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中华老年病研究电子杂志

中华老年病研究电子杂志 ›› 2023, Vol. 10 ›› Issue (04) : 1 -17. doi: 10.3877/cma.j.issn.2095-8757.2023.04.001

指南与共识

老年人心脑血管病和糖尿病共病管理中国专家共识
史凯蕾1, 翁婷雯1, 郑松柏1,†(), 陈旭娇2,†(), 刘幼硕3,†(), 中华医学会老年医学分会   
  1. 1. 200040　上海，复旦大学附属华东医院老年医学科
    2. 310013　杭州，浙江医院老年医学科
    3. 410011　长沙，中南大学湘雅医院老年医学科
  • 收稿日期:2023-10-11 出版日期:2023-11-28
  • 通信作者: 郑松柏, 陈旭娇, 刘幼硕
  • 基金资助:
    国家重点研发计划项目(2020YFC2009000、2020YFC2009001); 上海市级医院老年医学科临床能力促进与提升专科联盟项目(SHDC22023302); 复旦大学附属华东医院老年冠心病诊疗中心建设项目(LCZX2205)

Chinese expert consensus on the management of cardio-cerebrovascular disease and diabetes mutimorbidity in the elderly

Kailei Shi, Tingwen Weng, Songbai Zheng†()   

  • Received:2023-10-11 Published:2023-11-28
  • Corresponding author: Songbai Zheng
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史凯蕾, 翁婷雯, 郑松柏, 陈旭娇, 刘幼硕, 中华医学会老年医学分会. 老年人心脑血管病和糖尿病共病管理中国专家共识[J]. 中华老年病研究电子杂志, 2023, 10(04): 1-17.

Kailei Shi, Tingwen Weng, Songbai Zheng. Chinese expert consensus on the management of cardio-cerebrovascular disease and diabetes mutimorbidity in the elderly[J]. Chinese Journal of Geriatrics Research(Electronic Edition), 2023, 10(04): 1-17.

高血压病、冠心病、脑梗死、脑出血及糖尿病是一组最常见、最重要的慢性病，也是我国居民的主要死因。据统计，2019年我国居民心脏病和脑血管病的死亡率分别为148.51/10万和129.41/10万，占总死亡人数的23.65%和20.61%，心脑血管病合计占总死亡人数的43.81%[1]，严重威胁着我国居民的身体健康。糖尿病是心脑血管病的等危症，罹患糖尿病可使心脑血管病患病率和死亡率升高。由于心脑血管病和糖尿病这组共病存在共同的危险因素和病理生理基础[2,3,4]，在临床上常同时存在，进行整合和综合管理有其合理性和必要性。因此，控制该组共病的重要举措就是对其实施有效的慢病综合管理。

表1 不同身体活动水平的成年人糖尿病患者每日能量供给量[kJ（kcal）/kg（标准体重）][33]
身体活动水平 体重过低 正常体重 超重或肥胖
重（如搬运工） 188～209（45～50） 167（40） 146（35）
中（如电工安装） 167（40） 125～146（30～35） 125（30）
轻（如坐式工作） 146（35） 104～125（25～30） 84～104（20～25）
休息状态（如卧床） 104～125（25～30） 84～104（20～25） 62～84（15～20）
表2 ASCVD危险分层及治疗目标
危险分层 临床表现 目标值
超高危 年龄在60~75岁，ASCVD并存以下情况之一：复发的ASCVD事件、冠状动脉多支血管病变、近期ACS、心脑或外周多血管床动脉粥样硬化性血管疾病、LDL-C≥4.9 mmol/L（190 mg/dL）、糖尿病 LDL-C<1.4 mmol/L或基线降幅>50%；非HDL-C<2.2 mmol/L
极高危 患有以下任何一种疾病且不符合超高危分层：临床或影像学诊断明确的ASCVD、糖尿病合并高血压、糖尿病且LDL≥3.4 mmol/L LDL-C<1.8 mmol/L或基线降幅>50%；非HDL-C<2.6 mmol/L
表3 老年T2DM患者血糖控制标准及目标
项目 良好控制标准 中间过渡阶段 可接受标准
HbA1c（%） ≤7.0 7.0～8.0 8.0～8.5
FPG（mmol/L） 4.4～7.0 5.0～7.5 5.0～8.5
2 h PG（mmol/L） <10.0 <11.1 <13.9
治疗目标 预防并发症发生 减缓并发症进展 避免高血糖的急性损害
适用条件 适用于新诊断、病程短、低血糖风险低，应用非胰岛素促泌剂类降糖药物治疗为主、自理能力好或有良好辅助生活条件的老年糖尿病患者 适用于预期生存期>5年、中等程度并发症及伴发疾病，有低血糖风险，应用胰岛素促泌剂类降糖药物或以多次胰岛素注射治疗为主、自我管理能力欠佳的老年糖尿病患者。希望在治疗调整中转向良好控制 适用于预期寿命<5年、伴有影响寿命的疾病、从严格控制血糖获益有限、有严重低血糖发生史、反复合并感染、急性心脑血管病变、急性病入院治疗期间、完全丧失自我管理能力、缺少良好护理的患者。需避免高血糖造成的直接损害
表4 脑卒中合并冠心病运动康复危险分层
临床表现 低危 中危 高危
运动或恢复期症状及心电图改变 运动（≥7 METs）或恢复期无心绞痛症状或心电图缺血改变 中度运动（5.0～6.9 METs）或恢复期出现心绞痛症状或心肌缺血改变 低水平运动（<5.0 METs）或恢复期出现心绞痛症状或心肌缺血改变
心律失常 无休息或运动引起的复杂心律失常 休息或运动时未出现复杂室性心律失常 休息或运动时出现复杂室性心律失常
心理障碍（抑郁、焦虑等） 无心理障碍 无严重心理障碍 严重心理障碍
峰值摄氧量（mL·min-1·kg-1） ≥20 15～19 <15
无氧阈值（mL·min-1·kg-1） ≥15 12～14 <12
心肌钙蛋白浓度 正常 正常 升高
卒中分期 恢复期（1个月以上） 稳定期（第3～4周） 急性期（第1～2周）
Brunnstrom下肢功能分期 >5期 4～5期 ≤3期
言语交流障碍 无或轻度言语交流障碍 中度言语交流障碍 重度言语交流障碍
精神和认知功能障碍 无精神和认知功能障碍 无精神和认知功能障碍 轻度和可控的精神和认知功能障碍
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