:

. .

&

..

()

 ..

70-80%

75%

15 *
50%

Diab.Care 2011;Supll.1
* Lancet 2006; 368: 29

Z. Bloomgarden Diabetes Care 2005

Framingham Heart Study:

30 :
( 35-64)
Men
10

Women

Risk 6
radio
4
2
0

Total CVD

CHD

Cardiac
Failure

Intermittent
Claudication

Stroke

Age adjusted annual rate 1,000

P< 100 for all values except *P< 0,05.
Wilson PWF, Kannal WB. In : Hyperglycemia, Diabetes and Vascular Disease


( social RFs)
102 (RCTs)

Lancet 2010;375:2215-22

The Continuum of CV Risk in

Type 2 Diabetes

Adapted from American Diabetes Association. Diabetes Care. 2003;26:3160-3167.

Tsao PS, et al. Arterioscler Thromb Vasc Biol. 1998;18:947-953.
Hsueh WA, et al. Am J Med. 1998;105(1A):4S-14S.
American Diabetes Association. Diabetes Care. 1998;21:310-314.

 HbA1C , .

ARIC study: 11092 Fu = 15

HbA1C
Parameter
< 5.0%

5.0% to<5.5%c.

5.5% to < 6.0%

6.0% to <6.5%

6.5%

12

21

44

79

Diabetesb

0.52 (0.40
0.69)

1.00

1.86 (1.67
2.08)

4.48 (3.92
5.13)

16.47 (14.22
19.08)

CHD

0.96 ( 0.74
1.24)

1.00

1.23 (1.07
1.41)

1.78 ( 1.48
2.15)

1.95 (1.53
2.48)

Ischemic
stroke

1.09 ( 0.67
1.76)

1.00

1.17 ( 0.89
1.53)

2.22 (1.60
3.08)

3.16 ( 2.15
4.64)

Mortality

1.48 ( 1.21
1.82)

1.00

1.18 (1.04
1.35)

1 .59 ( 1.34
1.89)

1.65 ( 1.31
2.08)

Diabetes
Incidence (%)

NEJM 2010;362:800-811

 -
, ,
2

> 0.925
(p=0.02) R.R ( ) = 25
ROC CURVE
IMT=0.925

SENSITIVITY

1.00

0.75

0.50

0.25
ROC Area=0.79; SE=75% and SP=80%; p=0.02

0.00
0.00

.25

.50

.75

1.00

1 -SPECIFITY
Melidonis et al. Diabetes Care 2003: 26; 3189


30
175 874 30

18
3
5
(
)

(12
)

2
% HbA1C

53% 8%
Juutilainen et al: Diab. Care 2008;31:714-719



East-West Study

(%)

50
40

Nondiabetics with prior MI

45.0

Nondiabetics with no prior MI

p<0.001

Diabetics with prior MI

30
20

Diabetics with no prior MI

20.2

18.8

10

P<0.001
3.5

(n=69)
1.000 3.0

(n=1304)

(n=169)

(n=890)

0.5

7.8

3.2

Haffner SM et al. N Engl J Med 1998;339:229-234.

(NCEP ATPIII 2002)

 ;
13 38.578 . Fu = 13

U. Bulugahapitiya et al, Diabetic Medicine 2009;26:142 - 148



British Regional Heart Study 4045

Event

No diabetes and no
prior MI (n=3197)

Late-onset diabetes
(n=307) *

Early-onset diabetes
(n=107) *

Men with prior MI

and no diabetes
(n=368)

Major coronary heart

disease

1.0

1.54 (1.072.21)

2.39 (1.414.05)

2.51 (1.883.36)

Major cardiovascular
diseaseb

1.0

1.37 (1.011.84)

2.08 (1.333.25)

2.17 (1.712.77)

All-cause mortality

1.0

1.31 (1.061.62)

1.68 (1.192.38)

1.48 (1.221.78)

a. Adjusted for age, smoking, alcohol consumption, social factors, body-mass index, physical activity, stroke, blood pressure,
HDL and total cholesterol, respiratory factor , C-reactive protein, von Willebrand factor levels, and estimated glomerular filtration rate
* Early onset diab.: diagnosed <60years old age (mean duration of diabetes : 15 years)
Late onset diab.: diagnosed > 60 years old age (mean duration of diabetes : 5 years)

Wannamethee et al. Arch Int Med 2011;171:404-410

Idris Arch Int. Med 2011;171:411

 8-10

N. Sattar Diabetologia 2013;56:686 687

 : Screening
ADA 2014
Screening: ,
10
()
CVD a-Mea (C), ()
()

-blocker (A)
>40
(, , ,
, .., )
()

TZDs (C)

.
. . (C)
Diabetes Care 2014;34:Suppl I, S6 S12

O



1

4
.
&

Adapted from Stary HC et al. Circulation 1995; 92: 1355-1374

AGE

Stress

/:

NO

Endothelin 1

Prostacyclin

Thromboxan

TNF a

Diabetes Care 2010;33:442-449

,

2013

ESC 2013

L. Ryden et al EHJ August 30, 2013









( 2)



: 453
Control: 332
50

47.1%

43.8%

40
30

25.9%

27.0% 28.6%

27.6%

20
10
2.2

0
1
< 0,001

2
= NS

3
< 0,001

1.8

<0,001

* 2
,
.

elidonis et al. Angiology 1999;50:997-1005


(DIAD STUDY: SPECT )

78%
-n=563
70
60
50
40

- /
Spect:
- : R 5.6
(p<0.01)
- : R 5.2 (p<0.01)
- ..: R

30

22%

20
0

Wackers et al: Diabetes Care 2004; 27:1954-62

 SPECT

DIAD Study 1130 Fu = 5

Years

BMJ 2009;338:b1617

 . :
Screening
ADA 2014

. . ,
screening .
.
()
CVD
( C )
aspirin ()
. .

. . ( ).
,
, , ()
TZDs
(C)
A metformin
(C)

Diabetes Care January 2014 37:S11-S63


2013





>35 ,



ADA 2013-2014

HbA1c <7%
ADA: A

HbA1c <7%
ADA: B

,
CVD

HbA1c <6.5%
ADA: C

, HbA1c <8%

ADA: B

Diabetes Care 2014;37:Suppl.1

Diabetes Care 2013;36:Suppl.1

Most Cardiovascular Patients Have

Abnormal Glucose Metabolism
GAMI
n = 164
31%

35%
34%

Normoglycemia

EHS
n = 1920
37%

18%
45%

Prediabetes

CHS
n = 2263
27%

37%

36%

Type 2 Diabetes

GAMI = Glucose Tolerance in Patients with Acute Myocardial Infarction study;

EHS = Euro Heart Survey; CHS = China Heart Survey
Anselmino M, et al. Rev Cardiovasc Med. 2008;9:29-38.


:
ADA Guidelines 2014

:
140mg-180mg%.(A)


(C)

:
<140mg%
<180mg%


()
Diabetes Care2014;suppl1:15-60

Coronary revascularization
of patients with diabetes
2013

L. Ryden et al EHJ August 30, 2013

 (..)

:

.

:


(
Ca)

L. Ryden. Eur. Heart Journal 1999


LV
60% ( 1 2)
Bell. Diabetes Care 1995, Refield. JAMA 2003;

/ HF



Zoneraich S, Diabetes Care 1994

1,8

1,6

*
*

1,4

1,2
1

0,8

Control

0,6
0,4
0,2
0
E/A

Em/Am
E'/A'
Em'/Am'
.. .. P<0.01

p<0,05

Melidonis et al. Diabetologia (2007) 50:[Suppl1]S492

 . . .
Risk Factors
Endothelial
Dysfunction
Atherosclerosis
CAD
Myocardial
Ischemia
Coronary
Thrombosis
Myocardial
Infarction
Arrhythmia & Loss
of Muscle
Remodeling
Ventricular Dilation
Congestive Heart
Failure
Endstage Heart
Disease

Diabetic cardiomyopathy

 ...:

: 1% HbA1c 15%

UKPDS :
56% .
(RR : 0,44, p=0,0043).

LDL<70mg%
100 -160mg
- -
.
Guidelines ADA Diabetes Care 2005; Suppl. 1

Management of heart failure in diabetes

2013

L. Ryden et al EHJ August 30, 2013

LDL.

 2

Statement ADA 2014

<140/ 80 mmHg ()

LDL

<100 mg/dl ()
.LDL
>40+ . ()

LDL>100 . (C)

-<150 mg/dl (C)

DL

DL>40 mg/dl () >50 mg/dl () (C)

:75 -162 mg/ . >50

() >60 () 1
) (C)

- 1C <7%
1C (<6%)

(25)

5-7%

150 min/ .


placebo controlled

UKPDS

342
()

10,7

Metformin

150/

PROactive

2

.

5238

34,5

Pioglitazone

120/ (
end point)
143/ (
end points)

HOPE

2
CV
( )

9541 (3577
)

4,5

Ramipril

91/

ADVANCE

2

.

11140

4,3

Perindr. +
Indapamid

331/

HPS

2
.
(

20536
(3051
)

Simvastatin

75/

4S

2
( )

4398 (483
)

5,4

Simvastatin

42/

CARE

4159 (586
)

Pranast

54/



Steno2 Study

. Risk reduction : 50%

NNT:5

Goede P et al. NEJM 2003; 348: 383-393.

 4 .
( 1 ) RCT

23
18

14

8
4

. Farkouh et al JACC 2013;61(15):1607-15

Glycaemic, lipid and blood pressure control in 1998

and 2008 in Greek diab. Population
[Data are shown as mean value (SD)].

1998

On target

2008

On target

HbA1c (%)

8.1 (2.0)

36.1%

7.0 (1.2)

56.1%

< 0.001

SBP (mmHg)

139.3 (17.9)

22.5%

134.9 (18.7) 35.5%

< 0.001

DBP (mmHg)

80.9 (8.7)

23.0%

77.6 (9.8)

48.2%

< 0.001

HDL-C (mmol/l)

1.2 (0.3)

50.5%

1.3 (0.4)

52.3%

0.002

LDL-C (mmol/l)

3.9 (1.1)

10.4%

2.9 (0.9)

40.2 %

< 0.001

TGL (mmol/l)

2.0 (1.3)

53.6%

1.7 (0.9)

59.9%

< 0.001

All 3 targets: 12%

Liatis et al, Exp Clin Endocrinol Diabetes 2009

1924
...

Joslin EP. The treatment of diabetes mellitus, 3rd edition.

London, H.Kimpton, 1924

2014

To

Editorial: R . Nesto. Am. J .Med 2012;

.....

....

5-8 2014

-


!!!!!!

 !!!!!!


:
9RCTs : 100000 FU = 6

=120

H=73

Archives of Internal Medicine 2012, 9 Jan

Recommendations on diabetes mellitus

ESC GUIDELINES 2012

EHJ 2012;33(12):1635-1701









( 2)

Circulation 1996; 94:2013-2020.



- -

Kenneth E. Stone, Am J Cardiol 2007; 99[suppl]: 105B112B









( 2)



( >500 )

2006

2006

2004
2004
2004

2005

Bax et al. Diabetes Care 2007; 30 (5): 1295.

E E E

Acyl

ionpumps

Textbook : Diabetes and cardiovascular disease 2002

AMP

H

Canadian ACS registry: 4578 patients

n= 3429

n= 1149

(per
os)

94.5

91.0

<.001

..

30.6

32.3

Glyc. IIB/ IIIA

7.6

5.2

<.01

59.1

44.9

<.001

41.0

36.4

<.001

PCI

18.0

12.7

<.001

CABG

4.0

3.8

24

Yan R. et al. Am. Heart J. 2006; 152: 676-83