A carregar...
Publicação
Estratégia diagnóstica da diabetes na doença arterial coronária : as novas guidelines europeias são um retrocesso?
| Nome: | Descrição: | Tamanho: | Formato: | |
|---|---|---|---|---|
| 1.61 MB | Adobe PDF |
Autores
Orientador(es)
Resumo(s)
Introdução: As novas recomendações Europeias de Diabetes Mellitus tipo 2 (DM) e doença cardiovascular, sugerem que o risco de DM deve ser avaliado através do score de risco FINDRISC e que o rastreio de DM na população com doença arterial coronária (DAC) deve ser efetuado apenas com a glicemia plasmática em jejum (GPJ) e a HbA1, remetendo a prova de tolerância oral à glicose (PTOG) para os casos “inconclusivos”. Esta estratégia difere da previamente defendida nas Guidelines e poderá deixar por diagnosticar alguns casos de DM, identificáveis pela PTOG.
Objetivo. Avaliar o valor do score FINDRISC na seleção dos doentes candidatos a PTOG e avaliar a capacidade diagnóstica da estratégia proposta pelas Guidelines Europeias na identificação de novos casos de DM, numa população de doentes com DAC estabelecida
Métodos. A GPJ, HbA1c e a PTOG (75g, 2h) foram avaliadas prospectivamente num grupo de doentes consecutivos submetidos a intervenção coronária percutânea, sendo usada a classificação da ADA para pré-DM (GPJ 100-125 mg/dl e/ou glicemia 2h 140-199 mg/dl e/ou HbA1c 5.7–6.4%) e DM (GPJ ≥ 126 mg/dl e/ou glicemia 2-h ≥200 mg/dl e/ou HbA1c ≥ 6.5%). O risco de diabetes foi avaliado de acordo com o score FINDRISC (que inclui a idade, perímetro abdominal, IMC, hábitos de exercício físico, hábitos alimentares, história de HTA, distúrbios da glicemia previamente conhecidos e história familiar de DM).
Resultados. De uma população inicial de 185 doentes, 50 (27.0%) tinham história prévia de diabetes. Os restantes 135 doentes (idade média 62.3+/-13.1 anos, 99 homens) constituem a população do estudo. O score FINDRISC mostrou risco baixo, ligeiramente elevado, moderado ou alto/muito alto em respetivamente 17 (12.6%), 51 (37.8%), 38 (28.1%) e 29 (21.5%) dos doentes.
Usando a PTOG e a HbA1c, foram diagnosticados 18 (13.3%) novos casos de DM e 77 (57.0%) casos de pré-DM; apenas 40 doentes (29.6%) apresentavam um metabolismo da glicemia normal (21.6%, se considerarmos a população inicial, com os diabéticos já previamente conhecidos). O score FINDRISC nos doentes com DM de novo foi baixo em 1 (5.5%), ligeiramente elevado em 5 (27.8%), moderado em 5 (27.8%) e alto/muito alto em 7 (38.9%) doentes. Página 4 de 33
A GPJ+HbA1c identificou 12/18 doentes com DM (Sens 66.7%, VPN 95.1%, Kappa 0,78, p<0,0001) e 83 do total (pré-DM + DM) de 95 doentes com distúrbios da glucose (Sens 87.4%, VPN 76.9%). Realizar adicionalmente PTOG nos 29 doentes com um score de risco FINDRISC elevado permitiu diagnosticar 15/18 doentes com DM (Sens 83.3%, VPN 97.5%, Kappa 0.85, p<0.0001) e 86/95 dos doentes com distúrbios da glucose (Sens 90.5%, VPN 81.6%). Apesar da melhoria diagnóstica, 1 em cada 6 doentes com DM não seria diagnosticado por esta estratégia.
Conclusões. A utilização do score de risco FINDRISC como forma de selecionar os doentes candidatos a rastreio com PTOG melhora a capacidade diagnóstica, quando comparada com a simples avaliação da GPJ e da HbA1c. No entanto, 1 em cada 6 doentes com DM não é identificado com esta metodologia. Tendo em atenção o impacto prognóstico da DM na DAC, a identificação de todos os casos é fundamental, pelo que deveria recomendar-se a realização sistemática de HbA1c em conjunto com PTOG em todos os doentes com DAC e sem DM previamente conhecida.
Background: New European Guidelines on diabetes (DM) and cardiovascular diseases propose that the FINDRISC risk score should be used to evaluate the risk of DM and that DM screening in coronary artery disease (CAD) patients should be based on fasting glucose (FPG) and HbA1c. The 2h oral glucose tolerance test (OGTT), recommended for all pts in the previous guidelines, is now only recommended for “inconclusive” cases. Purpose. Evaluate the added value of the DM risk score FINDRISC in selecting patients that would gain with the OGTT and evaluate the diagnostic capacity of the strategy proposed by the European Guidelines on identifying new cases of DM in a population of patients with established CAD. Methods. FPG, HbA1c and OGTT (75g, 2-h) were prospectively evaluated in a consecutive group of pts with CAD. ADA criteria (both OGTT and HbA1c) were used to define DM and pre-DM. DM risk was evaluated according to the FINDRISC score (including age, body mass index, waist circumference, exercise and diet habits, history of hypertension or blood glucose disorders and family history of DM) Results. From an initial population of 185 patients, 50 (27.0%) had a previous history of DM and were excluded. The FINDRISC score classified the remaining 135 patients as having a low (n=17, 12.6%), slightly elevated (51; 37.8%), moderate (38; 28.1%) or high/very high (29; 21.5%) risk of DM. OGTT and HbA1c together diagnosed 18 (13.3%) new cases of DM and 77 (57.0%) patients with pre-DM. Only 40 patients (21.6% of the total initial population) had a normal glucose metabolism. FINDRISC score in patients with newly diagnosed DM was low in 1 (5.5%), slightly elevated in 5 (27.8%), moderate in 5 (27.8%) and high/very high in 7 (38.9%) patients. FPG+HbA1c (guidelines strategy) identified 12/18 patients with DM (Sens 66.7%, NPV 95.1%, Kappa 0,78, p<0,0001) and 83/95 patients with glucose anomalies (pre-DM + DM) (Sens 87.4%, NPV 76.9%). Performing OGTT in the 29 patients with an elevated FINDRISC score would allow identifying 15/18 patients with DM (Sens 83.3%, NPV 97.5%, Kappa 0.85, p<0.0001) and 86/95 patients with glucose anomalies (Sens 90.5%, NPV 81.6%). Although this strategy improved the screening accuracy, one in each six patients with DM would still remain undiagnosed, as compared to measuring HbA1c and performing an OGTT in all patients. Página 6 de 33 Conclusions. The screening strategy proposed by the guidelines (FPG+HbA1c) identified only 66.7% of new DM patients. Using the FINDRISC score to select candidates to additional OGTT improves the accuracy of this strategy. However, 1/6 patients with DM is still left undiagnosed. Considering the prognostic impact of DM in CAD patients, identification of new diabetes cases is essential and this can only be achieved with HbA1c and OGTT in all patients.
Background: New European Guidelines on diabetes (DM) and cardiovascular diseases propose that the FINDRISC risk score should be used to evaluate the risk of DM and that DM screening in coronary artery disease (CAD) patients should be based on fasting glucose (FPG) and HbA1c. The 2h oral glucose tolerance test (OGTT), recommended for all pts in the previous guidelines, is now only recommended for “inconclusive” cases. Purpose. Evaluate the added value of the DM risk score FINDRISC in selecting patients that would gain with the OGTT and evaluate the diagnostic capacity of the strategy proposed by the European Guidelines on identifying new cases of DM in a population of patients with established CAD. Methods. FPG, HbA1c and OGTT (75g, 2-h) were prospectively evaluated in a consecutive group of pts with CAD. ADA criteria (both OGTT and HbA1c) were used to define DM and pre-DM. DM risk was evaluated according to the FINDRISC score (including age, body mass index, waist circumference, exercise and diet habits, history of hypertension or blood glucose disorders and family history of DM) Results. From an initial population of 185 patients, 50 (27.0%) had a previous history of DM and were excluded. The FINDRISC score classified the remaining 135 patients as having a low (n=17, 12.6%), slightly elevated (51; 37.8%), moderate (38; 28.1%) or high/very high (29; 21.5%) risk of DM. OGTT and HbA1c together diagnosed 18 (13.3%) new cases of DM and 77 (57.0%) patients with pre-DM. Only 40 patients (21.6% of the total initial population) had a normal glucose metabolism. FINDRISC score in patients with newly diagnosed DM was low in 1 (5.5%), slightly elevated in 5 (27.8%), moderate in 5 (27.8%) and high/very high in 7 (38.9%) patients. FPG+HbA1c (guidelines strategy) identified 12/18 patients with DM (Sens 66.7%, NPV 95.1%, Kappa 0,78, p<0,0001) and 83/95 patients with glucose anomalies (pre-DM + DM) (Sens 87.4%, NPV 76.9%). Performing OGTT in the 29 patients with an elevated FINDRISC score would allow identifying 15/18 patients with DM (Sens 83.3%, NPV 97.5%, Kappa 0.85, p<0.0001) and 86/95 patients with glucose anomalies (Sens 90.5%, NPV 81.6%). Although this strategy improved the screening accuracy, one in each six patients with DM would still remain undiagnosed, as compared to measuring HbA1c and performing an OGTT in all patients. Página 6 de 33 Conclusions. The screening strategy proposed by the guidelines (FPG+HbA1c) identified only 66.7% of new DM patients. Using the FINDRISC score to select candidates to additional OGTT improves the accuracy of this strategy. However, 1/6 patients with DM is still left undiagnosed. Considering the prognostic impact of DM in CAD patients, identification of new diabetes cases is essential and this can only be achieved with HbA1c and OGTT in all patients.
Descrição
Trabalho Final do Curso de Mestrado Integrado em Medicina, Faculdade de Medicina, Universidade de Lisboa, 2016
Palavras-chave
Diabetes mellitus Doença das coronárias Guias de prática clínica