- 學位論文
糖尿病視網膜病變與腦心血管疾病發生相關性分析
Diabetes Mellitus retinopathy and major cardiovascular events
摘要
背景 心血管疾病（cardio-vascular disease, CVD）是全世界發病率和死亡率排名最高，糖尿病視網膜病變（DR）是糖尿病患者長期的高血糖所引起眼部視網膜血管病變疾病，其中又以增殖型視網膜病變(proliferative diabetic retinopathy, PDR)的併發症較為嚴重。在這項研究中，透過健保資料庫的分析，試圖探討糖尿病視網膜病變與心血管疾病兩者的相關性，並且釐清糖尿病患者自罹患非增殖性視網膜病變（NPDR）和增殖性視網膜病變（PDR）後心血管疾病發生的風險。 方法 本研究使用1999年至2013年的全民健康保險資料庫，隨機選取 200萬歸人且具樣本代表性的大型資料，進行了一項連結研究。首先選取糖尿病診斷者及年齡性別配對的對照進行分析。評估研究對象的系統性疾病、眼疾病、共存病症、併用藥物的分布。建立Cox比例風險模型以探索糖尿病視網膜病變造成心血管疾病發生的相對風險關係。 結果 在發病率，每 1000 人月，經調整後的任何心血管事件風險對比值：以糖尿病無視網膜病變病（NDR）發生心血管疾病的風險進行對比，糖尿病視網膜病變(DR）組，達到統計上的顯著意義。糖尿病視網膜病變（DR）罹患任何心血管事件風險、缺血性心臟病風險比、充血性心力衰竭風險、缺血性腦中風皆有達到統計上的顯著意義。 年齡<40歲、40-59歲與糖尿病視網膜病變有顯著的交互作用，並且與心血管事件發生的風險增加有關。 以糖尿病無視網膜病變病（NDR）做為參考時，在非增殖性視網膜病變（NPDR）與增殖性視網膜病變（PDR）罹患心血管事件（CVD）的風險差異。增殖性視網膜病變族群中罹患任何心血管事件風險、缺血性心臟病風險比、鬱血性心衰竭風險、缺血性腦中風風險皆有達到統計上的顯著意義。非增殖性視網膜病變則未見任一項心血管事件的發生風險顯著的高於糖尿病無視網膜病變病（NDR）組。 分析糖尿病族群發生心血管事件（CVD）的可能危險因子，以糖尿病史 <2年做為參考組，糖尿病史2-5年、>5年以上均達到統計上的顯著意義。 比較不同類型的視網膜病變，以糖尿病無視網膜病變病（NDR）組作為對照：增殖性視網膜病變（PDR）達到統計上的顯著意義。 年齡部分以40-59歲發生心血管疾病的風險為對照，<40歲、60-79歲、>=80歲皆有達到統計上的顯著意義。 性別部分，以女性發生心血管疾病風險為基準，男性達到統計上的顯著意義。 共存病症部分，高血壓、慢性肺部疾病、腎臟疾病、肝炎和肝硬化、達到統計上的顯著意義。 眼疾病部分，白內障，達到統計上的顯著意義。 併用藥物部分，全身性類固醇、抗精神分裂藥物、抗心律不整藥物、降血糖藥物，達到統計上的顯著意義。 結論 糖尿病視網膜病變對無論是男女還是年齡，發生心血管疾病事件的相對風險皆大於對照。糖尿病有針對性的監測和管理，特別是發現糖尿病視網膜病變時，應該針對病患的心血管疾病風險因子進行調查與管理，在糖尿病人群的臨床護理中可能是重要的。
並列摘要
Objectives: Cardio-vascular disease (CVD) ranks highest in morbidity and mortality worldwide. Many literatures have demonstrated the relationship between CVD and diabetic retinopathy (DR), a long-term hyperglycemia in diabetic patients with ocular retinal vasculopathy which is concurrent with proliferative diabetic retinopathy (PDR) In this study, an analysis of the health care database was conducted to investigate the association between DR and CVD, and to clarify the risk of CVD in diabetic patients after non-proliferative diabetic retinopathy (NPDR) or PDR. Methods: This study uses the 1999 to 2013 universal health insurance database, and after an election of 2 million returned files with the representative of the large-scale information, conducted a study on the links. First, the study selects the diabetes diagnosis, age and sex matching the snapshot for analysis. Assessment study on the systemic disease, eye diseases, and coexisting disease were combined with the distribution. This study established Cox proportional risk model to explore the relative risk relationship of CVD caused by DR. Results: In morbidity, for every 1000 people, the study was adjusted for any cardiovascular event risk comparison: compared with the risk of cardiovascular disease without retinopathy in diabetes, the diabetic retinopathy group reached statistically significant significance. The risk of any cardiovascular event, ischemic heart disease risk ratio, congestive heart failure risk, and ischemic stroke all reached statistical significance for diabetic retinopathy. Age 40, 40-59 years old and diabetes retinopathy had a significant interaction and was associated with an increased risk of cardiovascular events. When diabetes-free retinopathy is used as a reference, there is a difference in the risk of cardiovascular events in non-proliferative retinopathy and proliferative retinopathy. Any risk of cardiovascular events, ischemic heart disease risk ratio, risk of depression and blood failure, and ischemic stroke risk in the population of proliferative retinopathy all reached statistical significance. Non-proliferative retinopathy did not see any cardiovascular event risk significantly higher than that of diabetic non-retinopathy group. Analysis of possible risk factors for cardiovascular events in the diabetes population, with the history of diabetes for 2 years as a reference group, the history of diabetes for 2-5 years and more than 5 years have both reached statistical significance. Comparing different types of retinopathy, the group without retinopathy was the control group. The age segment was statistically significant in terms of the risk of cardiovascular events between 40 and 59 years of age, and those aged 40-79 and 80 years old. The gender component, based on the risk of cardiovascular events in women, reached a statistically significant point in men. Co-existing diseases, hypertension, chronic lung disease, kidney disease, hepatitis and cirrhosis of the liver, reached statistical significance. The eye disease part, cataract, achieves statistical significance. The drug part, systemic steroids, antipsychotic drugs, anti-heart rhythm disorder drugs, blood sugar-lowering drugs, also achieved statistical significance. Conclusion: The relative risk of CVD events in DR was greater than that in control group for both men and women as well as for age. The targeted monitoring and management of , especially the detection of diabetic retinopathy, should be based on the patient's cardiovascular disease risk factors for investigation and management, which may be important in the clinical care of DM population.