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长期血糖变异性与糖尿病患者肢体和心血管不良事件的关系

Long-Term Visit-to-Visit Glycemic Variability as a Predictor of Major Adverse Limb and Cardiovascular Events in Patients With Diabetes.

机构信息

Division of Cardiology, Department of Internal Medicine Fu Jen Catholic University Hospital New Taipei City Taiwan.

Division of Cardiology, Department of Internal Medicine National Taiwan University College of Medicine and Hospital Taipei Taiwan.

出版信息

J Am Heart Assoc. 2023 Feb 7;12(3):e025438. doi: 10.1161/JAHA.122.025438. Epub 2023 Jan 25.

Abstract

Background Peripheral arterial disease (PAD) is a severe complication in patients with type 2 diabetes. Glycemic variability (GV) is associated with increased risks of developing microvascular and macrovascular diseases. However, few studies have focused on the association between GV and PAD. Methods and Results This cohort study used a database maintained by the National Taiwan University Hospital, a tertiary medical center in Taiwan. For each individual, GV parameters were calculated, including fasting glucose coefficient of variability (FGCV) and hemoglobin A1c variability score (HVS). Multivariate Cox regression models were constructed to estimate the relationships between GV parameters and composite scores for major adverse limb events (MALEs) and major adverse cardiovascular events (MACEs). Between 2014 and 2019, a total of 45 436 adult patients with prevalent type 2 diabetes were enrolled for analysis, and GV was assessed during a median follow-up of 64.4 months. The average number of visits and time periods were 13.38 and 157.87 days for the HVS group and 14.27 and 146.59 days for the FGCV group, respectively. The incidence rates for cardiac mortality, PAD, and critical limb ischemia (CLI) were 5.38, 20.11, and 2.41 per 1000 person-years in the FGCV group and 5.35, 20.32, and 2.50 per 1000 person-years in HVS group, respectively. In the Cox regression model with full adjustment, the highest FGCV quartile was associated with significantly increased risks of MALEs (hazard ratio [HR], 1.57 [95% CI, 1.40-1.76]; <0.001) and MACEs (HR, 1.40 [95% CI, 1.25-1.56]; <0.001). Similarly, the highest HVS quartile was associated with significantly increased risks of MALEs (HR, 1.44 [95% CI, 1.28-1.62]; <0.001) and MACEs (HR, 1.28 [95% CI, 1.14-1.43]; <0.001). The highest FGCV and HVS quartiles were both associated with the development of PAD and CLI (FGCV: PAD [HR, 1.57; <0.001], CLI [HR, 2.19; <0.001]; HVS: PAD [HR, 1.44; <0.001], CLI [HR, 1.67; =0.003]). The Kaplan-Meier analysis showed significantly higher risks of MALEs and MACEs with increasing GV magnitude (log-rank <0.001). Conclusions Among individuals with diabetes, increased GV is independently associated with the development of MALEs, including PAD and CLI, and MACEs. The benefit of maintaining stable glycemic levels for improving clinical outcomes warrants further studies.

摘要

背景

外周动脉疾病(PAD)是 2 型糖尿病患者的严重并发症。血糖变异性(GV)与微血管和大血管疾病风险增加相关。然而,很少有研究关注 GV 与 PAD 之间的关系。

方法和结果

本队列研究使用了台湾大学医院维护的数据库,该数据库是一家三级医疗中心。对于每一位患者,计算了 GV 参数,包括空腹血糖变异系数(FGCV)和糖化血红蛋白变异评分(HVS)。构建了多变量 Cox 回归模型来估计 GV 参数与主要不良肢体事件(MALEs)和主要不良心血管事件(MACEs)复合评分之间的关系。在 2014 年至 2019 年期间,共纳入了 45436 名患有 2 型糖尿病的成年患者进行分析,并在中位随访 64.4 个月期间评估了 GV。HVS 组的平均就诊次数和时间分别为 13.38 次和 157.87 天,FGCV 组分别为 14.27 次和 146.59 天。FGCV 组的心血管死亡率、PAD 和严重肢体缺血(CLI)发生率分别为每 1000 人年 5.38、20.11 和 2.41 例,HVS 组分别为每 1000 人年 5.35、20.32 和 2.50 例。在经过充分调整的 Cox 回归模型中,FGCV 四分位最高 quartile 与 MALEs(风险比[HR],1.57[95%CI,1.40-1.76];<0.001)和 MACEs(HR,1.40[95%CI,1.25-1.56];<0.001)风险显著增加相关。同样,HVS 四分位最高 quartile 与 MALEs(HR,1.44[95%CI,1.28-1.62];<0.001)和 MACEs(HR,1.28[95%CI,1.14-1.43];<0.001)风险显著增加相关。FGCV 和 HVS 四分位最高 quartile 均与 PAD 和 CLI 的发生相关(FGCV:PAD[HR,1.57;<0.001],CLI[HR,2.19;<0.001];HVS:PAD[HR,1.44;<0.001],CLI[HR,1.67;=0.003])。Kaplan-Meier 分析显示,随着 GV 幅度的增加,MALEs 和 MACEs 的风险显著增加(对数秩检验<0.001)。

结论

在糖尿病患者中,血糖变异性增加与 MALEs(包括 PAD 和 CLI)和 MACEs 的发生独立相关。为改善临床结局而保持血糖水平稳定的益处值得进一步研究。

https://cdn.ncbi.nlm.nih.gov/pmc/blobs/af36/9973660/7c671ff17508/JAH3-12-e025438-g001.jpg

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