Valensi P
Hôpital Jean Verdier, AP-HP, Université Paris-Nord, Avenue du 14 Juillet, 93140 Bondy, France.
Rev Med Liege. 2005 May-Jun;60(5-6):531-5.
More than half of diabetic individuals will die from a coronary event. Coronary artery disease often presents an atypical form among diabetic subjects. Silent myocardial ischaemia may be detected in 20 to 35% of diabetic patients with associated cardiovascular risk factors. When a coronarography is performed in patients with silent myocardial ischaemia, it demonstrates significant coronary stenosis in one to two thirds of patients. The prognosis of diabetic patients with silent myocardial ischaemia is associated with a higher incidence of cardiac events in the next three years, especially when silent ischaemia is associated with angiographically coronary stenosis. French guidelines jointly published in 2004 by the ALFEDIAM and the French Society of Cardiology propose the search for silent myocardial ischaemia--in diabetic patients with peripheral arteriopathy or overt nephropathy with proteinuria,--in diabetic patients with microalbuminuria and two other classical cardiovascular risk factors,--in a sedentary diabetic patient who wants to begin a physical activity,--in type I diabetic patients above 45 years or with a disease lasting for more than 15 years and in type 2 diabetic patients above 60 years or with a known disease lasting for more than 10 years, when at least two other traditional cardiovascular risk factors are present. Besides the standard annual electrocardiogram, these high risk patients should benefit first from an exercise test or when the latter is impossible, under-maximal or doubtful, from a myocardial scintigraphy combined with dipyridamole injection or from a stress echocardiography. The demonstration of a silent myocardial ischaemia should lead to a coronarography when the general status of the patient and the absence of severe comorbidities allow considering a coronary revascularisation procedure in these diabetic patients.
超过半数的糖尿病患者将死于冠状动脉事件。冠状动脉疾病在糖尿病患者中常呈现非典型形式。在伴有心血管危险因素的糖尿病患者中，20%至35%可检测到无症状心肌缺血。对无症状心肌缺血患者进行冠状动脉造影时，三分之一至三分之二的患者显示有明显的冠状动脉狭窄。无症状心肌缺血的糖尿病患者的预后与未来三年内心脏事件的较高发生率相关，尤其是当无症状缺血与冠状动脉造影显示的冠状动脉狭窄相关时。2004年由ALFEDIAM和法国心脏病学会联合发布的法国指南建议，在以下糖尿病患者中筛查无症状心肌缺血：患有外周动脉病变或显性肾病伴蛋白尿的患者；患有微量白蛋白尿且伴有其他两种典型心血管危险因素的患者；想要开始体育活动的久坐不动的糖尿病患者；45岁以上或患病超过15年的1型糖尿病患者，以及60岁以上或已知患病超过10年且至少存在其他两种传统心血管危险因素的2型糖尿病患者。除了标准的年度心电图检查外，这些高危患者首先应接受运动试验，或者在运动试验无法进行、结果不充分或结果存疑时，接受联合双嘧达莫注射的心肌闪烁扫描或负荷超声心动图检查。当患者的一般状况允许且不存在严重合并症，从而可以考虑对这些糖尿病患者进行冠状动脉血运重建术时，无症状心肌缺血的确诊应促使进行冠状动脉造影。
