hPG (-), FPG (.), and HbA1 (-) concentrations,1-Specificity,Relative risk (95% CI) of mortality significantly increased in subjects with IGT,Multivariate adjusted: for age, center, sex, cholesterol, BMI, BP, smoking,The DECODE group, Arch Intern Med 2001; 161:397-404,Hazards ratio for mortality in diabetic patients according to FPG,The DECODE group, Arch Intern Med 2001; 161:397-404,Adjusted for age, center, sex, cholesterol, BMI, BP, smoking,Hazards ratio for mortality in diabetic patients according to 2-hour glucose,The DECODE group, Arch Intern Med 2001; 161:397-404,Adjusted for age, center, sex, cholesterol, BMI, BP, smoking,