高三酸甘油酯-腰圍肥胖表現型於空腹血糖偏高患者與冠狀動脈疾病之相關性

Association of Hypertriglyceridemic waist phenotype with coronary artery disease among patients with impaired fasting glucose

楊淵琪(Yuan-Chi Yang)

指導教授 ： 賴德仁

中山醫學大學/醫學院/醫學研究所/碩士(2012年)

https://doi.org/10.6834/CSMU.2012.00070

摘要

引言:血糖偏高患者容易發展成糖尿病與心血管疾病，同時危險性因為合併其他危險因子越多而增加。臨床上常見空腹血糖偏高(IFG)但尚未達到糖尿病診斷標準的患者，目前處理方式常是進一步評估是否符合代謝症候群(MS)標準。高三酸甘油酯-腰圍肥胖表現型(HTGW)被認為是代謝症候群標準的替代方案，也在糖尿病人族群中被認為是簡單卻強而有力的血管硬化預測工具。

研究目的:本研究想要探討空腹血糖偏高患者中，比較台灣國健局版代謝症候群定義及高三酸甘油酯-腰圍肥胖表現型與心血管疾病危險度及冠狀動脈疾病之相關性。

研究方法及結果:回溯性分析中部某醫學中心自費進行高階心臟血管健檢的823名個案資料。定義多偵測器電腦斷層掃描冠狀動脈攝影術下發現斑塊為冠狀動脈疾病，若斑塊大於等於50%的狹窄定義為阻塞性冠狀動脈疾病。先篩選出空腹血糖偏高患者165位，將不屬於代謝症候群者為第一組(MS(-)/IFG(+),75人, 45.5%)，符合高三酸甘油酯-腰圍肥胖表現型為第三組(HTGW(+)/MS(+), 37人, 22.4%)，其餘為第二組(HTGW(-)/MS(+), 53人, 32.1%)。觀察傳統心血管危險因子、非傳統心血管危險因子與冠狀動脈疾病於三組的分佈差異。
研究結果發現第三組的危險度最高而第二組次之。第三組的高密度脂蛋白膽固醇明顯較低而同半胱胺酸明顯提高。冠狀動脈鈣化分數存在的機會以第三組最高(51.4%)，中度以上的冠狀動脈鈣化也以第三組為主。冠狀動脈疾病在三組的存在依序為36.0%、49.1% 與70.2%,，阻塞性冠狀動脈疾病在三組的存在依序為9.3%、17.0%及29.7% (P=0.009)。以第一組為參考組做羅吉斯迴歸分析，經年紀與性別校正後，冠狀動脈疾病與阻塞性冠狀動脈疾病的危險性在第三組明顯增加(勝算比2.89 (95% 信賴區間1.19-7.02)與3.08 (1.02-9.22))，但在第二組則無顯著統計意義(1.58 ( 0.75-3.34)與1.79 (0.60-5.23))。

結論與建議:由於第二組與第三組分組皆屬於代謝症候群定義，由第三組於各項評估顯著優於第二組，可以知道高三酸甘油酯-腰圍肥胖表現型確實是代謝症候群定義中具代謝異常表現的決定因子。本研究嘗試將空腹血糖偏高患者做心血管疾病危險度的再分類，證實使用高三酸甘油酯-腰圍肥胖表現型於空腹血糖偏高患者上是實用之篩檢工具，在心血管危險度與冠狀動脈疾病等各項評估都比台灣國健局版本的代謝症候群定義具更顯著的相關性。相對的，在沒有此高三酸甘油酯-腰圍肥胖表現型表現狀況下，空腹血糖偏高與心血管疾病的相關性似乎是相對較低的，但需要未來更多的研究來證實。高三酸甘油酯-腰圍肥胖在空腹血糖偏高患者盛行率高而且簡單便宜又實用，建議在基層醫療多加運用此表現型來分辨出空腹血糖偏高患者中的高風險族群，藉由提早並加強控制心血管疾病危險因子，以期降低未來發生糖尿病與心血管疾病的風險。

關鍵字

空腹血糖偏高；高三酸甘油酯-腰圍肥胖表現型；代謝症候群； 心血管疾病風險 ； 冠狀動脈疾病

並列摘要

Introduction :Impaired fasting glucose (IFG) is associated with a substantially increased risk of developing diabetes and cardiovascular diseases (CVD), with the greater risk in people with other risk factors simultaneously. To identify high risk IFG patients may screen for metabolic syndrome (MS) in current practices. Hypertriglyceridemic waist phenotype (HTGW) is an alternative definition of MS, and is also a strong predictor for coronary artery disease (CAD) in diabetic patients.

Objective :The present study tested whether in IFG patients the HTGW is better than MS(using definition of Bureau of Health Promotion, Taiwan) to correlate with CVD risks and presence of CAD as assessed by multi- detector computed tomographic coronary angiography.

Methods and Results :In this retrospective study, we consecutively collected the data of 823 participants joined high-level cardiovascular health examination in one medical center in middle Taiwan. 165 Subjects met IFG definition (fasting plasma glucose 100-125 mg/dl & HbA1C<6.5%) was divided into 3 groups: who without MS as Group(1)( (MS(-)/IFG(+), n=75, 45.5%), who met HTGW criteria as Group(3) (HTGW(+)/MS(+), n=37, 22.4%) and others as Group(2) (HTGW(-)/MS(+), n=53, 32.1%). Group(1) was considered the reference group. CAD was defined as presence of any plague, and obstructive CAD was defined as the plague led to luminal reduction in diameter to ≧ 50%.
Regarding to traditional CVD risk factors, non-traditional CVD risk factors and CAD, Group(3) has the greatest risks, followed by group(2). Extraordinary, Group (3) has significant lower high-density lipoprotein cholesterol levels and higher plasma homocysteine levels but not in Group(2). Group(3) also has higher possibility of detectable coronary calcification score and higher proportion of moderate to severe coronary calcification. CAD was found in 36.0% of group(1), 49.1% of group(2) and 70.2% of group(3) and 9.3%,17.0% and 29.7% (P=0.009) for obstructive CAD respectively. After adjusted for age and gender, logistic regression analyses reveal elevated risks for CAD and obstructive CAD in Group(3)(odds ratio 2.89 ( 95% confidence interval 1.19-7.02) and 3.08 (1.02 -9.22)), but not significantly in Group(2)( 1.58 (0.75-3.34) and 1.79 (0.60-5.23)).

Conclusion and Suggestion :Both fit MS definition, Group(3) exhibited much more significant finding than Group(2). Therefore, HTGW indeed is the determinant in metabolic syndrome features, and may serve as a better biomarker then traditional MS definition. In addition, it seems that the relationship between hyperglycemia and cardiovascular disease may diminish in IFG subjects without HTGW, even fit the MS criteria.
In conclusion, HTGW is prevalent in IFG patients and is a simple and practical tool for risk stratification in IFG patients in general practices.

並列關鍵字

impaired fasting glucose (IFG) ； metabolic syndrome (MS) ； hypertriglyceridemic waist phenotype (HTGW) ； cardiovascular disease risk, coronary artery disease (CAD)

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