Автореферат и диссертация по медицине (14.00.06) на тему:Сочетание хронической сердечной недостаточности и сахарного диабета 2-го типа: общая характеристика больных, клиническая картина, проблемы лечения и прогноза
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Оглавление диссертации Джахангиров, Тофик Шахмур оглы :: 2006 :: Москва
Условные обозначения.
Оглавление.
ВВЕДЕНИЕ.
Введение диссертации по теме "Кардиология", Джахангиров, Тофик Шахмур оглы, автореферат
Цель исследования. 8
Задачи исследования. 8
Научная новизна.8
Практическая значимость.10
Основные положения, выносимые на защиту.10
Внедрение в практику.11
Количество опубликованных работ и сообщений по теме диссертации. 11
Заключение диссертационного исследования на тему "Сочетание хронической сердечной недостаточности и сахарного диабета 2-го типа: общая характеристика больных, клиническая картина, проблемы лечения и прогноза"
выводы
1. Основными характеристиками пациентов с сочетанием ХСН и СД 2 типа, в сравнении с больными с ХСН, по данным как про-, так и ретроспективного исследований являются: пожилой возраст, женский пол, а г также достоверно более частая встречаемость ИБС (и постинфарктного кардиосклероза) и АГ , в качестве главных этиологических причин декомпенсации. Более часто сохраняется синусовый ритм.
2. Присоединение СД 2 типа к ХСН лишь увеличивает степень декомпенсации (процент больных с III ФК увеличивается с 49,5% до 73,2%) и не оказывает значимого влияния ни на систолическую, ни на диастоличе-скую функцию ЛЖ, хотя качество жизни пациентов при сочетании ХСН и СД 2 типа достоверно ухудшается в сравнении с больными с «изолированной» ХСН.
3. Длительность диабета более 10 лет максимально ухудшает клиническое течение болезни у пациентов с ХСН и приводит к поражению органов - мишеней (сердца, почек). При этом максимально возрастает роль присоединившейся АГ и подъемов АД, начинает снижаться систолическая функция сердца и достоверно повышается степень альбуминурии, т.е. ухудшается функция почек. Только длительно существующий СД 2 типа реально ухудшает клиническое течение ХСН.
4. Пациенты с сочетанием ХСН и СД 2 типа имеют не только более высокий уровень гликемии и частоту глюкозурии, но и склонность к ожирению (достоверно повышенный ИМТ) и нарушению функции почек, что характеризуется повышенным уровнем креатинина и микроальбуминурии, т.е. сама ХСН не «маскирует» клинических и лабораторных проявлений СД 2 типа, а в нарушение функции почек вносят вклад оба компонента сочетанной патологии.
5. Несмотря на характерное для ХСН нарушение функции печени (в том числе способности к синтезу холестерина), при сочетании декомпенсации с СД 2 типа проявляются типичные черты диабетической дислипидемии в виде повышения триглицеридов и общего холестерина при достоверном увеличении холестерина ЛПОНП и снижении антиатерогенного холестерина ЛПВП. ■
6. Применение ИАПФ в комплексной терапии больных с сочетанием ХСН и СД 2 типа оказалось высоко эффективным и позволило одновременно уменьшить типичные проявления ХСН, а также и СД 2 типа в виде нормализации уровня гликемии, снижения глюкозурии, альбуминурии и индекса массы тела, и АГ с нормализацией цифр АД.
7. Применение БАБ в комплексной терапии больных с сочетанием ХСН и СД 2 типа оказалось абсолютно безопасным: также как при лечении ИАПФ снижался уровень гликемии (на 15,3%), и альбуминурии (с 67,8 до 27,3%) и нормализовался липидный спектр в виде достоверного снижения уровня общего (с 6,4 до 5,9 ммоль/л) и холестерина ЛПОНП (на 11%) и триглицеридов (на 13,6%), при одновременном увеличении холестерина ЛПВП (на 9,7%). То есть реальных препятствий к назначению БАБ в комплексном лечении ХСН, сочетающейся с СД 2 типа не имеется.
8. Использование в комбинации ИАПФ с БАБ для лечения больных с сочетанием ХСН и СД 2 типа не позволило добиться дополнительных преимуществ в улучшении клинических и лабораторных показателей, даже снижение ЧСС и АД, являющихся «зеркалом» успешного применения БАБ было одинаковым в подгруппах больных с назначением только ИАПФ и комбинации ИАПФ с БАБ.
9. Изменения центральной гемодинамики были отмечены в обеих группах лечения и при применении ИАПФ и их комбинации с БАБ, причем в динамике систолической функции различий не было выявлено, и лишь нормализация диастолической функции левого желудочка достигалась только при сочетанном применении ИАПФ и БАБ, т.е совместное применение двух нейрогуморальных модуляторов имеет больший потенциал в блокаде процессов ремоделирования и замедлении прогрессирования болезни.
10.По данным ретроспективного анализа имелась тенденция к увеличению риска смерти больных с ХСН и СД 2 типа в сравнении с больными с ХСН (на 22%), при этом наличие СД 2 типа достоверно ухудшает прогноз у женщин (на 45%), у пациентов с относительно сохранной ФВ ЛЖ (на 46%) и при сохранном САД (на 42%). При низкой ФВ и гипотонии тяжесть прогноза определяется самой ХСН, а не присоединившимся СД 2 типа.
11 .При проспективном исследовании частота сердечно — сосудистых осложнений (ОИМ + инсульты + обострение ХСН + новая МАУ + стенокардия) в группе больных с сочетанием ХСН и СД 2 типа была достоверно выше, чем при «изолированной» ХСН (при СД 2 типа длительностью более 10 лет — 63,5% против 37,9%). При однофакторном анализе, факторами, достоверно определяющими развитие сердечно- сосудистых осложнений являлись: возраст, длительность диабета, наличие АГ в анамнезе, больший индекс массы тела, увеличение триглицеридов, диастолическая дисфункция, а также наличие микроальбуминурии.
12.Лечение ингибиторами АПФ изолированно или в сочетании с |3-блокаторами не позволяет достоверно снизить число сердечно - сосудистых осложнений и уровнять риск больных с сочетанием ХСН + СД 2 типа с пациентами с изолированной ХСН. При комплексной терапии ингибиторами АПФ и р-блокаторами больных с ХСН и СД 2 типа имеется тенденция к меньшему возникновению сердечно - сосудистых осложнений, прежде всего, случаев обострения ХСН. Видимо для достоверного снижения риска необходимо агрессивное лечение не только ХСН, но и второго компонента -СД 2 типа.
ПРАКТИЧЕСКИЕ РЕКОМЕНДАЦИИ
1. Учитывая, что присоединение СД 2 типа серьезно осложняет течение ХСН и требует специального воздействия, необходимо рекомендовать всем пациентам с декомпенсацией проведение исследований, направленных на своевременное выявление СД 2 типа (контроль за уровнем глюкозы натощак, пробы на толерантность к глюкозе, уровень глюкозурии)
2. Для больных с сочетанием ХСН и СД 2 типа необходимым является тщательный контроль за функцией почек (определение уровня креатини-на и микроальбуминурии, глюкозурии), что позволит своевременно проводить коррекцию этих нарушений.
3. Несмотря на наличие выраженной декомпенсации и ухудшение функции печени, больным с сочетанием СД 2 типа и ХСН должно проводиться регулярное исследование липидного профиля, что позволит своевременно присоединять гиполипидемическую терапию
4. Максимальное внимание должно уделяться женщинам и пациентам с сохранной сократительной функцией ЛЖ (ФВ > 38%) и сохраненным уровнем систолического АД (> 120 мм.рт.ст), т.к. у этих категорий больных именно течение СД 2 типа максимально определяет число осложнений и прогноз заболевания. Эти группы больных требуют совместного контроля кардиологов и эндокринологов.
5. Лечение больных с сочетанием СД 2 типа и ХСН должно включать применение ИАПФ, которые позволяют уменьшить выраженность декомпенсации, одновременно нормализовать АД, защитить почки и улучшить течение СД 2 типа и облегчить контроль за уровнем гликемии
6. Применение БАБ у больных с ХСН и СД 2 типа оказалось »крайне эффективным и абсолютно безопасным, не усугубляющим течения СД 2 типа.
7. Сочетанное применение ИАПФ и БАБ позволяет максимально снижать риск осложнений, улучшать течение ХСН и максимально блокировать процессы ремоделирования ЛЖ, что делает такой режим терапии показанным всем больным с сочетанием ХСН и СД 2 типа, не имеющим специальных индивидуальных противопоказаний.
8. Учитывая, что даже при комплексной терапии ИАПФ с БАБ риск сердечно - сосудистых осложнений у больных с ХСН и СД 2 типа остается достоверно повышенным, важным компонентом терапии, позволяющей добиваться снижения риска сердечно-сосудистых осложнений должна быть агрессивная гипогликемическая терапия.
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