2小时糖耐量试验的临床意义课件

Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,2小时糖耐量试验的临床意义19,2小时糖耐量试验的临床意义19,1,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,糖尿病诊断试验:历史回顾糖尿病症状Jacobsen A.,2,Normal Glucose Homeostasis,Daytime Profile (N=12, health,; Mean + 95%CI),Owens D ,Zinman B & Bolli G : Lancet 358,739,2001,Meal Times,80,40,0,Insulin (mU/L),08.00,13.00,16.00,19.00 h,Glucose (mmol/L),8,4,2,6,Normal Glucose Homeostasis Owe,3,什么是糖耐量异常?,1. 高于均值+2标准差可诊断糖尿病:,根据年轻 (20-30 岁) 健康人群资料, 纯统计！不考虑临床，预后及年龄 (50年代),2h全血血糖=120mg/dl (100g糖耐量)诊断糖尿病 (血浆血糖比全血高14-16%!),发病率高,诊断标准混乱 (血样，服糖量，时间),直到70年代,Mosenthal H.O. and Barry E (Ann Intern Med 33: 1175, 1950),什么是糖耐量异常?1. 高于均值+2标准差可诊断糖尿病: M,4,什么是糖耐量异常?,1. 均值+2标准差,2. 血糖双峰分布,小血管病变 (眼病，肾病等):,糖尿病高发人群, 如Pima Indians (1971), Mexican-Americans, Micronesians, Polynesians,什么是糖耐量异常?1. 均值+2标准差,5,Bimodal distribution of glucoseand prevalence of retinopathy and proteinuria in Pima Indians,Knowler WC etc. Diabetes Metab Rev 6: 1-27, 1990,Bimodal distribution of glucos,6,Copyright 1994 BMJ Publishing Group Ltd.,McCane, D R et al. BMJ 1994;308:1323-8,5,year cumulative incidence (top) and prevalence (bottom) of retinopathy in relation to tenths of,2hPG,FPG, and,HBa1c,Copyright 1994 BMJ Publishing,7,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,现用诊断标准NDDG1979: FPG=7.8 mmol/,8,什么是糖耐量异常?,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,什么是糖耐量异常?1. 均值+2标准差,9,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 & 1857 (66%) elective pts before discharge or within 2 mo.,Euro Heart Survey,Bartnik,M,et al; Eur Ht J 2004;1880,NGT,IFG,IGT,Known DM,New DM,29%,35%,22%,22%,31%,30%,15%,10%,3%,3%,0,20,40,60,80,100,%,Acute,Elective,Dysglycemia Normoglycemia i,10,The,DECODE,Study (,http:/www.ktl.fi/decode/index.html),D,iabetes,E,pidemiology:,C,ollaborative analysis,O,f,D,iagnostic criteria in,E,urope,The DECODE Study (http:/www.k,11,2-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,2-hour plasma glucose (mmo,12,Discrepancy of FPG and 2hPG criteria in the DECODA study,Diabetologia 2000; 43: 1470-1475,Discrepancy of FPG and 2hPG cr,13,30-39 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.,30-39,14,30-39 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.,30-39 40-,15,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),7.06.16.96.1,11.1,7.811.0,7.8,Fasting plasma glucose (mmol/l),2.5,2.0,1.5,1.0,0.5,0.0,Hazard ratio,Adapted from DECODE Study Group, Lancet 1999;354:617621,Hazards ratio for all-cause mo,16,All-cause mortality has a linear,relationship with 2-hour plasma glucose,DECODE,Diabetes Care 2003;,26,: 688-696,All-cause mortality has a line,17,CVD mortality by 2-hour plasma glucose,Frequency,Hazard ratio,DECODE,Diabetes Care,26,: 688-696,CVD mortality by 2-hour plasma,18,CVD mortality by fasting plasma glucose,Frequency,Hazard ratio,DECODE,Diabetes Care,26,: 688-696,CVD mortality by fasting plasm,19,Hazard ratio for mortality by FPG categories, the DECODA Study,FPG,(mmol/l),6.1,(n=5547),6.1-6.9,(n=462),7.0,(n=297),P for trend,CVD,Model 1,Model 2,1,1,1.4 (0.9-2.1),1.1 (0.7-1.7),2.0 (1.3-3.1),0.9 (0.5-1.5),0.006,0.83,All-cause,Model 1,Model 2,1,1,1.2 (0.9-1.6),0.9 (0.7-1.3),1.8 (1.3-2.5),0.9 (0.6-1.3),0.001,0.81,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,20,Hazard ratio for mortality by 2hPG categories, the DECODA Study,2hPG,(mmol/l),7.8,(n=4753),7.8-11.0,(n=1106),11.1,(n=447),P for trend,CVD,Model 1,Model 2,1,1,1.3 (0.9-1.9),1.3 (0.9-1.9),3.2 (2.2-4.7),3.4 (2.1-5.4),0.001,0.001,All-cause,Model 1,Model 2,1,1,1.3 (1.0-1.7),1.4 (1.0-1.8),2.9 (2.2-3.8),3.0 (2.2-4.2),0.001,0.001,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,Hazard ratio for mortality by,21,Non-diabetic,Diabetic,Follow-up,Baseline 2hPG,NGT,IGT,Non-diabetic,CHD incidence,5.3,9.7,16.1,CVD mortality,3.1,7.9,8.7,All-cause mortality,7.6,12.8,15.5,Incidence density (no./per 1000 person-years),Qiao et al. Diabetes Care 2003; 26:2910-2914,Non-diabetic DiabeticFollow-up,22,Hazard ratio (95% CI) by glucose status at baseline and at follow-up,Follow-up,Non-diabetic,Diabetic,Baseline 2hPG,NGT,IGT,Non-diabetic,CHD incidence,1,1.5 (1.0-2.3),1.8 (1.0-3.2),CVD mortality,1,2.3 (1.4-3.9),1.7 (0.8-3.5),All-cause mortality,1,1.7 (1.1-2.4),1.5 (0.9-2.5),Adjusted for age, sex, WHR, SBP, Chol, HDL and smoking,Qiao et al. Diabetes Care 2003; 26:2910-2914,Hazard ratio (95% CI) by gluco,23,Effect of intensive glycemic control on the risk for any type of macrovascular events,C Stettler, Am Heart J 2006; 152:27-38,Effect of intensive glycemic c,24,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,STOP-NIDDM Trial (1)Myocardial,25,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 p,50 conventional pts - CV event 11 yrs post DCCT; 17 yrs altogether,GHb Results:,DCCT End,EDIC End,Intensive,7.4 (1.1),7.9 (1.3),Conventional,9.1 (1.5),7.8 (1.3),Intensive Insulin Rx & CVD: T1,30,Intensive Insulin Rx & CVD: T1 DM,DCCT/EDIC NEJM 2005;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 & CVD: T1,31,Intensive Insulin Rx 353:2643,MI, Stroke, CV Death,RRR= 57% (12-79),Intensive Insulin Rx & CVD: T1,32,Chronic G Lowering & CVD: IGT,STOP NIDDM Analysis: Chiasson et al. JAMA 2003;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),Chronic G Lowering & CVD: IGT,33,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,Copyright 1994 BMJ Publishing,34,Relative risk (95% CI) of mortality significantly increased in subjects with IGT,Multivariate adjusted: for age, center, sex, cholesterol, BMI, BP, smoking,Mortality,RR, multivariate,adjusted,RR, adjusted,also for FPG,CVD,1.34,(1.14-1.57),1.32,(1.12-1.56),CHD,1.28,(1.02-1.59),1.27,(1.03-1.58),Stroke,1.26,(0.88-1.80),1.21,(0.84-1.74),All-cause,1.40,(1.27-1.54),1.37,(1.25-1.51),The DECODE group, Arch Intern Med 2001; 161:397-404,Relative risk (95% CI) of mort,35,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,36,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,Hazards ratio for mortality 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