作者:Steven J. Lavine、Steven D. Gellman
DOI:10.2165/00003495-200262020-00004
日期:——
Patients with diabetes mellitus have an increased morbidity and mortality from cardiovascular disease. Both coronary artery disease and congestive heart failure (CHF) are largely responsible for the increased cardiovascular adverse events in patients with diabetes. This review discusses the pathophysiology of CHF, the mechanisms of left ventricular (LV) dysfunction and the neurohormonal mechanisms involved in both LV dysfunction and CHF. Diabetes with and without hypertension is an important cause of LV dysfunction and CHF. Diabetes may be responsible for the metabolic and ultrastructural causes of LV dysfunction, while hypertension may be responsible for the marked fibrotic changes that are found. Experimental induction of diabetes in animals has shed light on the biochemical and ultrastructural changes seen. The role of insulin to reverse both metabolic and structural changes is reviewed both from experimental data and with the limited amount of clinical data available. The therapy of CHF in patients with diabetes is similar to that of patients without diabetes, with therapy directed toward the use of β-blockers and angiotensin converting enzyme (ACE) inhibitors. As the morbidity and mortality are higher in patients with diabetes, several studies have pointed out the importance of this subgroup where the opportunity to make a significant clinical impact exists. A significant opportunity exists to reduce morbidity and mortality with β-blockers and ACE inhibitors when ischaemia and CHF are both present. However, studies in patients diabetes have been limited to post hoc subgroup analyses and rarely as predefined subgroups. Clinical trials involving patients with diabetes with and without hypertension and LV dysfunction are clearly needed in the future to adequately address the needs of this high risk subgroup.
糖尿病患者的冠心病和充血性心力衰竭(CHF)发病率及死亡率较高。本文综述了充血性心力衰竭的病理生理、左心室功能障碍的机制及左室功能不全和充血性心力衰竭时的神经激素机制。糖尿病合并或未合并高血压是左室功能障碍和充血性心力衰竭的重要原因。糖尿病可能是引起左室功能障碍的代谢和超微结构方面的原因,高血压则可引起显著的纤维化改变,对这些病变的认识来自糖尿病动物模型实验。胰岛素可逆转糖尿病患者左室功能障碍的代谢和结构方面的改变,有关胰岛素治疗充血性心力衰竭的临床资料极其有限。糖尿病患者的充血性心力衰竭治疗与非糖尿病患者相似,主要采用β阻滞剂和血管紧张素转换酶抑制剂进行治疗。因糖尿病患者发病率和死亡率较高,故对糖尿病人群进行临床干预能产生十分显著的效果。显著降低死亡率和发病率的机会存在于可用β阻滞剂和血管紧张素转换酶抑制剂治疗的缺血和充血性心力衰竭。但糖尿病人群研究大多集中在入选后的组间分析,很少作为预先确定的亚组参与研究。将来显然需要针对上述高风险人群进行研究,以满足糖尿病合并或未合并高血压及左室功能障碍进行治疗的临床需求。