Zuanetti G, Latini R
Department of Cardiovascular Research, Istituto di Ricerche Farmacologiche Mario Negri, Milano, Italy.
J Diabetes Complications. 1997 Mar-Apr;11(2):131-6. doi: 10.1016/s1056-8727(97)00100-1.
Several studies performed before and after the introduction of fibrinolysis as a routine treatment of patients with myocardial infarction (MI) consistently showed that diabetic patients have a higher mortality in-hospital and after discharge. Women with insulin-dependent diabetes (IDD) appear to have a particularly ominous prognosis. So far, very few randomized prospective studies evaluated the effect of pharmacological treatments on prognosis of diabetic patients during acute MI: most of the information on the effect of commonly used cardiovascular drugs in diabetic patients with acute MI (AMI) has been obtained only from retrospective subgroup analyses of some of the large trials or as nonrandomized comparisons. The overview of fibrinolytic trials in acute MI found that fibrinolytic treatment was associated with a 35 days mortality of 13.6% versus 17.3% in diabetics (-21.7%) and 8.7% versus 10.2% in nondiabetics (-14.3%). Data from trials with aspirin suggest that the beneficial effect of this drug is maintained in diabetic patients with acute MI, but the optimal dosage remains undefined. Based on available evidence, beta blockers appear to be able to reduce mortality post-MI in diabetic patients, with an absolute and relative beneficial effect that is, in most cases, larger than that observed in nondiabetic patients. The pooled data from studies non beta blockers indicate a 37% mortality reduction in diabetic patients, compared to 13% in nondiabetics during the acute phase, and a 48% reduction of mortality compared to 33% in nondiabetics post-discharge. Data on outcome of diabetic patients in trials evaluating calcium antagonists are lacking, and there is a strong need for a reevaluation of data from completed trials to obtain some hints on the possible effect of these agents in this population. The "long-term" studies on angiotensin-converting enzyme (ACE) inhibitors in patients with left ventricular dysfunction some time after AMI have shown that the beneficial effect documented in the overall population is present also when limiting the analysis to patients with a history of diabetes, whereas the "acute" studies enrolling patients within 24-36 h after the onset of symptoms have shown a marked beneficial effect of ACE inhibitors in diabetic patients. For example, in the GISSI 3 study, treatment with lisinopril was associated with a decreased 6-week mortality in both IDD (11.8% versus 21.1, p < 0.05) and non-IDD (8.0% versus 10.6%, p < 0.05) patients corresponding to a 44.1% and 24.5% reduction, respectively. All these results must be taken with great caution because in no studies the effect of treatment in diabetic patients was a predefined analysis. They strongly suggest, however, that ACE inhibitors and beta blockers may be particularly beneficial during the acute phase of MI and also post-discharge, offering a strong rationale for their widespread use in diabetic patients with acute MI.
在将纤溶疗法作为心肌梗死（MI）患者的常规治疗方法引入之前和之后进行的多项研究一致表明，糖尿病患者在住院期间和出院后的死亡率更高。胰岛素依赖型糖尿病（IDD）女性的预后似乎尤其不佳。到目前为止，很少有随机前瞻性研究评估药物治疗对急性心肌梗死期间糖尿病患者预后的影响：关于常用心血管药物对急性心肌梗死（AMI）糖尿病患者疗效的大多数信息仅来自一些大型试验的回顾性亚组分析或非随机比较。急性心肌梗死纤溶试验的综述发现，纤溶治疗使糖尿病患者35天死亡率为13.6%，而非糖尿病患者为17.3%（降低21.7%）；非糖尿病患者为8.7%，糖尿病患者为10.2%（降低14.3%）。阿司匹林试验的数据表明，这种药物对急性心肌梗死糖尿病患者具有有益作用，但最佳剂量仍未确定。根据现有证据，β受体阻滞剂似乎能够降低糖尿病患者心肌梗死后的死亡率，其绝对和相对有益作用在大多数情况下大于非糖尿病患者。非β受体阻滞剂研究的汇总数据表明，急性期糖尿病患者死亡率降低37%，而非糖尿病患者为13%；出院后糖尿病患者死亡率降低48%，而非糖尿病患者为33%。评估钙拮抗剂的试验中缺乏糖尿病患者的结局数据，迫切需要重新评估已完成试验的数据，以了解这些药物对该人群可能产生的影响。关于急性心肌梗死后一段时间左心室功能不全患者使用血管紧张素转换酶（ACE）抑制剂的“长期”研究表明，将分析局限于有糖尿病病史的患者时，总体人群中记录的有益作用同样存在；而在症状发作后24 - 36小时内纳入患者的“急性”研究表明，ACE抑制剂对糖尿病患者有显著有益作用。例如，在GISSI 3研究中，赖诺普利治疗使IDD患者（11.8%对21.1%，p < 0.05）和非IDD患者（8.0%对10.6%，p < 0.05）6周死亡率均降低，分别降低44.1%和24.5%。所有这些结果都必须谨慎看待，因为在任何研究中，对糖尿病患者的治疗效果都不是预先设定的分析。然而，这些结果强烈表明，ACE抑制剂和β受体阻滞剂在心肌梗死急性期及出院后可能特别有益，这为它们在急性心肌梗死糖尿病患者中的广泛应用提供了有力依据。
