Bonke Florian C, Donnachie Ewan, Schneider Antonius, Mehring Michael
Institute of General Practice, University Hospital Klinikum rechts der Isar, Technische Universität München, Orleansstr. 47, 81667, München, Germany.
Association of Statutory Health Insurance Physicians of Bavaria, Munich, Germany.
Diabetologia. 2016 Feb;59(2):286-93. doi: 10.1007/s00125-015-3797-z. Epub 2015 Oct 30.
AIMS/HYPOTHESIS: In patients with type 2 diabetes mellitus, the effects of HbA1c variability on macrovascular events remain uncertain. The present investigation evaluates the association of HbA1c variability with non-fatal cardiovascular events, emergency admissions and episodes of severe hypoglycaemia in a cohort of patients newly started on insulin therapy.
HbA1c variability was defined as the rate of change in values between observations. The medical records of 406,356 patients enrolled in a disease management programme for type 2 diabetes mellitus were analysed to identify a cohort of 13,777 patients with observed transition to insulin therapy. The cohort was observed for a period of at least 5 years. Cox regression models were applied to quantify the association of HbA1c variability with the events of interest.
The models reveal a significant non-linear association between HbA1c variability and the risk of experiencing myocardial infarction, stroke and hypoglycaemia. The lowest risk is seen with a variability of approximately 0.5% (5.5 mmol/mol) per quarter. Using Cox models to predict survival curves for the cohort with hypothetical HbA1c variability of 0.5% (5.5 mmol/mol) and 1.5% (16.4 mmol/mol) per quarter, the proportion experiencing myocardial infarction within 2 years increases significantly from 1% to 10%. The proportion experiencing stroke increases from 1% to 29%, hypoglycaemia from 2% to 24% and the risk of emergency admission from 2% to 21%.
CONCLUSIONS/INTERPRETATION: In patients newly started on insulin therapy, rapid and higher HbA1c variability is associated with an increased risk of myocardial infarction, stroke, severe hypoglycaemia and emergency admission.
目的/假设：在2型糖尿病患者中，糖化血红蛋白（HbA1c）变异性对大血管事件的影响仍不明确。本研究评估了HbA1c变异性与一组新开始胰岛素治疗患者的非致命心血管事件、急诊入院及严重低血糖发作之间的关联。
HbA1c变异性定义为观察值之间的变化率。分析了406356名参加2型糖尿病疾病管理项目患者的病历，以确定13777名观察到开始胰岛素治疗的患者队列。对该队列进行了至少5年的观察。应用Cox回归模型量化HbA1c变异性与感兴趣事件之间的关联。
模型显示HbA1c变异性与发生心肌梗死、中风和低血糖风险之间存在显著的非线性关联。每季度变异性约为0.5%（5.5 mmol/mol）时风险最低。使用Cox模型预测假设每季度HbA1c变异性为0.5%（5.5 mmol/mol）和1.5%（16.4 mmol/mol）队列的生存曲线，2年内发生心肌梗死的比例从1%显著增加到10%。发生中风的比例从1%增加到29%，低血糖从2%增加到24%，急诊入院风险从2%增加到21%。
结论/解读：在新开始胰岛素治疗的患者中，快速且较高的HbA1c变异性与心肌梗死、中风、严重低血糖和急诊入院风险增加相关。
