Download PDF
Dtsch Med Wochenschr 2004; 129(24): 1385-1389
DOI: 10.1055/s-2004-826879
Übersichten
Diabetologie / Kardiologie
© Georg Thieme Verlag Stuttgart · New York

Diabetes mellitus Typ 2 und koronare Herzkrankheit

Intensive Sekundärprävention versus perkutane oder chirurgische RevaskularisierungTherapeutic options in patients with diabetes mellitus type 2 and coronary artery diseaseIntensified secondary prevention versus percutaneous or surgical revascularizationS. Sixt1 , G. Schuler1 , J. Niebauer1
  • 1Universität Leipzig - Herzzentrum Leipzig GmbH, Klinik für Innere Medizin/Kardiologie
Further Information

Publication History

eingereicht: 27.11.2003

akzeptiert: 26.2.2004

Publication Date:
21 July 2004 (online)

Also available at
    Permissions and Reprints

Zusammenfassung

Diabetes mellitus zählt zu den Hauptrisikofaktoren für die Entstehung der koronaren Herzkrankheit, welche bei Diabetikern akzeleriert verläuft und mit einer schlechten Prognose assoziiert ist. Wenngleich bei stabiler koronarer Herzkrankheit durch eine Revaskularisierung mittels Bypass-Operation oder interventionelle Stentimplantation eine schnelle Beschwerdefreiheit erzielt werden kann, so hat dies keinen wesentlichen Einfluss auf die Prognose. Lediglich bei Patienten mit Haupstammstenose oder hochgradiger Stenose des proximalen Ramus interventricularis anterior konnte die Prognose günstig beeinflusst werden. Durch eine multifaktorielle Intervention, die neben Diät, Blutzucker- und Blutdruckeinstellung auch regelmäßiges körperliches Training beinhaltet, kommt es zu einer Verbesserung der modifizierbaren Risikofaktoren und einer Steigerung der beschwerde- und ischämiefreien Belastbarkeit, so dass die multifaktorielle Intervention eine alternative Therapiestrategie darstellt.

Summary

Diabetes mellitus is a major risk factor for coronary artery disease and is associated with accelerated disease progression and adverse prognosis. Although relief of symptoms can quickly be obtained by percutaneous intervention or bypass surgery, it does not change patients’ prognoses, with the exception of stenoses of the left main stem or left anterior descending artery. A multifactorial intervention, which consists of a low-fat diet, glucose and arterial blood pressure control, smoking cessation and regular physical exercise, emerges as an alternative strategy since it leads to improvement of the modifiable risk factors, exercise tolerance and quality of life.

Literatur

  • 1 Abizaid A, Costa M A, Centemero M. et al . Clinical and economic impact of diabetes mellitus on percutaneous and surgical treatment of multivessel coronary disease patients: insights from the Arterial Revascularization Therapy Study (ARTS) trial.  Circulation. 2001;  104 533-538
    Google Scholar
  • 2 Aronson D, Rayfield E J, Cheselro J H. Mechanisms determing course and outcome of diabetic patients who have acute myocardial infarction.  Ann Intern Med. 1997;  126 296-306
    Google Scholar
  • 3 Batty G D, Shipley M J, Marmot M. et al . Physical activity and cause-specific mortality in men with Type 2 diabetes/impaired glucose tolerance: evidence from the Whitehall study.  Diabet Med. 2002;  19 580-588
    Google Scholar
  • 4 Collins R, Armitage J, Parish S. et al . MRC/BHF Heart Protection Study of cholesterol-lowering with simvastatin in 5963 people with diabetes: a randomised placebo-controlled trial.  Lancet. 2003;  361 2005-2016
    Google Scholar
  • 5 RITA-2 trial participants . Coronary angioplasty versus medical therapy for angina: the second Randomised Intervention Treatment of Angina (RITA-2) trial.  Lancet. 1997;  350 461-468
    Google Scholar
  • 6 Diegeler A, Thiele H, Falk V. et al . Comparison of stenting with minimally invasive bypass surgery for stenosis of the left anterior descending coronary artery.  N Engl J Med. 2002;  347 561-566
    Google Scholar
  • 7 Feener E P, King G L. Endothelial Dysfunction in Diabetes Mellitus: Role in Cardiovascular Disease.  Heart Fail Monit. 2001;  1 74-82
    Google Scholar
  • 8 Gaede P, Vedel P, Larsen N. et al . Multifactorial intervention and cardiovascular disease in patients with type 2 diabetes.  N Engl J Med. 2003;  348 383-393
    Google Scholar
  • 9 Gohlke H, Kubler W, Mathes P. et al . Positionspapier zur Primärprevention kardiovaskulärer Erkrankungen: Aktuelle Fassung vom 25.03.2003. Herausgegeben vom Vorstand der Deutschen Gesellschaft für Kardiologie, Herz und Kreislauferkrankungen: Bearbeitet im Auftrag des Vorstandes durch die Projektgruppe Prävention.  Z Kardiol. 2003;  92 522-523
    Google Scholar
  • 10 Goldberg R B, Mellies M J, Sacks F M. et al. The Care Investigators . Cardiovascular events and their reduction with pravastatin in diabetic and glucose-intolerant myocardial infarction survivors with average cholesterol levels: subgroup analyses in the cholesterol and recurrent events (CARE) trial.  Circulation. 1998;  98 2513-2519
    Google Scholar
  • 11 Haskell W L, Alderman E L, Fair J M. et al. The Stanford Coronary Risk Intervention Project (SCRIP) . Effects of intensive multiple risk factor reduction on coronary atherosclerosis and clinical cardiac events in men and women with coronary artery disease.  Circulation. 1994;  89 975-990
    Google Scholar
  • 12 Helmrich S P, Ragland D R, Leung R W. et al . Physical activity and reduced occurrence of non-insulin-dependent diabetes mellitus.  N Engl J Med. 1991;  325 147-152
    Google Scholar
  • 13 Hu F B, Manson J E, Stampfer M J. et al . Diet, lifestyle, and the risk of type 2 diabetes mellitus in women.  N Engl J Med. 2001;  345 790-797
    Google Scholar
  • 14 Hu F B, Sigal R J, Rich-Edwards J W. et al . Walking compared with vigorous physical activity and risk of type 2 diabetes in women: a prospective study.  JAMA. 1999;  282 1433-1439
    Google Scholar
  • 15 Hu F B, Stampfer M J, Solomon C. et al . Physical activity and risk for cardiovascular events in diabetic women.  Ann Intern Med. 2001;  134 96-105
    Google Scholar
  • 16 Hu F B, Stampfer M J, Haffner S M. et al . Elevated risk of cardiovascular disease prior to clinical diagnosis of type 2 diabetes.  Diabetes Care. 2002;  25 1129-1134
    Google Scholar
  • 17 Hueb W A, Soares P R, Almeida De Oliveira S. et al . Five-year follow-op of the medicine, angioplasty, or surgery study (MASS): A prospective, randomized trial of medical therapy, balloon angioplasty or bypass surgery for single proximal left anterior descending coronary artery stenosis.  Circulation. 1999;  100 107-113
    Google Scholar
  • 18 Investigators B. Influence of diabetes on 5-year mortality and morbidity in a randomized trial comparing CABG and PTCA in patients with multivessel disease: the Bypass Angioplasty Revascularization Investigation (BARI).  Circulation. 1997;  96 1761-1769
    Google Scholar
  • 19 Jolliffe J A, Rees K, Taylor R S. et al . Exercise-based rehabilitation for coronary heart disease.  Cochrane Database Syst Rev. 2000;  CD001800
    Google Scholar
  • 20 Kolenda K D. Secondary prevention of coronary heart disease. How effective are modern therapy methods?.  Dtsch Med Wochenschr. 2003;  128 1849-1853
    Google Scholar
  • 21 Laakso M, Lehto S, Penttilä I. et al . Lipids and lipoproteins predicting coronary heart disease mortality and morbidity in patients with non-insulin-dependent diabetes.  Circulation. 1993;  88 1421-1430
    Google Scholar
  • 22 Lagerqvist B, Husted S, Kontny F. et al . A long-term perspective on the protective effects of an early invasive strategy in unstable coronary artery disease: two-year follow-up of the FRISC-II invasive study.  J Am Coll Cardiol. 2002;  40 1902-1914
    Google Scholar
  • 23 Morice M C, Serruys P W, Sousa J E. et al . A randomized comparison of a sirolimus-eluting stent with a standard stent for coronary revascularization.  N Engl J Med. 2002;  346 1773-1780
    Google Scholar
  • 24 Moses J W, Leon M B, Pompa J J. et al . Angiographic and clinical outcomes after a sirolimus-eluting stent compared to a standard stent in patients with complex coronary stenosis.  N Eng J Med. 2003;  in press
    Google Scholar
  • 25 Niebauer J, Hambrecht R, Velich T. et al . Attenuated progression of coronary artery disease after 6 years of multifactorial risk intervention: Role of physical exercise.  Circulation. 1997;  96 2534-2541
    Google Scholar
  • 26 Niebauer J, Hambrecht R, Velich T. et al . Predictive value of lipid profile for salutary coronary angiographic changes in patients on a low fat diet and physical exercise program.  Am J Cardiol. 1996;  78 163-167
    Google Scholar
  • 27 Niebauer J, Cooke J P. Cardiovascular effects of exercise: role of endothelial shear stress.  J Am Coll Cardiol. 1996;  28 1652-1660
    Google Scholar
  • 28 Niebauer J, Maxwell A J, Lin P S, Tsao P S, Kosek J, Bernstein D, Cooke J P. Impaired aerobic capacity in hypercholesterolemic mice: partial reversal by exercise training.  Am J Physiol. 1999;  276 H1346-H1354
    Google Scholar
  • 29 Niebauer J, Maxwell A J, Lin P S. et al . NOS inhibition accelerates atherogenesis: reversal by exercise.  Am J Physiol Heart Circ Physiol. 2003;  285 H535-H540
    Google Scholar
  • 30 Niebauer J, Dulak J, Chan J R. et al . Gene transfer of nitric oxide synthase: effects on endothelial biology.  J Am Coll Cardiol. 1999;  34 1201-1207
    Google Scholar
  • 31 Ornish D, Scherwitz L W, Billings J H. et al . Intensive lifestyle changes for reversal of coronary heart disease.  JAMA. 1998;  280 2001-2007
    Google Scholar
  • 32 Parisi A F, Folland E D, Hartigan P. Veterans Affairs ACME Investigators . A comparison of angioplasty with medical therapy in the treatment of single-vessel coronary artery disease.  N Engl J Med. 1992;  326 10-16
    Google Scholar
  • 33 Peschel T, Beitz F, Tarnok A. et al . Diabetes mellitus type 2 is associated with upregulation of atherogenic surface markers: Normalization through exercise training (abstr).  Circulation. 2002;  106 712
    Google Scholar
  • 34 Pyorala K, Pedersen T R, Kjekshus J. et al . Cholesterol lowering with simvastatin improves prognosis of diabetic patients with coronary heart disease. A subgroup analysis of the Scandinavian Simvastatin Survival Study (4S).  Diabetes Care. 1997;  20 614-620
    Google Scholar
  • 35 Schachinger V, Britten M B, Zeiher A M. Prognostic impact of coronary vasodilator dysfunction on adverse long-term outcome of coronary heart disease.  Circulation. 2000;  101 1899-1906
    Google Scholar
  • 36 Schuler G, Hambrecht R, Schlierf G. et al . Regular physical exercise and low-fat diet. Effects on progression of coronary artery disease.  Circulation. 1992;  86 1-11
    Google Scholar
  • 37 Schuler G, Hambrecht R, Schlierf G. et al . Myocardial perfusion and regression of coronary artery disease in patients on a regimen of intensive physical exercise and low fat diet.  J Am Coll Cardiol. 1992;  19 34-42
    Google Scholar
  • 38 Sculpher M, Smith D, Clayton T. et al . Coronary angioplasty versus medical therapy for angina. Health service costs based on the second Randomized Intervention Treatment of Angina (RITA-2) trial.  Eur Heart J. 2002;  23 1291-1300
    Google Scholar
  • 39 Sobel B E, Frye R, Detre K M. Burgeoning dilemmas in the management of diabetes and cardiovascular disease: rationale for the Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) Trial.  Circulation. 2003;  107 636-642
    Google Scholar
  • 40 Stamler J, Vaccaro O, Neaton J D. et al . Diabetes, other risk factors, and 12-yr cardiovascular mortality for men screened in the Multiple Risk Factor Intervention Trial.  Diabetes Care. 1993;  16 434-444
    Google Scholar
  • 41 Syvänna M, Taskinen M R. Lipids and lipoproteins as coronary risk factor in non-insulin-dependent diabetes mellitus.  Lancet. 1997;  350 20-23
    Google Scholar
  • 42 Tanasescu M, Leitzmann M F, Rimm E B, Hu F B. Physical activity in relation to cardiovascular disease and total mortality among men with type 2 diabetes.  Circulation. 2003;  107 2435-2439
    Google Scholar
  • 43 UK Prospective Diabetes Study Group . Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38.  BMJ. 1998;  317 703-713
    Google Scholar
  • 44 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
  • 45 Turner R, Cull C, Holman R. United Kingdom Prospective Diabetes Study 17: a 9-year update of a randomised, controlled trial on the effect of improved metabolic control on complications in NIDDM.  Ann Intern Med. 1996;  124 136-145
    Google Scholar
  • 46 Turner R C, Millns H, Neil H A. et al . Risk factors for coronary artery disease in non-insulin dependent diabetes mellitus: United Kingdom Prospective Diabetes Study (UKPDS: 23).  BMJ. 1998;  316 823-828
    Google Scholar
  • 47 Webster M WI, Scott R S. What cardiologists need to know about diabetes.  Lancet. 1997;  350 23-28
    Google Scholar
  • 48 Wei M, Gibbons L W, Mitchell T L. et al . The association between cardiorespiratory fitness and impaired fasting glucose and type 2 diabetes mellitus in men.  Ann Intern Med. 1999;  130 89-96
    Google Scholar
  • 49 Wei M, Gibbons L W, Kampert J B. et al . Low cardiorespiratory fitness and physical inactivity as predictors of mortality in men with type 2 diabetes.  Ann Intern Med. 2000;  132 605-611
    Google Scholar

Priv.-Doz. Dr. Dr. Josef Niebauer

Herzzentrum der Universität Leipzig

Strümpellstraße 39

04289 Leipzig

Phone: +49/341/8650

Fax: +49/341/8651461

Email: j.niebauer@medizin.uni-leipzig.de

      >