Diabetes mellitus und kardiovaskuläre Erkrankungen – Sinnvolle Diagnostik und Therapie aus Sicht des Kardiologen

Der Diabetes mellitus ist einer generalisierten Gefäß- und kardiovaskulären Erkrankung gleichgestellt und geht mit einer stark erhöhten kardiovaskulären Morbidität und Mortalität einher. Treten weitere Risikofaktoren, insbesondere ein arterieller Hypertonus hinzu, sinkt die Prognose des Patienten rapide. Da beide Erkrankungen zu einem großen Teil durch den Lebensstil des Betroffenen bedingt sind, sollte der Hausarzt das Risiko des Patienten anhand von etablierten Scores möglichst frühzeitig evaluieren und gegebenenfalls eine umfassende Lebensstilberatung anbieten. Besteht ein manifester Diabetes mellitus, ist einmal pro Jahr eine weiterführende kardiologische Diagnostik indiziert. Andererseits sollte bei kardiovaskulär vorgeschädigten Patienten einmal jährlich ein Diabetes mellitus sowie seine Vorstufen durch einen oralen Glukosetoleranztest ausgeschlossen werden. Ein bestehender arterieller Hypertonus bedarf einer strikten, risikoadaptierten medikamentösen Therapie, wobei die Zielwerte für Diabetiker unter Werten von 130/80 mmHg liegen. Aus prognostischer Sicht sind dabei ACE-Hemmer bzw. Angiotensinrezeptorblocker zu bevorzugen. Kalziumantagonisten vom Dihydropyridintyp eignen sich ebenso wie Nicht-Thiaziddiuretika gut als Kombinationspartner.

Diabetes mellitus is on an equal level with a generalized vascular and cardiovascular disease and is associated with greatly increased cardiovascular morbidity and mortality. Patient prognosis worsens rapidly if there are additional risk factors, especially if there is also an arterial hypertension. Since both of these diseases mainly depend on the individual's life habits, the general practitioner should evaluate this factor as early as possible as revealed by available scores and if necessary offer a comprehensive consultation regarding a more useful lifestyle. If diabetes mellitus is an established fact, it is advisable to initiate a comprehensive annual cardiologic check-up. On the other hand, cardiovascular impaired patients should undergo an annual oral glucose tolerance test to exclude both diabetes mellitus and its preliminary stages while offering maximum comprehensive advice on the style and habits of life. In case arterial hypertension is established, the patient must be subjected to a rigid risk-adapted medical therapy, the target values for diabetics being below 130/80 mmHg. From a prognostic point of view, ACE inhibitors or angiotensin receptor blockers are preferable. Suitable combination partners are calcium channel blockers of the dihydropyridine type as well as thiazide diuretics.

Key words

diabetes mellitus - cardiovascular risk - arterial hypertension - risk evaluation - risk-adapted therapy

Literatur

• 1 Rydén L, Standl E, Bartnik M. et al. . The Task Force on Diabetes and Cardiovascular Diseases of the European Society of Cardiology (ESC) and of the European Association for the Study of Diabetes (EASD).  Eur Heart J. 2007;  28 88-136
• 2 Neumann T, Biermann J, Neumann A. et al. . Herzinsuffizienz: Häufigster Grund für Krankenhausaufenthalte – Medizinische und ökonomische Aspekte.  Dtsch Arztebl Int. 2009;  106 269-275
• 3 Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38. UK Prospective Diabetes Study Group.  BMJ. 1998;  317 703-713
• 4 Bhatia RS, Tu JV, Lee DS. et al. . Outcome of heart failure with preserved ejection fraction in a population-based study.  N Engl J Med. 2006;  355 260-269
• 5 Lam CS, Roger VL, Rodeheffer RJ. et al. . Cardiac structure and ventricular-vascular function in persons with heart failure and preserved ejection fraction from Olmsted County, Minnesota.  Circulation. 2007;  115 1982-1990
• 6 Paulus WJ, Tschöpe C, Sanderson JE. et al. . How to diagnose diastolic heart failure: a consensus statement on the diagnosis of heart failure with normal left ventricular ejection fraction by the Heart Failure and Echocardiography Associations of the European Society of Cardiology.  Eur Heart J. 2007;  28 2539-2550
• 7 Nagueh SF, Appleton CP, Gillebert TC. et al. . Recommendations for the evaluation of left ventricular diastolic function by echocardiography.  J Am Soc Echocardiogr. 2009;  22 108-133
• 8 Norhammer A, Tenerz A, Nilsson G. et al. . Glucose metabolism in patients with acute myocardial infarction and no previous diagnosis of diabetes mellitus: a prospective study.  Lancet. 2002;  359 2140-2144
• 9 Malmberg K, Norhammar A, Wedel H, Rydéen L.. Glycometabolic state at admission: important risk marker of mortality in conventionally treated patients with diabetes mellitus and acute myocardial infarction: long-term results from the Diabetes and Insulin-Glucose Infusion in Acute Myocardial Infarction (DIGAMI) Study.  Circulation. 1999;  25 2626-2632
• 10 Lindstrom J, Tuomilehto J.. The diabetes risk score: a practical tool to predict type 2 diabetes risk.  Diabetes Care. 2003;  26 725-731
• 11 ESC-SCORE Chart.  www.escardio.org/Policy/prevention/tools/health-toolkit/Pages/SCORE-Risk-Charts.aspx
• 12 Assmann G, Cullen P, Schulte H.. Simple scoring scheme for calculating the risk of acute coronary events based on the 10-year follow-up of the Prospective Cardiovascular Munster (PROCAM) study.  Circulation (www.chd-taskforce.com). 2002;  105
• 13 www.leitlinien.net/046-001.pdf . 
• 14 Schrier EW, Estacio RO, Mehler PS, Hiatt WR.. Appropriate blood pressure control in hypertensive and normotensive type 2 diabetes mellitus: a summary of the ABCD trial.  Nat Clin Pract Nephrol. 2007;  3 428-438
• 15 Patel A, MacMahon S, Chalmers J. et al. . Effects of a fixed combination of perindopril and indapamide on macrovascular and microvascular outcomes in patients with type 2 diabetes mellitus (the ADVANCE trial): a randomised controlled trial.  Lancet. 2007;  370 829-840
• 16 Dickstein K, Cohen-Solal A, Filippatos G. et al. . ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2008: the Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2008 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association of the ESC (HFA) and endorsed by the European Society of Intensive Care Medicine (ESICM).  Eur Heart J. 2008;  29 2388-2442
• 17 Lindholm LH, Ibsen H, Dahlöf B. et al. . Cardiovascular morbidity and mortality in patients with diabetes in the Losartan Intervention for Endpoint reduction in hypertension study (LIFE): a randomised trial against atenolol.  Lancet. 2002;  359 1004-1010
• 18 Brenner BM, Cooper ME, De Zeeuw D. et al. . Effects of losartan on renal and cardiovascular outcomes in patients with type 2 diabetes and nephropathy.  N Engl J Med. 2001;  345 861-869

1 FINnish Diabetes RISK

2 PROspective CArdivascular Münster

3 Appropriate Blood pressure Control in Diabetes

4 Action in Diabetes and Vascular disease: PreterAx and DiamicroN-MR Controlled Evaluation

5 Losartan Intervention For Endpoint reduction

6 Reduction of Endpoints in NIDDM with the Angiotensin II Antagonist Losartan

7 Metoprolol CR/XL Randomized Intervention Trial in Congestive Heart Failure

8 Cardiac Insufficiency Bisoprolol Study

Korrespondenz