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Diabetes mellitus und koronare Herzkrankheit

—eine Risikokombination

Diabetes mellitus and coronary artery disease—a high risk combination

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Summary

Patients with diabetes mellitus are often not recognized in clinical routine, but also not well characterized in clinical trials.

As a diagnostic approach it is recommended to test fasting glucose and glycosylated hemoglobin (HbA1c) in every patient with coronary artery disease (CAD). HbA1c, in addition, provides important prognostic information.

Patients with diabetes mellitus do have an enhanced cardiovascular risk in all stages and during all kind of interventions of CAD. However, diabetes is not equal to diabetes; risk modifying factors such as HbA1c, concomitant diseases and medication have to be considered.

Absolute benefit of pharmacological therapies is also enhanced in patients with diabetes compared to non-diabetics. However, statins or anti-hypertensive treatment seem to be even more effective in reducing cardiovascular events than pure control of glucose levels alone. During percutaneous interventions (PCI) glycoprotein IIb/IIIa—inhibitors reduce mortality in diabetics, an effect which may be partially also achieved by Clopidogrel. Glitazones reduce restenosis rates; however, clinical end point studies are still ongoing.

After PCI, restenosis may be a predictor of mortality in patients with diabetes. Whether drug eluting stents, besides effectively reducing restenosis, may also reduce hard clinical events in patients with diabetes remains to be demonstrated. Current available studies comparing PCI with bypass are limited due to not considered factors (stenosis morphology), randomization bias, and faster progress of technology compared to study termination.

During an acute coronary syndrome/myocardial infarction, hyperglycemia is an adverse prognostic marker. However, so far studies using glucose-insulin-potassium (GIK) infusion have not been convincingly demonstrate to be beneficial.

Zusammenfassung

Patienten mit Diabetes mellitus bleiben in der klinischen Praxis oftmals unerkannt und sind in Studien häufig schlecht charakterisiert.

Als diagnostische Minimalmaßnahme ist es sinnvoll, bei jedem Patienten mit einer KHK—unabhängig davon, ob ein Diabetes mellitus bereits bekannt ist—einen HbA1c-Wert (Prognosemarker) und die Nüchternglucose zu bestimmen.

Patienten mit Diabetes mellitus haben ein höheres Risiko in allen Stadien und bei allen Interventionen der koronaren Herzkrankheit. Aber Diabetes mellitus ist nicht gleichzusetzen mit Diabetes mellitus. Modifizierende Faktoren wie HbA1c, Begleiterkrankung, Begleitmedikation sind zu berücksichtigen.

Patienten mit Diabetes mellitus haben einen größeren Nutzen von Pharmaka wie Statinen und Antihypertonika, wobei die Lipidsenkung und antihypertensive Therapie mindestens genauso—möglicherweise sogar effektiver—in der Prävention von kardiovaskulären Erkrankungen sind als die reine Glucose-Einstellung.

Im Rahmen der Intervention ist die Gabe von Glykoprotein-IIb/IIIa-Rezeptorblockern und Clopidogrel nützlich. Neuere Studien weisen auch auf einen Nutzen von Glitazone hin (Restenose-Reduktion), wobei klinische Endpunktstudien derzeit noch ausstehen.

Bei koronarer Revaskularisation ist die Restenose bei Patienten mit Diabetes mellitus möglicherweise mit einer erhöhten Mortalität assoziiert. Inwiefern Drug Eluting Stents, welche die Restenose signifikant reduzieren, auch mit einem prognostischen Vorteil bezüglich kardiovaskulärer Ereignisse assoziiert sind, ist derzeit noch offen. Bisherige Vergleichsstudien zwischen PTCA und Bypassoperationen bei Patienten mit Diabetes mellitus sind durch nichtberücksichtigte Faktoren (z. B. Koronarmorphologie, Randomisationsbias und einem schnelleren Fortschritt des aktuellen Stands der Revaskularisation als im Vergleich zu den Studien) limitiert.

Eine Hyperglykämie ist auch prognostisch ungünstig bei Patienten mit akutem Koronarsyndrom/Myokardinfarkt. Die Glucose-Insulin-Kalium(GIK)-Therapie muss allerdings nach der aktuellen Studienlage nicht empfohlen werden.

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Authors and Affiliations

  1. J. W. Goethe-Universität Frankfurt, Medizinische Klinik III/Kardiologie, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany

    V. Schächinger, M. B. Britten & A. M. Zeiher

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  1. V. Schächinger
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  2. M. B. Britten
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  3. A. M. Zeiher
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Correspondence to V. Schächinger.

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Schächinger, V., Britten, M.B. & Zeiher, A.M. Diabetes mellitus und koronare Herzkrankheit. Clin Res Cardiol 95 (Suppl 1), i18–i26 (2006). https://doi.org/10.1007/s00392-006-1115-y

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