Cortez-Dias Nuno, Martins Susana, Belo Adriana, Fiuza Manuela
Serviço de Cardiologia do Hospital de Santa Maria, Lisboa, Portugal, Faculdade de Medicina de Lisboa, Lisboa, Portugal.
Rev Port Cardiol. 2010 Apr;29(4):509-37.
To assess the prevalence, treatment and control of diabetes mellitus (DM) in primary health care users, to characterize associated cardiovascular (CV) risk factors and effectiveness of their treatment, and to estimate the clinical impact of DM on the occurrence of coronary artery disease (CAD) and stroke.
The VALSIM Study was performed in a primary care setting and involved 719 general practitioners (GPs), based on stratified distribution and proportional to the population density of each region of mainland Portugal and the islands of Madeira and the Azores. A questionnaire on sociodemographic and clinical data (previous diagnosis of DM, CAD or stroke, antidiabetic and antihypertensive medication and statins) and laboratory tests (lipids and HbA1C) was applied by participating GPs to the first two adult patients scheduled for an appointment on a given day, and blood pressure (BP) was measured. DM was defined as fasting glucose of > or = 126 mg/dl or use of antidiabetic agents.
The study included 16,856 individuals (mean age 58.1 +/- 15.1 years; 61.6% women), of whom 3215 were identified as diabetic. The prevalence of DM adjusted for gender and age in primary health care users was 14.9%, higher in men (M: 16.8%; F: 13.2%), and increased with age. Among the diabetic population, 90.2% were being treated with antidiabetic drugs and 51.7% had HbA1C lower than 7%. Around 91% had high BP (> or = 130/80 mmHg or were taking antihypertensive medication), 39.5% were overweight, 45.1% were obese, 69.3% had abdominal obesity, 71.8% had metabolic syndrome (ATP III criteria), 12% presented CAD and 5% had past history of stroke. The association between these CV risk factors and DM was stronger in women, and the impact of DM on occurrence of CAD and stroke was also higher in women. Among diabetic hypertensives, 78.4% were being treated with antihypertensive drugs, but only 9.3% had BP < 130/80 mmHg (M: 9.5%; F: 9.1%). Of diabetic patients with CAD, 94.2% were taking antihypertensive medication, but only 9.8% had controlled BP (M: 13.7%; F: 6.1%). Although 59% of the diabetic population were being treated with statins, only 6.7% had total cholesterol < 200 mg/dl, triglycerides < 150 mg/dl and HDL-cholesterol > 60 mg/dl. Of diabetic patients with CAD, 76.5% were being treated with statins, but only 29.4% had total cholesterol < 175 mg/dl (M: 34.2%; F: 24.1%).
The management of DM in a primary care setting in Portugal can and should be improved, since 9.8% of patients are not treated and 48.3% are not controlled. DM has a considerable clinical impact due to its strong association with CAD and stroke. The risk of stroke and CAD is much higher in diabetic women, due firstly to a stronger association of DM with other risk factors in women, and secondly to less aggressive treatment.
评估基层医疗保健使用者中糖尿病（DM）的患病率、治疗情况及控制情况，对相关心血管（CV）危险因素及其治疗效果进行特征描述，并估计DM对冠状动脉疾病（CAD）和中风发生的临床影响。
VALSIM研究在基层医疗环境中开展，纳入了719名全科医生（GP），基于分层分布且与葡萄牙大陆各地区以及马德拉群岛和亚速尔群岛的人口密度成比例。参与研究的GP向指定日期预约就诊的前两名成年患者发放了一份关于社会人口统计学和临床数据（既往DM、CAD或中风诊断、抗糖尿病和抗高血压药物以及他汀类药物使用情况）以及实验室检查（血脂和糖化血红蛋白）的问卷，并测量了血压（BP）。DM定义为空腹血糖≥126mg/dl或使用抗糖尿病药物。
该研究纳入了16856名个体（平均年龄58.1±15.1岁；61.6%为女性），其中3215人被确诊为糖尿病患者。经性别和年龄调整后，基层医疗保健使用者中DM的患病率为14.9%，男性患病率更高（男性：16.8%；女性：13.2%），且随年龄增长而升高。在糖尿病患者群体中，90.2%正在接受抗糖尿病药物治疗，51.7%的糖化血红蛋白低于7%。约91%患有高血压（血压≥130/80mmHg或正在服用抗高血压药物），39.5%超重，45.1%肥胖，69.3%有腹型肥胖，71.8%患有代谢综合征（ATP III标准），12%患有CAD，5%有中风病史。这些CV危险因素与DM之间的关联在女性中更强，DM对CAD和中风发生的影响在女性中也更高。在糖尿病合并高血压患者中，78.4%正在接受抗高血压药物治疗，但只有9.3%的血压<130/80mmHg（男性：9.5%；女性：9.1%）。在患有CAD 的糖尿病患者中，94.2%正在服用抗高血压药物，但只有9.8%的血压得到控制（男性：13.7%；女性：6.1%）。尽管59%的糖尿病患者正在接受他汀类药物治疗，但只有6.7%的总胆固醇<200mg/dl、甘油三酯<150mg/dl且高密度脂蛋白胆固醇>60mg/dl。在患有CAD的糖尿病患者中，76.5%正在接受他汀类药物治疗，但只有29.4%的总胆固醇<175mg/dl（男性：34.2%；女性：24.1%）。
葡萄牙基层医疗环境中DM的管理能够且应该得到改善，因为9.8%的患者未接受治疗，48.3%的患者未得到控制。由于DM与CAD和中风密切相关，其具有相当大的临床影响。糖尿病女性发生中风和CAD的风险要高得多，首先是因为DM与女性其他危险因素的关联更强，其次是治疗不够积极。
