Kianoush Sina, Al Rifai Mahmoud, Whelton Seamus P, Shaya Gabriel E, Bush Aaron L, Graham Garth, Wong Nathan D, Blaha Michael J
Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD, USA.
Miller School of Medicine, University of Miami, FL, USA.
J Diabetes Complications. 2016 Sep-Oct;30(7):1408-15. doi: 10.1016/j.jdiacomp.2016.04.021. Epub 2016 Apr 30.
Diabetes is a major coronary heart disease (CHD) and cardiovascular disease (CVD) risk factor and has traditionally been classified as a CHD risk equivalent. CVD risk, however, is heterogeneous among diabetic patients and thus further evaluation is warranted before initiating or titrating preventive pharmacotherapy. Prognostic clinical characteristics of diabetes such as age of onset, duration, and severity of diabetes, as well as concomitant cardiometabolic factors account for much of the variability in CHD and CVD risk. This heterogeneity can also be evaluated directly using non-invasive imaging, which allows for a more individualized risk assessment in order to minimize both under and overtreatment. In this paper, we review guideline recommendations for atherosclerotic CVD risk assessment driving the use of statins or aspirin for certain subgroups of patients with diabetes. We further discuss imaging techniques, such as stress myocardial perfusion imaging, coronary computed tomography angiography, and coronary artery calcium (CAC) scoring that can guide the decision to treat high-risk patients. Among imaging tests, current guidelines consider CAC scoring the most appropriate risk stratification tool for asymptomatic individuals with diabetes that can guide initiating/intensifying or withholding the most aggressive pharmacological therapies among high-risk (CAC>100) or low-risk (CAC=0) individuals, respectively.
糖尿病是主要的冠心病（CHD）和心血管疾病（CVD）危险因素，传统上被归类为冠心病风险等同因素。然而，糖尿病患者的心血管疾病风险存在异质性，因此在开始或调整预防性药物治疗之前，有必要进行进一步评估。糖尿病的预后临床特征，如发病年龄、病程、严重程度，以及伴随的心脏代谢因素，在很大程度上解释了冠心病和心血管疾病风险的变异性。这种异质性也可以直接通过无创成像进行评估，从而实现更个性化的风险评估，以尽量减少治疗不足和过度治疗的情况。在本文中，我们回顾了关于动脉粥样硬化性心血管疾病风险评估的指南建议，这些建议推动了他汀类药物或阿司匹林在特定糖尿病患者亚组中的使用。我们还将讨论成像技术，如负荷心肌灌注成像、冠状动脉计算机断层扫描血管造影和冠状动脉钙化（CAC）评分，这些技术可以指导高危患者的治疗决策。在成像检查中，当前指南认为CAC评分是糖尿病无症状个体最合适的风险分层工具，分别可以指导在高危（CAC>100）或低危（CAC=0）个体中启动/强化或停止最积极的药物治疗。
