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Glucose Excursions Linked to Ventricular Tachycardia血糖波动与室性心动过速相关  

2012-10-31 15:53:38|  分类: 内分泌科 |  标签: |举报 |字号 订阅

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柏林——欧洲糖尿病研究协会(EASD)年会上公布的一项纳入30例有心血管病史的2型糖尿病患者的研究显示,低血糖事件和血糖波动发生率高与室性心动过速发生率增加相关。


这项研究连续纳入30例合并动脉粥样硬化性心血管疾病的2型糖尿病患者。患者的血红蛋白A1c水平低于9%,并且接受胰岛素和(或)磺酰脲类格列本脲的稳定治疗。排除接受任何其他抗糖尿病治疗的患者、原有心律失常的患者,以及除了β受体阻滞剂以外还使用任何抗心律失常药物的患者。入组患者的平均年龄为68岁,平均血红蛋白A1c为7.3%,除1例之外,所有受试者均为男性。


每例患者接受连续5天的同步连续血糖监测和心电图监测。在此期间,观察到23例患者共发生35次重度低血糖事件(定义为血糖水平低于3.1 mmol/L)。各次重度低血糖发作的平均时间为40 min。


30例患者中的28例发生室性期前收缩(VES),5天心电图监测期间的发生次数平均超过3600次。17例患者发生二联律,10例发生三联律,5例发生室性心动过速。


分析显示,血糖平均波动幅度至少4.02 mmol/L的患者的重度VES发生率显著增加,其中发生至少1次重度低血糖事件且血糖平均波动幅度大于5.61 mmol/L的患者的VES发生率最高。


研究者表示,特别容易因血糖控制不佳而发生心律失常的患者是那些具有心血管疾病史和接受可能导致低血糖的治疗(如复杂胰岛素方案或含有磺酰脲类药物的方案)的患者。医生除了应对达到相似标准的所有患者进行1天血糖监测之外,还应对既往发生主要心血管事件的患者、接受复杂胰岛素方案治疗的患者和接受长效磺酰脲类药物的患者进行24 h心电图监测。如果能够进行1天以上的心电图监测则更好,但费用也会非常高。


低血糖的3种最常见并发症是室性心动过速、房颤和缺血反应。由于室性心动过速可导致室颤和猝死,因此本研究将其作为研究重点。


研究者建议,医生应制定个体化治疗方案以改善患者的血糖,并识别出那些心律失常风险较高的患者。对于许多患者,除了可使用额外或替代性抗糖尿病药物改善血糖控制之外,还可使用β受体阻滞剂减少室性心律失常的潜在影响。但β受体阻滞剂不适用于所有具有动脉粥样硬化性心血管疾病史的2型糖尿病患者,因为一些患者患有心动过缓且不耐受β受体阻滞剂。


研究者声明无经济利益冲突。




By: MITCHEL l. ZOLER, Cardiology News Digital Network


BERLIN – A hypoglycemic event and a high rate of glucose excursions were associated with an increased rate of ventricular tachycardia, in a study of 30 patients with type 2 diabetes and a history of cardiovascular disease.


The findings highlight the potentially important role that glycemic excursions and hypoglycemic events play in patient health. "We have underestimated the risk from hypoglycemia as a cause of death," Dr. Markolf Hanefeld said in an interview at the annual meeting of the European Association for the Study of Diabetes.


"Hypoglycemia is very dangerous, and is also under-recognized and under-reported. Our results are another reason to avid glycemic excursions and hypoglycemia," he said.


Patients who may be especially at danger for arrhythmias triggered by poor glycemic control are those with a history of cardiovascular disease and on treatment that can produce hypoglycemia, such as a complex insulin regimen or a regimen that includes a sulfonylurea, said Dr. Hanefeld, professor and director of the Centre for Clinical Studies at Dresden (Germany) Technical University.


Dr. Hanefeld recommended that in addition to performing 1-day glucose monitoring on all patients who meet similar criteria, physicians should perform 24-hour ECG monitoring on patients with a prior major cardiovascular event, patients on a complex insulin regimen, and patients treated with a long-acting sulfonylurea.


"If you record their ECG [for a day or more,] that’s even better, but also very expensive," he said. "The three most dangerous complications of hypoglycemia are ventricular tachycardia, atrial fibrillation, and ischemic reactions. Ventricular tachycardia was our focus because it can lead to ventricular fibrillation and sudden death."


The patient’s treatment should then be tailored to improve their glycemic profile, and patients at higher risk for arrhythmias should be identified.


In addition to improved glycemic control with additional or alternative antidiabetic drugs, many patients like the ones studied could benefit from treatment with a beta-blocker to minimize the potential impact of a ventricular arrhythmia. But beta-blockers cannot be given to all patients with type 2 diabetes and a history of atherosclerotic cardiovascular disease, because some patients have bradycardia and would not tolerate a beta-blocker.


Dr. Hanefeld enrolled 30 consecutive patients with type 2 diabetes and documented atherosclerotic cardiovascular disease. Patients had a hemoglobin A1c of less than 9% and were on stable treatment with insulin, a sulfonylurea-like glyburide, or both. The investigators excluded patients on any other antidiabetic treatment, patients with preexisting arrhythmias, and patients on any antiarrhythmic drug except for a beta-blocker. Enrolled patients averaged 68 years old, their average hemoglobin A1c was 7.3%, and all but one was a man.


Each patient underwent 5 consecutive days of simultaneous continuous glucose monitoring and ECG recording. During this period, severe hypoglycemic events – defined as a blood glucose level less than 3.1 mmol/L – occurred in 23 patients, with a total of 35 episodes. The average time of each severe episode was 40 minutes.


Twenty-eight of 30 patients had ventricular extrasystoles (VESs), with an average of more than 3,600 during 5 days of ECG recording. Seventeen patients had couplets, 10 had triplets, and 5 had ventricular tachycardia.


Analysis showed a statistically significant increase in the rate of severe VESs in patients who had a mean amplitude of glycemic excursions of at least 4.02 mmol/L, Dr. Hanefeld and his colleagues reported. The highest rate by far of VES occurred in patients who had at least one severe hypoglycemic event and a mean amplitude of glycemic excursions of greater than 5.61 mmol/L.


Dr. Hanefeld said that he and his associates on the study had no disclosures.


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