Komori Hiromi
Division of Diabetology, Department of Internal Medicine, Toho University, Ohashi Hospital, Tokyo, Japan.
Curr Ther Res Clin Exp. 2005 Nov;66(6):600-12. doi: 10.1016/j.curtheres.2005.12.010.
In diabetic patients, cardiac autonomic neuropathy is an important factor affecting prognosis. Whether this condition in diabetic patients is caused directly by neurovisceral metabolic disorder and/or indirectly by micro circulation remains to be clarified.
The aim of this study was to determine whether cardiac sympathetic nerve dysfunction can be detected using adenosine triphosphate (ATP) testing, while also investigating the effects of metabolic and/or myocardial microcirculatory abnormalities on the pathogenesis of cardiac autonomic nerve dysfunction in patients with type 2 diabetes mellitus (DM-2) in Japan.
This prospective study was performed at the Division of Diabetology Department of Internal Medicine, Toho University, Ohashi Hospital, Tokyo, Japan. Patients aged ≥ 18 years with DM-2 with no abnormalities on electrocardiography (ECG) or echocardiography were enrolled. An ATP thallium (Tl)-201 myocardial scintigraphy test (ATP test) and iodine (I)-123 metaiodobenzylguanidine (MIBG) scintigraphy were performed. ATP was administered by continuous IV infusion over 6 minutes at 0.16 mg/kg · min. Five minutes after the ATP infusion was started, T1-201 111 MBq IV was administered. Single-photon emission computed tomography (SPECT) imaging was begun immediately after the end of ATP infusion and was completed 3 hours after stress to show washout from stress to rest. I-123 MIBG 111 MBq IV was administered. A planar image from the front side and a SPECT image (early phase) was obtained 15 to 30 minutes later. After 3 hours, a planar image from the front side and a SPECT image (late phase) were obtained to show washout from stress to rest. The mean TI washout rate (ATP-WR) and heart-to-mediastinum (H/M) ratio in the late-phase scintigraphic images and the washout rate of MIBG (MIBG-WR) in the left ventricle was determined. The correlations of these measurements with the mean values of glycosylated hemoglobin (HbA1c) and fasting plasma glucose obtained from monthly measurements over the previous 6 and 24 months were determined.
A total of 25 patients were enrolled (13 men, 12 women; mean [SD] age, 59.86 [8.28] years). Significant negative correlations between both ATP-WR and MIBG-WR and HbA1c were found (r = -0.52 [P = 0.02] and -0.47 [P = 0.03], respectively). Although no correlation was found between ATP-WR values and the early phase H/M ratio, a significant positive correlation was observed between ATP-WR and H/M ratio (r = 0.54; P = 0.02).
In the present study in Japanese diabetic patients without subjective signs of coronary artery disease and without abnormalities on ECG or echocardiography, ATP-WR, an indicator of myocardial blood flow, was correlated with myocardial sympathetic nerve dysfunction and 24-month glycemic control. However, sympathetic nerve dysfunction was not correlated with 24-month glycemic control.
在糖尿病患者中，心脏自主神经病变是影响预后的重要因素。糖尿病患者的这种情况是直接由神经内脏代谢紊乱引起和/或间接由微循环引起，仍有待阐明。
本研究的目的是确定是否可以使用三磷酸腺苷（ATP）试验检测心脏交感神经功能障碍，同时研究代谢和/或心肌微循环异常对日本2型糖尿病（DM-2）患者心脏自主神经功能障碍发病机制的影响。
这项前瞻性研究在日本东京都东邦大学大森医院内科糖尿病科进行。纳入年龄≥18岁、心电图（ECG）和超声心动图无异常的DM-2患者。进行了ATP铊（Tl）-201心肌闪烁扫描试验（ATP试验）和碘（I）-123间碘苄胍（MIBG）闪烁扫描。ATP以0.16mg/kg·min的速度通过静脉持续输注6分钟。在ATP输注开始5分钟后，静脉注射111MBq的Tl-201。在ATP输注结束后立即开始单光子发射计算机断层扫描（SPECT）成像，并在应激后3小时完成，以显示从应激到静息的洗脱情况。静脉注射111MBq的I-123 MIBG，并在15至30分钟后获得前位平面图像和SPECT图像（早期）。3小时后，获得前位平面图像和SPECT图像（晚期），以显示从应激到静息的洗脱情况。确定晚期闪烁扫描图像中的平均Tl洗脱率（ATP-WR）和心/纵隔（H/M）比值以及左心室中MIBG的洗脱率（MIBG-WR）。确定这些测量值与过去6个月和24个月每月测量获得的糖化血红蛋白（HbA1c）和空腹血糖平均值之间的相关性。
共纳入25例患者（13例男性，12例女性；平均[标准差]年龄，59.86[8.28]岁）。发现ATP-WR和MIBG-WR与HbA1c之间均存在显著负相关（分别为r=-0.52[P=±0.02]和r=-0.47[P=0.03]）。虽然ATP-WR值与早期H/M比值之间未发现相关性，但观察到ATP-WR与H/M比值之间存在显著正相关（r=0.54；P=0.02）。
在本研究中，对于无冠状动脉疾病主观体征且ECG和超声心动图无异常的日本糖尿病患者，作为心肌血流指标的ATP-WR与心肌交感神经功能障碍和24个月血糖控制相关。然而，交感神经功能障碍与24个月血糖控制无关。
