Gori Mauro, Gupta Deepak K, Claggett Brian, Selvin Elizabeth, Folsom Aaron R, Matsushita Kunihiro, Bello Natalie A, Cheng Susan, Shah Amil, Skali Hicham, Vardeny Orly, Ni Hanyu, Ballantyne Christie M, Astor Brad C, Klein Barbara E, Aguilar David, Solomon Scott D
Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA Cardiovascular Department, Azienda Ospedaliera Papa Giovanni XXIII Hospital, Bergamo, Italy.
Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA Vanderbilt Heart and Vascular Institute, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN.
Diabetes Care. 2016 May;39(5):677-85. doi: 10.2337/dc15-1760. Epub 2016 Jan 6.
Cardiovascular disease (CVD) is the major cause of morbidity and mortality in diabetes; yet, heterogeneity in CVD risk has been suggested in diabetes, providing a compelling rationale for improving diabetes risk stratification. We hypothesized that N-terminal prohormone brain natriuretic peptide (NTproBNP) and high-sensitivity troponin T may enhance CVD risk stratification beyond commonly used markers of risk and that CVD risk is heterogeneous in diabetes.
Among 8,402 participants without prevalent CVD at visit 4 (1996-1998) of the Atherosclerosis Risk in Communities (ARIC) study there were 1,510 subjects with diabetes (mean age 63 years, 52% women, 31% African American, and 60% hypertensive).
Over a median follow-up of 13.1 years, there were 540 incident fatal/nonfatal CVD events (coronary heart disease, heart failure, and stroke). Both troponin T ≥14 ng/L (hazard ratio [HR] 1.96 [95% CI 1.57-2.46]) and NTproBNP >125 pg/mL (1.61 [1.29-1.99]) were independent predictors of incident CVD events at multivariable Cox proportional hazard models. Addition of circulating cardiac biomarkers to traditional risk factors, abnormal electrocardiogram (ECG), and conventional markers of diabetes complications including retinopathy, nephropathy, and peripheral arterial disease significantly improved CVD risk prediction (net reclassification index 0.16 [95% CI 0.07-0.22]). Compared with individuals without diabetes, subjects with diabetes had 1.6-fold higher adjusted risk of incident CVD. However, participants with diabetes with normal cardiac biomarkers and no conventional complications/abnormal ECG (n = 725 [48%]) were at low risk (HR 1.12 [95% CI 0.95-1.31]), while those with abnormal cardiac biomarkers, alone (n = 186 [12%]) or in combination with conventional complications/abnormal ECG (n = 243 [16%]), were at greater risk (1.99 [1.59-2.50] and 2.80 [2.34-3.35], respectively).
Abnormal levels of NTproBNP and troponin T may help to distinguish individuals with high diabetes risk from those with low diabetes risk, providing incremental risk prediction beyond commonly used markers of risk.
心血管疾病（CVD）是糖尿病发病和死亡的主要原因；然而，糖尿病患者的心血管疾病风险存在异质性，这为改善糖尿病风险分层提供了令人信服的理由。我们假设N末端前脑钠肽（NTproBNP）和高敏肌钙蛋白T可能比常用的风险标志物更能增强心血管疾病风险分层，并且糖尿病患者的心血管疾病风险存在异质性。
在社区动脉粥样硬化风险（ARIC）研究的第4次随访（1996 - 1998年）中，8402名无心血管疾病病史的参与者中，有1510名糖尿病患者（平均年龄63岁，52%为女性，31%为非裔美国人，60%患有高血压）。
在中位随访13.1年期间，发生了540例致死性/非致死性心血管疾病事件（冠心病、心力衰竭和中风）。在多变量Cox比例风险模型中，肌钙蛋白T≥14 ng/L（风险比[HR] 1.96 [95%可信区间1.57 - 2.46]）和NTproBNP>125 pg/mL（1.61 [1.29 - 1.99]）均为心血管疾病事件的独立预测因素。将循环心脏生物标志物添加到传统风险因素、异常心电图（ECG）以及糖尿病并发症的传统标志物（包括视网膜病变、肾病和外周动脉疾病）中，显著改善了心血管疾病风险预测（净重新分类指数0.16 [95%可信区间0.07 - 0.22]）。与无糖尿病个体相比，糖尿病患者发生心血管疾病的调整后风险高1.6倍。然而，心脏生物标志物正常且无传统并发症/异常心电图的糖尿病参与者（n = 725 [48%]）风险较低（HR 1.12 [95%可信区间0.95 - 1.31]），而单独心脏生物标志物异常的参与者（n = 186 [12%]）或伴有传统并发症/异常心电图的参与者（n = 243 [16%]）风险更高（分别为1.99 [1.59 - 2.50]和2.80 [2.34 - 3.35]）。
NTproBNP和肌钙蛋白T的异常水平可能有助于区分糖尿病高风险个体和低风险个体，提供超越常用风险标志物的额外风险预测。
