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[ADA2012]女性、糖尿病与心血管疾病
——埃默里大学医学院心脏病科Nanette K. Wenger教授访谈
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作者:N.K.Wenger 2012/6/10 16:02:00    加入收藏
内容概要:Prof.Wenger: The way I have chosen to approach it is to query whether this is biology or whether this is bias or whether this is both. To give you a preview of what I am going to say, I am going to end up saying it is both

  <International Diabetes>: What are you talking about in your presentation?
  Prof.Wenger: The way I have chosen to approach it is to query whether this is biology or whether this is bias or whether this is both. To give you a preview of what I am going to say, I am going to end up saying it is both. The one thing that we know is women with diabetes have more cardiovascular disease and worse outcomes from cardiovascular disease than do diabetic men. The question is why? The biology of it is substantial because the woman with diabetes has much more associated cardiovascular risk. She is more likely to have hypertension, obesity, metabolic syndrome, atherogenic dyslipidemia than men and even small changes in these features seem to disproportionately affect women. A little bit of weight gain is more likely to make a woman diabetic than a man and conversely, a little bit of weight loss may improve her diabetic status. Physical inactivity places the diabetic woman at disproportionate risk; physical activity lessens her risk. But then we have the background of cardiovascular disease in general whereas women, even without diabetes, tend to be diagnosed later, undertreated and underprevented. This is what is called by the organizers of this session, a “perfect storm”. So we have this biology. Hyperglycemia is a risk in itself with poor control of diabetes because you end up with the glycosylation of blood proteins and arterial wall proteins and this is a specific risk factor for endothelial dysfunction and oxidative stress and these women tend to be obese and they tend to have more inflammation. Again, it is the “perfect storm”. Then you have the bias in that there is abundant evidence that women who have diabetes are less well controlled in terms of their diabetes. Their HbA1cs are higher. Their hyperlipidemia is less often treated and when it is treated, it is less often treated to target. Their blood pressure is less well controlled. Even when they develop cardiovascular disease, they are less likely to be treated with statins and aspirin.

  《国际糖尿病》:您演讲的主题是什么?
  Dr Wenger:我想要通过一个问题来阐释我的演讲内容。这个问题就是“这只一个生物学问题还是偏见亦或两者都是”。我可以提前告诉你答案:两者都是。众所周知,女性糖尿病患者发生心血管病的概率高于男性,女性心血管病的结局也较男性要差。这是为什么呢?其中蕴藏的生物学原理非常重要,因为女性糖尿病患者的心血管病危险因子更多。与男性相比,女性更容易发生高血压,肥胖,代谢综合征和致动脉粥样硬化的血脂代谢异常,即使这些危险因子发生非常微小的变化,对女性造成的影响都会不成比例地增高。同样程度地体重增加,女性发生糖尿病的风险的增加量就会显著高于男性,而反过来,轻度的体重减轻给女性带来的益处要超过男性。体育锻炼少同样使女性的糖尿病风险不成比例地增高,而参加体育锻炼可以使糖尿病风险降低。而就心血管病而言,即使是没有糖尿病的女性,她们心血管病的诊断也较男性晚,采用治疗和预防措施也较男性少。这就是本届大会的组织者所说的“完美风暴”。我们了解了这个问题的生物学方面。高血糖本身是心血管病的一个危险因素,因为糖尿病可以导致血中蛋白质和动脉壁蛋白的糖基化,而这些是内皮细胞功能异常和氧化应激的特异性危险因素,同时糖尿病女性有肥胖和炎症反应增强的倾向。同样,这也是“完美风暴”。这样,就会使我们产生一种偏见,认为已有足够证据证实,糖尿病女性的病情控制较差,HbA1c较高;高脂血症治疗率较低,而接受治疗的患者的达标率较低;血压良好控制率较低;即使已经发展成了心血管病,她们接受他汀和阿司匹林治疗的比例也较低。

  <International Diabetes>:  Why is there this bias?
  Prof.Wenger:  Some of it may be the old bias that women don’t get heart disease. If women don’t get heart disease then we really won’t worry about it. We are learning that women do get heart disease and they have worse outcomes and it is a real problem. Even when it was recognized that women do get heart disease, most people thought of it as a disease of old ladies so why worry about the younger diabetic woman. Actually the greatest disparity between males and females is in the group under age 65. So again, this is the group that is less well treated. But one of the real challenges globally is that diabetes is undiagnosed or underdiagnosed in women and in men and of course it becomes a disproportionate risk for a woman to be undiagnosed since the diabetes puts her at greater risk. If she is recognized as diabetic, hopefully someone will realize that this is a coronary risk equivalent and treat her more aggressively. But lacking the diagnosis of diabetes is the problem. My conclusions from putting all of this together and there are some very good studies looking at women in managed care, both commercial managed care and the American Medicare managed care programs, are that they are less well treated than their male peers, both for their diabetes and for their risk factors. And remember that this doesn’t even take uninsured women into account, who are obviously more vulnerable and at greater risk. We don’t have a roadmap or an algorithm on what to do with a diabetic woman to prevent cardiovascular disease and what to do to aggressively treat the diabetic woman with cardiovascular disease. I think there are three conclusions I hope my audience will take away with them from my talk. The first is to recognize that the diabetic woman is at excess cardiovascular risk. Secondly, to recognize and very aggressively treat all of her risk factors, guideline-based. There is a 2011 prevention guideline for women from the American Heart Association that should be followed. And then, to use guideline-based therapy for established disease.

  《国际糖尿病》:这种偏见是如何产生的?
  《Dr Wenger》:有一些可能源自过去的认识,认为女性不会发生心脏病,从而没有提起重视。现在我们已经认识到,女性不仅会发生心脏病,他们的心脏病结局甚至更差。即使认识到女性同样会发生心脏病,多数人仍认为心脏病只会发生在老年女性中,于是不会对年轻的糖尿病女性提高重视,但事实上,男性和女性的心脏病发生率的差异主要发生在65岁以下的人群。糖尿病女性接受的治疗不足。全球范围内,无论男性还是女性,糖尿病未诊断和诊断不足的现象均普遍存在,而由于女性糖尿病患者本身的心血管病风险高于男性,她们的心血管病风险就会不成比例地增高。如果糖尿病诊断能够确立,医生就可以意识到患者是冠心病的等危症,就可能进行更加积极的治疗。但目前糖尿病诊断率低仍然是一个问题。综合我们能够获得的关于女性健康管理方面的一些设计良好的研究(包括来自商业医疗保险和美国医疗保险等项目)结果,发现无论是糖尿病还是危险因子方面,女性接受到的治疗力度均弱于男性。而且,还不包括那些未参保的女性,显然那些女性的心血管病风险更高。关于如何预防糖尿病女性发生心血管病以及如何更加积极地治疗糖尿病女性的心血管病,我们没有现成的路线图或计算方法。但我希望听众们能够记住3点结论。第一,女性糖尿病患者的心血管病风险更高。第二,要以指南为依据,更加积极的对女性糖尿病患者的危险因子进行治疗。目前,美国心脏病学会已经发表了2011版的女性预防指南,我们应当遵照指南执行。第三,对于已经确立的心血管病患者,遵照指南进行治疗。
 



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