Vinik Aaron I, Vinik Etta
Diabetes Research Institute, Eastern Virginia Medical School, Norfolk, USA.
Am J Manag Care. 2003 Mar;9(3 Suppl):S63-80; quiz S81-4.
For patients with diabetes mellitus (DM), chronic complications can be devastating. Cardiovascular illness, the major cause of morbidity and mortality among these patients, encompasses macrovascular disease, with heart attacks, strokes, and gangrene; and microvascular disease, with retinopathy, nephropathy, and neuropathy (somatic and autonomic). Macrovascular events occur earlier in individuals with DM than in people without DM, and the underlying pathologies are often more diffuse and severe. Diabetic arteriopathy, which encompasses endothelial dysfunction, inflammation, hypercoagulability, changes in blood flow, and platelet abnormalities, contributes to the early evolution of these events. Efforts are under way to determine interventions that may have the potential to prevent or halt the complications of DM. Tight glucose and blood pressure (BP) control is known to improve the vascular status of patients with DM by varying degrees. Use of anti-inflammatory drugs and lowering low-density lipoprotein cholesterol (LDL-C) levels are also useful. An emerging understanding of the importance of small, dense LDL-C and the anti-inflammatory effects of statins has provided new algorithms for primary prevention of macrovascular disease. Antiplatelet agents have also been shown to be effective in the secondary prevention of cardiovascular events. In the ideal world every risk factor would be addressed and each person with DM would have excellent glycemic control, low to normal BP, and a low LDL level, and would be taking an angiotensin-converting enzyme (ACE) inhibitor, together with a statin, aspirin, and clopidogrel. Under these near-perfect conditions, the emerging epidemic of macrovascular disease could be contained. Microvascular disease, however, is a consequence of hyperglycemia. For every 1% reduction in glycosylated hemoglobin it is possible to achieve a 22% to 35% reduction in the microvascular complications. BP control is vital and the liberal use of ACE inhibitors and angiotensin receptor blockers to slow the progression of renal disease should drastically reduce the incidence of blindness, dialysis, and amputations. This article provides an overview of prevention of macrovascular disease such as stroke, myocardial infarction, and peripheral arterial disease and microvascular complications such as retinopathy, nephropathy, and neuropathy in patients with DM.
对于糖尿病（DM）患者而言，慢性并发症可能是毁灭性的。心血管疾病是这些患者发病和死亡的主要原因，包括大血管疾病，如心脏病发作、中风和坏疽；以及微血管疾病，如视网膜病变、肾病和神经病变（躯体性和自主性）。糖尿病患者发生大血管事件的时间比非糖尿病患者更早，其潜在病理状况往往更广泛、更严重。糖尿病性动脉病包括内皮功能障碍、炎症、高凝状态、血流变化和血小板异常，促使这些事件早期发展。人们正在努力确定可能有潜力预防或阻止糖尿病并发症的干预措施。已知严格控制血糖和血压（BP）可在不同程度上改善糖尿病患者的血管状况。使用抗炎药物和降低低密度脂蛋白胆固醇（LDL-C）水平也很有用。对小而密LDL-C的重要性以及他汀类药物抗炎作用的新认识为大血管疾病的一级预防提供了新的算法。抗血小板药物在心血管事件的二级预防中也已被证明有效。在理想情况下，每个危险因素都应得到处理，每位糖尿病患者都应实现血糖良好控制、血压低至正常、LDL水平低，并服用血管紧张素转换酶（ACE）抑制剂，同时服用他汀类药物、阿司匹林和氯吡格雷。在这些近乎完美的条件下，大血管疾病的新发流行可能得到控制。然而，微血管疾病是高血糖的结果。糖化血红蛋白每降低1%，微血管并发症就有可能降低22%至35%。控制血压至关重要，大量使用ACE抑制剂和血管紧张素受体阻滞剂以减缓肾病进展应能大幅降低失明、透析和截肢的发生率。本文概述了糖尿病患者大血管疾病（如中风、心肌梗死和外周动脉疾病）以及微血管并发症（如视网膜病变、肾病和神经病变）的预防。
