Natali A, Vichi S, Landi P, Severi S, L'Abbate A, Ferrannini E
CNR Institute of Clinical Physiology, and the Department of Internal Medicine of the University of Pisa School of Medicine, Italy.
Diabetologia. 2000 May;43(5):632-41. doi: 10.1007/s001250051352.
AIMS/HYPOTHESIS: Prevalence and incidence of coronary heart disease (CHD) are increased in patients with Type II (non-insulin-dependent) diabetes mellitus; whether this is entirely due to more extensive coronary atherosclerosis is, however, controversial.
We analysed the clinical, angiographic and follow-up data of 2253 consecutive patients undergoing coronary angiography over the decade 1983-1992.
Abnormal coronary arteries (> or =50% stenosis) were found more frequently in diabetic than in non-diabetic subjects (85 vs 67%, p < 0.0001), the excess being explained by a higher prevalence of three-vessel disease (36 vs 17%, p < 0.0001). The sum of all angiographically detectable lumen stenoses (atherosclerosis score, ATS) was higher in diabetic than in non-diabetic subjects (352 +/- 232 vs 211 +/- 201 units, p < 0.0001). After adjusting for measured cardiovascular risk factors, diabetes was still associated with an excess ATS (114 units in men and 187 units in women, p < 0.0001 for both, p < 0.03 for the interaction ATS x sex). Within the diabetic group, the only variable that was independently (of sex and age) associated with ATS was serum cholesterol, whereas plasma glucose concentration, disease duration and type of treatment were not correlated with the severity of coronary atherosclerosis. In contrast, clinical grade proteinuria was not associated with a more diffuse coronary atherosclerosis either in diabetic (366 +/- 243 vs 354 +/- 233 units) or non-diabetic subjects (231 +/- 201 vs 207 +/- 197 units). Over a mean follow-up period of 88 months, 19% of diabetic patients compared with 10% of non-diabetic patients died of a cardiac cause (age and sex-adjusted odds ratio OR = 1.34 [1.14-1.57]). In a Cox model adjusting for age, sex and all major risk factors, diabetes was still associated with a significant excess risk of dying of a cardiac cause (OR = 1.37 [1.14-1.60]); this excess was similar to, and independent of, that carried by the presence of prior myocardial infarction in the whole population (OR = 1.42 [1.25-1.62]). Proteinuria was associated with a higher risk of cardiac death, particularly in diabetic patients, independently of coronary atherosclerosis (adjusted OR = 1.46 [1.03-1.99]).
CONCLUSION/INTERPRETATION: In patients undergoing angiography, diabetes, especially in women, is associated with more severe and diffuse coronary atherosclerosis which is not explained by either the traditional risk factors or the presence of proteinuria. On follow-up, these patients experience an excess of cardiac deaths, to which coronary atherosclerosis and proteinuria make independent, quantitative contributions.
目的/假设：冠心病（CHD）在II型（非胰岛素依赖型）糖尿病患者中的患病率和发病率有所增加；然而，这是否完全归因于更广泛的冠状动脉粥样硬化仍存在争议。
我们分析了1983年至1992年这十年间连续接受冠状动脉造影的2253例患者的临床、血管造影及随访数据。
糖尿病患者中发现异常冠状动脉（狭窄≥50%）的频率高于非糖尿病患者（85%对67%，p<0.0001），三支血管病变患病率较高（36%对17%，p<0.0001）可解释这一差异。糖尿病患者血管造影可检测到的所有管腔狭窄总和（动脉粥样硬化评分，ATS）高于非糖尿病患者（352±232对211±201单位，p<0.0001）。在对测量的心血管危险因素进行校正后，糖尿病仍与ATS升高相关（男性为114单位，女性为187单位，两者p<0.0001，ATS×性别交互作用p<0.03）。在糖尿病组中，唯一与ATS独立（不受性别和年龄影响）相关的变量是血清胆固醇，而血糖浓度、病程和治疗类型与冠状动脉粥样硬化严重程度无关。相比之下，临床蛋白尿在糖尿病患者（366±243对354±233单位）和非糖尿病患者（231±201对207±197单位）中均与更弥漫的冠状动脉粥样硬化无关。在平均88个月的随访期内，19%的糖尿病患者死于心脏原因，而非糖尿病患者为10%（年龄和性别校正后的优势比OR=1.34[1.14-1.57]）。在Cox模型中对年龄、性别和所有主要危险因素进行校正后，糖尿病仍与死于心脏原因的显著额外风险相关（OR=1.37[1.14-1.60]）；这一额外风险与整个人群中既往心肌梗死存在所带来的额外风险相似且独立（OR=1.42[1.25-1.62]）。蛋白尿与心脏死亡风险较高相关，尤其是在糖尿病患者中，与冠状动脉粥样硬化无关（校正后OR=1.46[1.03-1.99]）。
结论/解读：在接受血管造影的患者中，糖尿病，尤其是女性患者，与更严重和弥漫的冠状动脉粥样硬化相关，这既不能用传统危险因素也不能用蛋白尿的存在来解释。在随访中，这些患者心脏死亡过多，冠状动脉粥样硬化和蛋白尿对此有独立的定量贡献。
