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DOI: 10.1055/s-0028-1100921
© Georg Thieme Verlag KG Stuttgart · New York
Risiken der Koronaräquivalente Diabetes mellitus und Periphere Arterielle Verschlusskrankheit im Vergleich
Comparison of two coronary risk equivalents: diabetes mellitus and peripheral arterial diseasePublication History
eingereicht: 22.7.2008
akzeptiert: 1.9.2008
Publication Date:
28 October 2008 (online)
Zusammenfassung
Hintergrund und Fragestellung: Sowohl der Diabetes mellitus (DM) als auch die periphere arterielle Verschlusskrankheit (PAVK) werden als Koronaräquivalente angesehen. (1) Inwieweit sich beide Krankheitsentitäten hinsichtlich ihres Risikos für vorzeitige Mortalität unterscheiden, (2) wie häufig DM und PAVK bei älteren Patienten in der Hausarztpraxis gemeinsam auftreten und (3) wie das Risiko der Patienten mit DM/PAVK zu quantifizieren ist, waren Fragestellungen dieser Untersuchung.
Patienten und Methodik: Im Rahmen der prospektiven, nicht-interventionellen Studie „German Epidemiological Trial on Ankle Brachial Index (getABI)” wurden 6880 unselektierte Patienten ≥ 65 Jahre von 344 Hausärzten über den Zeitraum von 5 Jahren hinsichtlich Tod und kardiovaskulärer Ereignisse beobachtet. DM wurde definiert: (i) nach ärztlicher Diagnose und/oder (ii) Verschreibung von oralen Antidiabetika und/oder Insulin und/oder (iii) HbA1c ≥ 6,5 %. Der Knöchel-Arm-Index (ABI) wurde dopplersonographisch bestimmt. Eine PAVK wurde definiert als Ankle Brachial Index (ABI) < 0,9 bzw. Claudicatio intermittens oder periphere Revaskularisation/Amputation in Folge einer PAVK. Überlebenszeitanalysen wurden mittels Kaplan-Meier-Kurven und Cox-Proportional-Hazard-Modellen durchgeführt. Hazard Ratios (HR; 95 % Konfidenzintervall [KI]) wurden nach bekannten Risikofaktoren adjustiert.
Ergebnisse: Die Beobachtungszeit für die 6821 Patienten betrug nahezu 33 000 Personenjahre (PJ) bezüglich des Todes jeglicher Ursache. Das Mortalitätsrisiko von Patienten mit DM aber ohne PAVK (n = 1220; 17,9 %) entsprach dem 1,5-fachen Mortalitätsrisiko (HR; 95 % KI 1,2 – 1,8) von Personen ohne beide Erkrankungen (n = 4172; 61,2 %). Das Risiko von solchen ohne DM aber mit PAVK (n = 918; 13,5 %) entsprach dem 1,7-fachen Risiko (HR; 95 % KI 1,4 – 2,0) von Personen ohne beide Erkrankungen. Bei Personen mit DM und mit PAVK (n = 511; 7,5 %) war das Mortalitätsrisiko im Vergleich zu dem von Personen ohne beide Erkrankungen nach Adjustierung für andere kardiovaskuläre Risikofaktoren fast verdreifacht (HR 2,8; 95 % KI 2,3 – 3,4). Je niedriger die ABI-Kategorie bei Personen mit und ohne DM war, desto größer war die Anzahl der Todesfälle pro 1000 Personenjahre.
Folgerung: Die Ergebnisse bestätigen, dass Diabetiker und PAVK-Patienten einem deutlich erhöhten Risiko für ein vorzeitiges Versterben ausgesetzt sind. Diese Patienten bedürfen einer intensiven Behandlung der Risikofaktoren. Dies scheint in besonderem Maße bei gleichzeitigem Vorliegen beider Erkrankungen zu gelten.
Summary
Background and Objective: Diabetes mellitus (DM) and peripheral arterial disease (PAD) are both coronary artery disease equivalents („coronary equivalents”). It was the aim of this study to ascertain (1) to what extent each of these diseases differs from the other in respect of early death, (2) how frequently DM and PAD occur together in elderly patients seen in general practice and (3) what risk patients with DM and concomitant PAD carry.
Patients and Methods: In the prospective non-interventional study – „German Epidemiological Trial on Ankle Brachial Index” – 6 880 unselected patients, aged 65 years or more, from 344 general medical practices were followed over five years and the incidence of deaths and of cardiovascular events recorded. DM was defined according to the medical diagnosis and/or if the HbA1c was ≥ 6.5% and the ankle brachial index (ABI), determined by Doppler sonography. PAD was defined as an ABI of < 0.9 or the presence of intermittent claudication or state after peripheral revascularization/amputation. Survival rates were obtained using Kaplan-Meier estimate curves and Cox's proportional hazard model. 59 patients with an ABI > 1.5 were excluded from the study. Hazard ratios (HR with 95% confidence intervals [CI]) were adjusted according to known risk factors.
Results: The overall observation period for all the patients amounted to nearly 33000 patient-years (PY). The risk of death of patients with DM but no PAD (n = 1,220; 17.9%) was 1.5 times the risk of death (HR, 95% CI 1.2-1.8) of persons with neither disease (n = 4 172; 61.2%) and the risk of those with PAD but no DM (n = 918, 13;5%) was 1.7 times of those persons without either disease (HR, 95% CI 1.4–2.0). The risk for persons with DM and PAD (n = 511; 7.5%) was nearly 3 times that of persons without either disease, after adjustment for other cardiovascular risk factors (HR 2.8, 95% CI 2.3-3.4). The lower the ABI in persons with or without DM the greater the number of deaths per 1000 PY.
Conclusions: These results confirm that diabetics and patients with PAD have a clearly increased risk of early death. These patients need intensive treatment of the risk factors. This is especially true for patients who have DM and PAD concomitantly.
Schlüsselwörter
Diabetes mellitus - periphere arterielle Verschlusskrankheit - Koronaräquivalent - Knöchel-Arm-Index - kardiovaskuläres Risiko - Screening - Sekundärprävention
Keywords
diabetes mellitus - peripheral arterial disease - coronary equivalent - ankle brachial index - cardiovascular risk - screening - secondary prevention
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Prof. Dr. med. Curt Diehm
Klinikum Karlsbad-Langensteinbach, Akademisches
Lehrkrankenhaus der Universität Heidelberg
Guttmannstr.
1
76307 Karlsbad
Phone: 07202/61
3340
Fax: 07202/61 6167
Email: Curt.Diehm@kkl.srh.de