Hyperglykämie und kardiovaskuläre Erkrankungen

 

 Buy Article Permissions and Reprints

Zusammenfassung

Neben den klassischen, beeinflussbaren kardiovaskulären Risikofaktoren wie arterielle Hypertonie, Hypercholesterinämie und Zigarettenrauchen werden Glukosestoffwechselstörungen (z. B. Insulinresistenz, pathologische Glukosetoleranz, Diabetes mellitus) in den nächsten Jahren zunehmend an Bedeutung gewinnen. Epidemiologische Untersuchungen zeigen, dass bereits jetzt bei ca. 8 % der Bevölkerung und bei bis zu 60 % der Patienten mit akutem Koronarsyndrom ein manifester Diabetes mellitus oder latente Glukosestoffwechselstörungen bestehen. Durch eine alternde Gesellschaft und die Zunahme des Übergewichtes wird die Prävalenz dieser Störungen in den nächsten Jahren drastisch zunehmen. Erhöhte Glukosewerte schädigen das Endothel unter anderem durch verstärkten oxidativen Stress, chronisch subklinische Entzündung, Expression von Leukozytenadhäsionsmolekülen, Anstieg prothrombogener Faktoren im Blut und eine gesteigerte Aggregation und Adhäsion von Thrombozyten. Die Hinweise, dass eine blutzuckernormalisierende Therapie die Inzidenz kardiovaskulärer Ereignisse vermindert, häufen sich. Bei Patienten mit akutem Myokardinfarkt verbessert die Normalisierung erhöhter Blutglukosewerte durch eine frühe Insulintherapie die Prognose dieser Patienten. Zusammengefasst unterstreichen diese Daten die Notwendigkeit einer frühen Diagnose und Therapie von manifesten und latenten Störungen des Glukosestoffwechsels für die Reduktion prognostisch bedeutsamer kardiovaskulärer Ereignisse.

Summary

Besides classical, modifiable risk factors (hypercholesterolemia, hypertension, smoking) abnormalities of the glucose metabolism (diabetes mellitus, impaired glucose tolerance) are strong emerging cardiovascular risk factors. Epidemiological data indicate that 8 % of the population and up to 60 % of patients with coronary artery disease have abnormalities of glucose metabolism. The prevalence of these abnormalities will increase as the population ages and the mean body weight increases. An abnormal glucose concentration damages the endothelium in several ways: increased oxidative stress, inflammatory processes and an activation of procoagulant factors all impair endothelial function. A blood glucose normalising therapy is thought to decrease the incidence of cardiovascular events in these patients. In patients with an acute myocardial infarction and diabetes mellitus an early intensive insulin therapy improves the outcome of these patients. In summary, the early detection and treatment of abnormalities of glucose metabolism reduces cardiac events.

Literatur

• 1 Almbrad B, Johannesson M, Sjostrand B, Malmberg K, Ryden L. Cost-effectiveness of intense insulin treatment after acute myocardial infarction in patients with diabetes mellitus: results from the DIGAMI study.  Eur Heart J. 2000;  21 733-739
  Google Scholar
• 2 American Diabtes Association . Clinical practice recommendations 2004. Position statement. Screening for Type2 Diabetes.  Diabetes Care. 2004;  27 S11-S14 ((Suppl 1))
  Google Scholar
• 3 Advani A, Marshall S M, Thomas T H. Impaired neutrophil actin assembly causes persistent CD11b expression and reduced primary granule exocytosis in Type II diabetes.  Diabetologia. 2002;  45 719-727
  Google Scholar
• 4 Brownlee M. Biochemistry and molecular cell biology of diabetic complications.  Nature. 2001;  414 813-820
  Google Scholar
• 5 Ceriello A, Bortoloti N, Motz E. et al . Meal-generated oxidative stress in type 2 diabetic patients.  Diabetes Care. 1998;  21 1529-1533
  Google Scholar
• 6 Ceriello A, Mercuri F, Quagliaro L. et al . Detection of nitrotyrosine in the diabetic plasma: evidence of oxidative stress.  Diabetologia. 2001;  44 834-838
  Google Scholar
• 7 Chiasson J L, Josse R G, Gomis R, Hanefeld M, Karasik A, Laakso M. Acarbose for prevention of type 2 diabetes mellitus: the STOP-NIDDM randomised trial.  Lancet. 2002;  359 2072-2077
  Google Scholar
• 8 Chiasson J L, Josse R G, Gomis R, Hanefeld M, Karasik A, Laakso M. Acarbose treatment and the risk of cardiovascular disease and hypertension in patients with impaired glucose tolerance: the STOP-NIDDM trial.  Jama. 2003;  290 486-494
  Google Scholar
• 9 De Vegt F, Nijpels G, Dekker J M. et al . Similar 9-year mortality risks and reproducibility for the WHO and American Diabetes Association glucose tolerance categories.  Diabetes Care. 2000;  23 40-44
  Google Scholar
• 10 Duckworth W C. Hyperglycemia and cardiovascular disease.  Curr Atheroscler Rep. 2001;  3 333-391
  Google Scholar
• 11 Gitt A K, Schiele R, Wienbergen H. et al . Increased hospital and long-term mortality for non-ST elevation myocardial infarction in patients with diabetes: results from the ACOS registry (Abstract).  Eur Heart J. 2003;  24 674 (Suppl)
  Google Scholar
• 12 Haffner S M, Lehto S, Röonnema T. et al . Mortality from coronary heart disease in subjects with type 2 diabetes and nondiabetic subjects with and without prior myocardial infarction.  N Engl J Med. 1998;  339 229-234
  Google Scholar
• 13 Haller H. Postprandial glucose and vascular disease.  Diabetic Medicine. 1997;  14 50-56
  Google Scholar
• 14 Hanefeld M, Cagatay M, Petrowitsch T, Neuser D, Petzinna D, Rupp M. Acarbose reduces the risk for myocardial infarction in type 2 diabetic patients: meta-analysis of seven long-term studies.  Eur Heart J. 2004;  25 10-16
  Google Scholar
• 15 Herlitz J, Malmberg K. How to improve the cardiac prognosis for diabetes.  Diabetes Care. 1999;  22 B89-96 (Suppl 2)
  Google Scholar
• 16 Kawano H, Motoyama T, Hirashima O. et al . Hyperglycemia rapidly suppresses flow-mediated endothelium dependent vasodilation of brachial artery.  J Am Coll Cardiol. 1999;  34 146-154
  Google Scholar
• 17 King H, Aubert R E, Herman W H. Global burden of diabetes, 1995 - 2025: prevalence, numerical estimates, and projections.  Diabetes Care. 1998;  21 1414-1431
  Google Scholar
• 18 Lakka H M, Laaksonen D E, Lakka T A. et al . The metabolic syndrome and total and cardiovascular disease mortality in middle-aged men.  JAMA. 2002;  288 2709-2716
  Google Scholar
• 19 Lee I K, Kim H S, Bae J H. Endothelial dysfunction: its relationship with acute hyperglycaemia and hyperlipidemia.  Int J Clin Pract Suppl. 2002;  129 59-64
  Google Scholar
• 20 Malmberg K. Prospective randomised study of intensive insulin treatment on long term survival after acute myocardial infarction in patients with diabetes mellitus. DIGAMI (Diabetes Mellitus, Insulin Glucose Infusion in Acute Myocardial Infarction) Study Group.  Br Med J. 1997;  314 1512-1515
  Google Scholar
• 21 Malmberg K, Norhammar A, Wedel H, Ryden L. Glycometabolic state at admission: important risk marker of mortality in conventionally treated patients with diabetes mellitus and acute myocardial infarction: long-term results from the Diabetes and Insulin-Glucose Infusion in Acute Myocardial Infarction (DIGAMI) study.  Circulation. 1999;  99 2626-2632
  Google Scholar
• 22 Mazzone A, De Servi S, Mazzucchelli I. et al . Increased expression of CD11b/CD18 on phagocytes in ischaemic disease: a bridge between inflammation and coagulation.  Eur J Clin Invest. 1997;  27 648-652
  Google Scholar
• 23 Meier J J, Deifuß S, Gallwitz B. et al . Einfluss einer eingeschränkten Glucosetoleranz auf das Langzeitüberleben nach akutem Myokardinfarkt.  Dtsch Med Wochenschr. 2002;  127 1123-1129
  Google Scholar
• 24 Norhammar A, Tenerz A, Nilsson G. et al . Glucose metabolism in patients with acute myocardial infarction and no previous diagnosis of diabetes mellitus: a prospective study.  Lancet. 2002;  359 2140-2144
  Google Scholar
• 25 Norhammar A, Malmberg K, Ryden L. et al . Under utilisation of evidence-based treatment partially explains for the unfavourable prognosis in diabetic patients with acute myocardial infarction.  Eur Heart J. 2003;  24 838-844
  Google Scholar
• 26 Rathmann W, Haastert B, Icks A. et al . High prevalence of undiagnosed diabetes mellitus in southern Germany: target populations for efficient screening. The KORA survey 2000.  Diabetologia. 2003;  46 182-189
  Google Scholar
• 27 Sampson M J, Davies I R, Brown J C. et al . Monocyte and Neutrophil Adhesion Molecule Expression During Acute Hyperglycemia and After Antioxidant Treatment in Type 2 Diabetes and Control Patients.  Arterioscler Thromb Vasc Biol. 2002;  22 1187-1193
  Google Scholar
• 28 Schiekofer S, Andrassy M, Chen J. et al . Acute hyperglycemia causes intracellular formation of CML and activation of ras, p42/44 MAPK, and nuclear factor kappaB in PBMCs.  Diabetes. 2003;  52 621-633
  Google Scholar
• 29 Stern M P. Diabetes and cardiovascular disease. The „common soil” hypothesis (Review).  Diabetes. 1995;  44 369-374
  Google Scholar
• 30 Taubert G, Winkelmann B R, Schleiffer T. et al . Prevalence, predictors and consequences of unrecognized diabetes mellitus in 3266 patients scheduled for coronary angiography.  Am Heart J. 2003;  145 285-291
  Google Scholar
• 31 Temelkova-Kurktschiev T, Henkel E, Koehler C, Karrei K, Hanefeld M. Subclinical inflammation in newly detected type II diabetes and impaired glucose tolerance.  Diabetologia. 2002;  45 151
  Google Scholar
• 32 Temelkova-Kurktschiev T, Siegert G, Bergmann S, Henkel E, Koehler C, Jaroß W, Hanefeld M. Subclinical inflammation is strongly related to insulin resistance but not to impaired insulin secretion in a high risk population for diabetes.  Metabolism. 2002;  51 743-749
  Google Scholar
• 33 The Diabetes Prevention Program (DPP): description of lifestyle intervention.  Diabetes Care. 2002;  25 2165-2171
  Google Scholar
• 34 Tominaga M, Eguchi H, Managa H. et al . Impaired glucose tolerance is a risk factor for cardiovascular disease, but not impaired fasting glucose.  Diabetes Care. 1999;  22 883-885
  Google Scholar
• 35 Tuomilehto J, Lindstrom J, Eriksson J G. et al . Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance.  N Engl J Med. 2001;  344 1343-1350
  Google Scholar
• 36 UKPDS Study Group . UKPDS 33 Intensive blood glucose control with sulphon-ylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes.  Lancet. 1998;  352 837-853
  Google Scholar
• 37 van den Berghe G, Wouters P, Weekers F. et al . Intensive insulin therapy in the critically ill patients.  N Engl J Med. 2001;  345 1359-1367
  Google Scholar

Priv.-Doz. Dr. C. Schneider

Klinik III für Innere Medizin, Universität zu Köln

Joseph-Stelzmann-Straße 9

50924 Köln

Email: christian.schneider@medizin.uni-koeln.de