摘要
背景糖尿病有着定期监测、实时随访、地域便利等社区管控的优势,社区规范管理现况有待进一步明确。目的了解并分析社区2型糖尿病患者阿司匹林一、二级预防使用现况。方法按照分层随机抽样原则,选取2017年12月上海市沪东社区卫生服务中心下设5个全科团队管控的2型糖尿病患者490例为调查对象。调查内容由问卷(基本信息、既往史、家族史、吸烟史、阿司匹林服用情况)、体检(体质量、血压)、实验室数据(血常规、肝肾功能、血糖、血脂)组成。依据冠状动脉粥样硬化性脑心血管疾病风险进行评定,了解阿司匹林一、二级预防在糖尿病患者中的使用现况,同时调查有预防指征而未用药的原因,以及预测高龄糖尿病患者阿司匹林预防使用的出血风险。结果最终纳入465例,其中男225例(48.4%),女240例(51.6%)。有阿司匹林一级预防指征者219例(47.1%),有阿司匹林二级预防指征者208例(44.7%),无阿司匹林预防指征者38例(8.2%)。有一级预防指征的糖尿病患者阿司匹林使用率为19.6%(43/219),有二级预防指征的糖尿病患者阿司匹林使用率为49.5%(103/208)。有阿司匹林预防指征但未用药原因中不知晓或医生未提及占比最大,为62.3%(175/281)。≥80岁年龄段的糖尿病患者使用阿司匹林预防者占50.0%(15/30),对其行抗血小板及抗凝治疗(CRUSADE)出血风险预测发现,出血风险高危者占26.7%(4/15),极高危者占13.3%(2/15)。结论社区糖尿病患者阿司匹林预防的使用率不足,特别是一级预防。对社区卫生服务中心管控的糖尿病患者,行阿司匹林脑心血管疾病一、二级预防,需要全科医生个体化评估其风险、获益,并进行动态规律随访。
Background For diabetic patients,community-based management is comparatively good,because by which glycemic and other essential indicators can be regularly monitored,real-time follow-up services can be obtained,and the management is easy to access owing to short spatial distance. However,how to deliver standardized community-based management for such patients is need to be cleared further. Objective To investigate the use of small-dose Aspirin for primary and secondary prevention of cardio-cerebrovascular diseases in community-dwelling type 2 diabetic patients. Methods We conducted this survey in December 2017 in a stratified and random sample of 490 type 2 diabetic patients who were under the management of 5 general practitioner teams from Shanghai Hudong Community Health Center. The survey contents consisted of 3 parts,namely,personal data(basic information,past history of ASCCVD,family history of ASCCVD,smoking history,and Aspirin use),anthropometric data(weight and blood pressure) and laboratory data(routine blood parameters,liver and kidney function parameters,and glycemic and lipid parameters),collected with a self-developed interview-based questionnaire,physical examination,fasting venous blood testing,respectively. Indications for using Aspirin for primary or secondary prevention of cardio-cerebrovascular diseases were assessed by the risk of developing ASCCVD,and the use status was evaluated. Reasons for those should use Aspirin but did not use were analyzed. Risk of Aspirin-related bleeding in the elderly was assessed. Results The study finally enrolled 465 cases,including 225(48.4%) males and 240(51.6%) females. Of them,219(47.1%)had indications for use of Aspirin for primary prevention of cardio-cerebrovascular diseases,with a rate of Aspirin use of 19.6%(43/219),208(44.7%) had indications for use of Aspirin for secondary prevention,showing a rate of Aspirin use of 49.5%(103/208),and other 38(8.2%) had no indications. Patients who had indications but did not use Aspirin were mostly due to knowing little about this or receiving no related information from the doctor〔62.3%(175/281)〕.The rate of using Aspirin for the prevention of cardio-cerebrovascular diseases in those aged ≥ 80 years was 50.0%(15/30),and 26.7%(4/15) of them were at high risk of Aspirin-related bleeding,13.3%(2/15) were found with extremely high risk predicted by the CRUSADE score.Conclusion Inadequate use of Aspirin for prevention of diabetes in community,especially primary prevention.For type2 diabetic patients under community-based management,before using Aspirin for primary or secondary prevention of cardiocerebrovascular diseases,individualized risk-benefit assessment of Aspirin use should be performed by GPs. Additionally,dynamic follow-ups should be delivered to the patients during Aspirin administration period.
引文
[1]XU Y,WANG L,HE J,et al.Prevalence and control of diabetes in Chinese adults[J].JAMA,2013,310(9):948-959.DOI:10.1001/jama.2013.168118.
[2]毕艳.中国糖尿病慢性并发症的流行病学研究现况[J].中华糖尿病杂志,2015,7(8):467-469.DOI:10.3760/cma.j.issn.1674-5809.2015.08.002.BI Y.The epidemiological study on chronic complications of diabetes mellitus in China[J].Chinese Journal of Diabetes,2015,7(8):467-469.DOI:10.3760/cma.j.issn.1674-5809.2015.08.002.
[3]中华医学会内分泌学分会.中国成人2型糖尿病患者动脉粥样硬化性脑心血管疾病分级预防指南[J].中华内分泌代谢杂志,2016,32(7):540-545.DOI:10.3760/cma.j.issn.1000-6699.2016.07.004.Chinese Society of Endocrinology.Guidelines of classified prevention for type 2 diabetes adults complicated with atherosclerotic cerebral and cardiovascular diseases in China[J].Chin J Endocrinol Metab,2016,32(7):540-545.DOI:10.3760/cma.j.issn.1000-6699.2016.07.004.
[4]梁峰,胡大一,沈珠军.2014美国糖尿病指南:糖尿病诊疗标准[J].中华临床医师杂志电子版,2014,8(6):1182-1190.DOI:10.3969/cma.j.issn.1674-0785.2014.06.042.LIANG F,HU D Y,SHEN Z J.American diabetes guide 2014:diagnostic and therapeutic criteria for diabetes mellitus[J].Chin JClinicians Electronic Edition,2014,8(6):1182-1190.DOI:10.3969/cma.j.issn.1674-0785.2014.06.042.
[5]中华医学会心血管病学分会流行病学组,中国医师协会心血管内科医师分会,中国老年学学会心脑血管病专业委员会.糖代谢异常与动脉粥样硬化性心血管疾病临床诊断和治疗指南[J].中华心血管病杂志,2015,43(6):488-506.DOI:10.3760/cma.j.issn.0253-3758.2015.06.008.Epidemiology Group of Chinese Society of Cardiovascular Diseases,Branch of Cardiovascular Internal Medicine of Chinese Medical Association,Professional Committee on Cardiovascular and Cerebrovascular Diseases of the Chinese Geriatric Society.Clinical diagnosis and treatment guidelines for abnormal glucose metabolism and atherosclerotic cardiovascular disease[J].Chin J Cardiol,2015,43(6):488-506.DOI:10.3760/cma.j.issn.0253-3758.2015.06.008.
[6]中华医学会心血管病学分会.抗血小板治疗中国专家共识[J].中华心血管病杂志,2013,41(3):183-194.DOI:10.3760/cma.j.issn.0253-3758.2013.03.004.Chinese Society of Cardiovascular Diseases.Chinese expert consensus on antiplatelet therapy[J].Chin J Cardiol,2013,41(3):183-194.DOI:10.3760/cma.j.issn.0253-3758.2013.03.004.
[7]中华医学会糖尿病学分会.中国2型糖尿病防治指南(2017年版)[J].中华糖尿病杂志,2018,10(1):4-67.DOI:10.3760/cma.j.issn.1674-5809.2018.01.003.Chinese Diabetes Society.Guidelines for the prevention and treatment of type 2 diabetes in China(2017 edition)[J].Chin J Diabetes Mellitus,2018,10(1):4-67.DOI:10.3760/cma.j.issn.1674-5809.2018.01.003.1631
[8]2014年中国胆固醇教育计划血脂异常防治建议专家组,中华心血管病杂志编辑委员会,血脂与动脉粥样硬化循证工作组,等.2014年中国胆固醇教育计划血脂异常防治专家建议[J].中华心血管病杂志,2014,42(8):633-636.DOI:10.3760/cma.j.issn.0253-3758.2014.08.003.Group of Experts on Prevention and Treatment of Abnormal Blood Lipid in China Cholesterol Education Program in 2014,Editorial Committee of Chinese Journal of Cardiology,Evidencebased Working Group on Blood Lipid and Atherosclerosis,et al.Expert suggestions on prevention and treatment of abnormal blood lipids in China cholesterol education programe in 2014[J].Chin J Cardiol,2014,42(8):633-636.DOI:10.3760/cma.j.issn.0253-3758.2014.08.003.
[9]中国成人血脂异常防治指南修订联合委员会.中国成人血脂异常防治指南(2016年修订版)[J].中国循环杂志,2016,31(10):937-950.DOI:10.3969/j.issn.1000-3614.2016.10.001.Joint Committee on Revision of Guidelines for Prevention and Treatment of Adult Hyperlipidemia in China.Guidelines for prevention and treatment of dyslipidemia in Chinese adults(revised2016)[J].Chinese Circulation Journal,2016,31(10):937-950.DOI:10.3969/j.issn.1000-3614.2016.10.001.
[10]CRUSADE出血风险预测模型[EB/OL].[2018-10-12].https://wenku.Baidu.com/view/ee41ab05ba1aa8114431d99b.html.
[11]DE BERARDIS G,SACCO M,STRIPPOLI G F,et al.Aspirin for primary prevention of cardiovascular events in people with diabetes:meta-analysis of randomised controlled trials[J].BMJ,2009,339:b4531.DOI:10.1136/bmj.b4531.
[12]郑颖,刘玉红,张海川,等.北京某社区阿司匹林预防心血管疾病应用调查[J].中华全科医师杂志,2017,16(7):557-559.DOI:10.3760/cma.j.issn.1671-7368.2017.07.018.ZHENG Y,LIU Y H,ZHANG H C,et al.The survey on the preventive use of Aspirin among cardiovascular disease patients in a community in Beijing[J].Chinese Journal of General Practitioners,2017,16(7):557-559.DOI:10.3760/cma.j.issn.1671-7368.2017.07.018.
[13]BAIGENT C,BLACKWELL L,COLLINS R,et al.Aspirin in the primary and secondary prevention of vascular disease:collaborative meta-analysis of individual participant data from randomised trials[J].Lancet,2009,373(9678):1849-1860.DOI:10.1016/S0140-6736(09)60503-1.
[14]YUSUF S,ISLAM S,CHOW C K.Use of secondary prevention drugs for cardiovascular disease in the community in high-income,middle-income,and low-income countries(the PURE study):a prospective epidemiological survey[J].Lancet,2011,378(9798):1231-1243.2019010720190326
