Monthly Archives: 11月 2018

糖尿病專家沒有許樟榮,敦促人們專注於下肢血管健康

臨床表現與診斷

王老伯今年68歲,患有高血壓,糖尿病20年,喜歡吸煙,每天10次。我來我們的糖尿病中心是因為我左腳有潰瘍。我接見他,發現他左腳有潰瘍,潰瘍周圍的皮膚明顯較厚。我們用醫學術語稱它為愈傷組織,普通人稱它為雞眼。老人跟我說,他的腳潰瘍已經有3個月,日常穿著,潰瘍表面是幹淨的,但是是不收斂的,不好,也不壞。我問是否還有其他的不適。他說,最近,他走得更久了,小腿兩側都感到腫脹和沉重。我不得不在路邊休息,然後在疼痛緩解後繼續走下去。我懷疑的老人下肢無力、痛苦和沉重,由於糖尿病患者下肢動脈閉塞。他立即被安排進一步檢查。踝部肱動脈壓指數(除上臂收縮壓<0.9外)為左足背動脈0.67、脛後動脈0.81、右足背動脈0.9、脛後動脈0.84。超聲檢查顯示雙下肢動脈血流緩慢、狹窄、斑塊。臨床診斷糖尿病下肢動脈閉塞。

過度活躍症特徵主要表現在注意力不足或過動症、情緒化等,AD/HD治疗就需要专门的ADHD藥物,例如多巴胺等,亦需專業訓練大腦執行能力,改善病情。

高先生,78歲,右側右腳潰瘍1個月。糖尿病有23年的曆史,已經用胰島素治療了5年。在過去的10年中,雙下肢出現了麻木和疼痛。近三年來,雙下肢肌肉疼痛,右邊很重,晚上疼痛。目前行走時間,雙下肢無力,右側更差。五年前發生了腦梗死。目前,胰島素注射治療,血糖控制良好。28年高先生50年吸煙、高血壓、冠心病(CHD) 20年。體檢:血壓156/72毫米汞柱。心率96/min。無膝關節反射和踝關節反射。左足背動脈、脛後動脈搏動性降低,右足背動脈和脛後動脈搏動消失。踝臂指數:0.86左足背動脈、脛後動脈0.90;0.36對0.50足背動脈、脛後動脈。腳部皮膚呈深紅色,右腳外側有潰瘍(見下圖)。血管造影顯示下肢彌漫性動脈硬化和右膝以下動脈硬化閉塞。左髂外動脈粥樣硬化斑塊形成。臨床診斷、糖尿病、糖尿病患者痛苦的神經病變,糖尿病足潰瘍、高血壓、冠心病、腦梗塞後遺症。

他們倆都有長期糖尿病、高血壓、冠心病和吸煙史。這次,他們因為下肢動脈阻塞和足部潰瘍住院。

糖尿病下肢動脈閉塞性病變和足部潰瘍是常見的問題。在西方國家,每年有30,000多名糖尿病患者由於下肢動脈閉塞性病變而不得不被截肢。在1年內的診斷糖尿病,5%的患者下肢動脈病變的症狀。經過12年的隨訪,該血管疾病的患病率上升到23%。隨機抽取北京市5所醫院治療1年以上、發病年齡≥40歲、病程≥5年的2型糖尿病患者393例。對下肢血管進行病史、體格檢查、生化檢查和多普勒超聲檢查。超聲檢查未發現下肢血管病變36例(9.2%)。下肢動脈病變總人數為90.8例,重度者占43.3%。

糖尿病下肢動脈疾病的風險因素與其他動脈粥樣硬化的風險因素,最重要的是年齡和性別。下肢動脈粥樣硬化在老年人和男性中更為常見,尤其是在長期吸煙的老年男性中。糖尿病是動脈硬化最重要的危險因素。吸煙與吸煙密切相關,戒煙能迅速降低間歇性跛行的風險。高血壓和血脂異常也與間歇性跛行增加有關。同時,纖維蛋白平台和血細胞壓積的增加也與外周動脈硬化有關。

同時存在多種危險因素,大大增加了下肢動脈病變的風險。吸煙、糖尿病和收縮期高血壓患者下肢動脈病變的相對危險度分別是吸煙、糖尿病和收縮期高血壓的2.3倍、3.3倍和6.3倍。在我國,三分之二的2型糖尿病患者與多個心血管危險因素,我們調查了4000例2型糖尿病患者,他們三個四分之一除糖尿病外,主要有兩個或兩個以上的血管病變的危險因素,如肥胖、高血壓、血脂紊亂等。

過度活躍症特徵主要表現在注意力不足或過動症、情緒化等,ADHD治疗就需要专门的ADHD藥物,例如多巴胺等,亦需專業訓練大腦執行能力,改善病情。

下肢動脈病變是全身動脈粥樣硬化的反映。90%的下肢動脈閉塞性病變患者在術前常規冠狀動脈造影中發現有一定程度的冠狀動脈硬化,28%的患者有嚴重的三支冠狀動脈病變。下肢動脈病患者的長期生存率明顯降低.55%的患者死於冠心病相關並發症,10%死於腦血管病,25%死於非血管平台。少於10%的患者死於下肢血管事件。甚至在無症狀動脈粥樣硬化患者,病死率遠遠超過人們沒有疾病。有症狀下肢動脈疾病患者的死亡率顯著升高,嚴重疾病患者的死亡率進一步升高。

本文調查了280例2型糖尿病患者,其中合並下肢動脈病變者占21.43%。年齡大、病程長、餐後血糖高、血脂異常多、血壓高、吸煙率高、冠心病發生率高。

下肢動脈病變的一個典型表現為下肢感覺異常酸麻、疼痛、發冷、肌肉,增加走路時。所謂典型的臨床表現是間歇性跛行。一般來說,患者步行100~200米後,由於下肢肌肉疼痛,不能繼續行走,但稍作休息後,疼痛會自發消失。腿部肌肉疼痛是下肢動脈病變最早也是最常見的臨床表現。對於輕度下肢缺血患者,步行後或劇烈運動後肌肉疼痛和麻醉也可提示下肢動脈病變。

隨著疾病的發展,嚴重的疼痛患者可以有一個休息,特別是在夜晚躺了下肢時更重要;也可以是由於位置變化症狀減輕。在疾病的晚期,超過三分之一的患者最終需要截肢以上的踝關節,由於血液供應不良,缺血性潰瘍和壞疽。這些患者的死亡率與休息期間的疼痛或組織損傷程度密切相關,稱為“嚴重肢體缺血”。

動脈粥樣硬化病的主要臨床表現因器官而異:短暫性缺血發作、缺血性卒中、心絞痛和心肌梗死。下肢和足部間歇性跛行,疼痛,潰瘍,甚至壞疽,而下肢休息。

下肢動脈疾病發病隱蔽,但診斷並不複雜,大多屬於非侵入性診斷。及時發現糖尿病患者下肢動脈病變,科學合理的介入治療,可避免患者病情惡化,降低截肢率,從而保證患者的生活質量。

脈搏觸診和踝臂指數測定是診斷糖尿病下肢動脈病變的基本方法。動脈搏動的觸診通常需要足背動脈、脛後動脈和膕動脈的觸診(見圖2)。疼痛的位置是動脈阻塞的重要組成部分。腓腸肌間歇性跛行通常由股淺動脈疾病引起。髖、股骨和臀部間歇性跛行常因主動脈和髂動脈狹窄引起。觸診可以判斷狹窄程度,確定狹窄部位。

過度活躍症特徵主要表現在注意力不足或過動症、情緒化等,ADHD治疗就需要专门的ADHD藥物,例如多巴胺等,亦需專業訓練大腦執行能力,改善病情。

采用多普勒法測定踝部肱動脈壓力指數,客觀地證實下肢動脈病變的存在,判斷病變程度。正常踝肱動脈壓指數大於1,指數在0.50 ~ 0.90,患者常常表現為間歇性跛行。在0.21 ~ 0.49之間,往往是下肢靜息痛,小於0.20往往需要截肢。間歇性跛行患者踝臂指數下降至0.50~0.90,休息時疼痛或組織丟失的患者踝臂指數下降至較低水平。糖尿病患者或腎功能衰竭患者可出現下肢動脈鈣化,使動脈不能收縮,假性延髓運動指數增加。足趾動脈壓力可以測量,因為腳趾動脈沒有鈣化。另一種無創性正逐漸應用在國內外是波的痕跡,下肢動脈正常動脈非常靈活,心髒收縮使血液加速前進,舒張早期會有血液回流,血管又向前回彈引起血流波形。動脈粥樣硬化和斑塊後,這種波形將發生變化。

超聲和經皮氧分壓測量也可用於評估周圍動脈阻塞的嚴重程度和預測適當的截肢水平在大多數患者。嚴重缺血或非創傷性異常應在血管造影上進行。核磁共振成像(mri)被用於診斷下肢動脈病變,比超聲診斷敏感性和特異性,接近標准血管造影術。

糖尿病患者,尤其是5年以上患病、吸煙、高血壓、血脂異常的男性患者,常發生下肢動脈閉塞性病變。雖然本病在臨床上不像心髒動脈和大腦動脈的狹窄或閉塞那樣危險,但其後果也是嚴重的。體重越輕,生活質量越差,嚴重時會導致足部潰瘍,甚至截肢。嚴重病變5年存活率顯著下降,應該引起醫生和患者的關注。如能及時檢查、早期發現和科學治療糖尿病合並下肢動脈疾病,效果良好。我們主張對下肢動脈疾病的危險因素進行篩查,這是一種簡單、經濟、可靠的下肢動脈疾病。最基本的方法是由經驗豐富的醫務人員檢查下肢動脈,特別是足背動脈、脛後動脈搏動和踝臂動脈壓力指數,這與一般的血壓測量方法相似。用多普勒個聽診法測量血壓。

只要發現及時,甚至嚴重的下肢動脈病變,有效的治療方法有很多,如血管的擴張和抗血小板藥物治療、介入治療、手術等。當然,嚴格控制高血糖、高血壓和維持血脂正常,戒煙是基本的治療方法。然而,如果診斷不及時,當糖尿病患者有嚴重的缺血性潰瘍被診斷為下肢動脈疾病時,治療效果會下降,醫療費用會顯著增加。因此,我們真誠地提醒廣大糖尿病患者,注意您的腳,您的下肢血管。

過度活躍症特徵主要表現在注意力不足或過動症、情緒化等,ADHD治療就需要专门的ADHD藥物,例如多巴胺等,亦需專業訓練大腦執行能力,改善病情。

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