Bệnh cơ tim đái tháo đường GS nguyễn hải thuỷ
Bạn đang xem bản rút gọn của tài liệu. Xem và tải ngay bản đầy đủ của tài liệu tại đây (7.42 MB, 128 trang )
DEMA-CVN
GIỚI THIỆU
GIỚI THIỆU CÁC ĐỀ TÀI NGHIÊN CỨU KHOA
HỌC TẠI HỘI NGHỊ NỘI KHOA TOÀN QUỐC TẠI
THÀNH PHỐ HỒ CHÍ MINH THÁNG 7/ 2011
DEMA-CVN.COM
Hue College of Medicine and Pharmacy
Vietnam
DEMA-CVN.COM
DIABETIC CARDIOMYOPATHY
Prof. Nguyen Hai Thuy. MD, PhD
DEMA-CVN.COM
Hue College of Medicine and Pharmacy
Congestive heart failure in diabetic patient without
CAD and HTN. HbA1c : 8%, BP: 110/70 mmHg
IVSd: 1.06 cm, IVSs: 1.23 cm
LA: 4.29 cm, LVMI :180 g/m2, EF :20.5%
What’s your diagnosis?
DEMA-CVN.COM
I.INTRODUCTION
• Diabetes is observed in 15% to 25% of HF
patients in major clinical trials.
• Among all patients hospitalized for heart
failure, 25% to 30% patient have DM as a
comorbid condition
• In large-scale mortality trials, in HF patients
with systolic dysfunction, diabetes was an
independent risk factor for death.
DEMA-CVN.COM
New England Journal
of Medicine 1999; 341(12): 857-865
DEMA-CVN.COM
• Framingham Study
• SOLVD ( Studies of Left
Ventricular Dysfunction)
1. A direct association
between DM and HF was
first demonstrated
2. Risk of developing
symptomatic HF
2.4-fold in diabetic men
5-fold in diabetic women,
1. Registry of 6791 patients with
heart failure,
2. 1310 diabetic patients were
more likely to be hospitalized
for HF exacerbation and
more likely to die.
3. independent of coexisting
hypertension or
ischemic heart disease.
DEMA-CVN.COM
DEMA-CVN.COM
DM and younger HF study
• Under 65 years old.
– Four fold in diabetic men
– Eight fold in diabetic women
• Gender-specific cardiovascular
protective effects can be considered to
be mitigated once overt diabetes
develops in women.
W H. Wilson Tang, MD, and James B. Young, MD
ENDOCRINOLOGY AND METABOLISM CLINICS OF NORTH AMERICA,
VOLUME 30 • NUMBER 4 • DECEMBER 2001
DEMA-CVN.COM
• Some diabetic patients do not have obvious
ischemic insults that lead to progressive HF.
• A number study challenged that Diabetic patients
may have more diffuse and severe coronary
insufficiency than nondiabetic patients.
• Every 1% increase in the baseline glycosylated
hemoglobin level translates into a 15% increase in
risk of developing HF
DEMA-CVN.COM
DEMA-CVN.COM
• Leyden E.(1881) commented that HF was a
―frequent and noteworthy complication of diabetes
mellitus‖.
• Mayer J. (1888) stated that ―heart disease in
diabetes can be traced to an abnormality in
metabolism‖.
• Rubler S.(1972) coined the term ‗diabetic
cardiomyopathy ‘ after performing post mortem
studies in 4 diabetic patients with cardiac failure,
having excluded alcohol, hypertension, and
coronary and structural heart disease as possible
aetiologies.
•
Clinical
Science (2009) 116, 741–760
DEMA-CVN.COM
Diabetic Cardiomyopathy
Clinical Evidence
Over 30 years ago 4 diabetic patients with CHF, normal coronary arteries,
and no other etiologies were proposed as having diabetic cardiomyopathy.
(Rubler et al. , Am J Cardiol 1972)
Diabetic cardiomyopathy is a unique entity, unassociated with coronary artery
disease, characterized by diastolic dysfunction. It is rarely clinically apparent
unless associated with hypertension
(Bell, Diabetes Care 1995)
Diastolic dysfunction can be recognized in type II diabetics, in the absence of
concomitant hypertension, in a proportion ranging from 30% to 60%
(Nicolino 1995, Di Bonito 1996, Poirier 2001)
DEMA-CVN.COM
II. STRUCTURAL FEATURES OF DIABETIC
CARDIOMYOPATHY AND THEIR
FUNCTIONAL RELEVANCE
DEMA-CVN.COM
1.Cardiomyocytes
cardiomyocyte hypertrophy and interstitial fibrosis in all except two samples.
mitochondrial degeneration and fatty infiltration of the myofibrils to contraction
band formation, perivascular and interstitial oedema and myocytolysis.
DEMA-CVN.COM
Mild myocardial
fibrosis stained with
Masons trichrome.
(A) Perivascular
fibrosis in diabetic
heart.
(B) Mild fibrosis
between myofibres.
DEMA-CVN.COM
2.Myocardial microvessels
• A study of human diabetic myocardium
found two characteristic abnormalities in
myocardial capillaries:
• endothelial swelling and/or
• degeneration and thickening of the
capillary basement membrane
DEMA-CVN.COM
Myocardial fragment stained with
hematoxylin and eosin shows arteriolar
hyalinization.
Microangiopathic changes of venules
and capillaries in diabetic heart
(magnified x360).
DEMA-CVN.COM
Electronmicrograph of a myocardial capillary from a diabetic patient, demonstrating
luminal occlusion withDEMA-CVN.COM
basement membrane thickening.
Diabetic cardiomyopathy. Clinical Science (2009)116:741-760
Changes in Myocardial Structure
Myocellular and Interstitial Fibrosis
The extent and frequency of diastolic
dysfunction is directly proportional to the
HbA1c level
(Devereux et al. Circulation 2000)
Fibrosis
HYPERGLICEMIA Accumulation of AGEs
Disturbed Ca++ handling Cross linking
of collagen FIBROSIS DIASTOLIC
DYSFUNCTION
Hypertrophy
DEMA-CVN.COM
Bell Diabetes Care 2003
III.DEFINITION OF DIABETIC
CARDIOMYOPATHY (DCM)
A distinct entity characterized by the presence of
abnormal myocardial performance or structure,
in the absence of epicardial coronary artery
disease, hypertension and significant valvular
disease
Aneja Am J Med 2008
DEMA-CVN.COM
Microvascular and tissue dysfunction in
DCM
MACRO vessels
MICRO vessels
TISSUE perfusion/metabolism
<< Flow
>> Glucose
In the absence of
stenosis
… blood flow can be reduced
by Microvascular Dysfunction
DEMA-CVN.COM
… causing ischemic metabolism
and Tissue Dysfunction
DEMA-CVN.COM
DEMA-CVN.COM
DIABETIC CARDIOMYOPATHY (DCM) and
DIABETIC HEART DISEASE (DHD)
DEMA-CVN.COM
Marwick, Heart 2004
