Association between coronary vascular dysfunction and cardiac mortality in patients with and without diabetes mellitus.
Association between coronary vascular dysfunction and cardiac mortality in patients with and without diabetes mellitus.
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DOI：
10.1161/circulationaha.112.120402
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发表时间：
2012-10-09
期刊：
影响因子：
37.8
通讯作者：
Di Carli MF
中科院分区：
文献类型：
--
作者：
Murthy VL;Naya M;Foster CR;Gaber M;Hainer J;Klein J;Dorbala S;Blankstein R;Di Carli MF
糖尿病增加了心脏不良结局的风险，被认为是冠状动脉疾病（CAD）的等价物。我们研究了冠状动脉血管功能障碍（CAD的早期表现）是否是糖尿病患者与非糖尿病患者相比风险增加的原因。2783例连续患者（1172例糖尿病患者和1611例非糖尿病患者）通过PET进行了冠状动脉血流储备（CFR=负荷除以静息心肌血流量）定量，并随访了中位数为1.4年（Q1-Q3：0.7-3.2）。主要终点为心源性死亡。CFR受损（低于中位数）与糖尿病患者和非糖尿病患者的心源性死亡率分别增加3.2倍和4.9倍相关（p=0.0004）。在临床和影像学风险模型中增加CFR改善了糖尿病患者和非糖尿病患者的风险区分（c指数：分别为0.77至0.79，p=0.04和0.82至0.85，p=0.03）。无已知CAD且CFR受损的糖尿病患者的心源性死亡率与已知CAD的非糖尿病患者的心源性死亡率相当（2.8 vs 2.0%/年，P=0.33）。相反，无已知CAD和CFR保留的糖尿病患者的年心源性死亡率非常低，与无已知CAD或糖尿病且负荷灌注和收缩功能正常的患者相似（0.3% vs 0.5%/年，P=0.65）。冠状动脉血管舒张功能障碍是糖尿病和非糖尿病患者心源性死亡率的强有力的独立相关因素，并提供了有意义的增量风险分层。在无CAD的糖尿病患者中，CFR受损患者的事件发生率与既往CAD患者相当，而CFR保留患者的事件发生率与非糖尿病患者相当。
Diabetes increases the risk of adverse cardiac outcomes and is considered a coronary artery disease (CAD) equivalent. We examined whether coronary vascular dysfunction, an early manifestation of CAD, accounts for increased risk among patients with diabetes compared to non-diabetics. 2783 consecutive patients (1172 diabetics and 1611 non-diabetics) underwent quantification of coronary flow reserve (CFR=stress divided by rest myocardial blood flow) by PET and were followed for a median of 1.4 years (Q1–Q3: 0.7–3.2). The primary endpoint was cardiac death. Impaired CFR (below the median) was associated with an adjusted 3.2 and 4.9-fold increase in the rate of cardiac death for diabetics and non-diabetics, respectively (p=0.0004). Addition of CFR to clinical and imaging risk models improved risk discrimination both diabetics and non-diabetics (c-index: 0.77 to 0.79, p=0.04, and 0.82 to 0.85, p=0.03, respectively). Diabetic patients without known CAD with impaired CFR experienced a rate of cardiac death comparable to that for non-diabetic patients with known CAD (2.8 vs 2.0%/year, P=0.33). Conversely, diabetics without known CAD and preserved CFR had very low annualized cardiac mortality, which was similar to patients without known CAD or diabetes and normal stress perfusion and systolic function (0.3 vs. 0.5%/year, P=0.65). Coronary vasodilator dysfunction is a powerful, independent correlate of cardiac mortality among both diabetics and non-diabetics and provides meaningful incremental risk stratification. Among diabetic patients without CAD, those with impaired CFR have event rates comparable to patients with prior CAD while those with preserved CFR have event rates comparable to non-diabetics.