<International Circulation>: The 2013 ESH EASD has issued a guideline on diabetes， pre-diabetes， and CVD.  We already have separate guidelines both on diabetes and also on various cardiovascular conditions.  So what are the purposes to release these joint statements?

　　Lars Ryden: The guideline were written by people from the European Association of the Study of Diabetes and from the European Society of Cardiology which means that we brought together people from two different medical specialties. Previous guidelines do not focus on specific problems with people with diabetes. In guidelines on coronary interventions you will find much more detailed information on the intervention. But in the diabetes guidelines you will find information on which patients with diabetes in need of revascularization， and if you have diabetes there are special things you need to have in mind when you choose the type of revascularization.  So in principle， the guidelines try to bring up questions that are unique to this population and then give indications on how you can manage， how you can diagnose， and how you can assess risk in the light of the presence of diabetes or pre-diabetes.  In some aspects， for instance， glycemic control and diagnostics， they are quite detailed. In other respects you can find more detailed information in the guidelines that you mentioned that are around as well.

　　<International Circulation>:  What contents in the guidelines do you want to emphasis?  What do you think is the most important?

　　Lars Ryden: This is the second guidelines of its kind. The first one was written and published in 2007.  Let’s talk about the new and updated information that made us to change and let’s start with diagnostics.  It is simplified.  We recommend starting with the use of glycated hemoglobin.  If  you have a negative result， i.e. if you have a normal value less than 6.5%， you have to proceed with a glucose tolerance test but if HbA1c is high you have the diagnosis of diabetes directly.  In a general population you can start with a simple questionnaire on risk for diabetes.  If you have a high score， you measure HbA1c and if this is OK you do not need to perform an oral glucose tolerance test.  This test is now only recommended for people at very high risk.  This is one aspect. Another aspect is risk stratification.  In the former guidelines we said that there are risk engines combining different variables to a score that express the risk level in an individual person. In the new guidelines we just say that people with cardiovascular disease and diabetes are at very high risk， and people with diabetes without any manifestation of cardiovascular disease are at high risk. The reason is that available risk engines do not really fit well.  They are old and partly done on different populations than the one we see today.

　　The part on coronary interventions is also updated considerably because some major trials， such as BARI 2D and the FREEDOM， have recently been published. The results of these tells us that first of all， if you have a not too complicated coronary artery disease and angina pectoris， you should optimize the medical treatment.  More than half patients do not need a coronary intervention if this is done properly.  Secondly， if you have a more threatening coronary artery disease and multi-vessel disease， or complex lesions， then coronary by pass surgery (CABG) is to be preferred because longevity after CABG is better than after PCI.  And finally， in the group in between with the remaining symptoms of angina and not too complex lesions you may use PCI but then always with drug eluting stents.  You can use the so called SYNTAX score to evaluate whether the coronary lesions are complex or not and a score above 22 indicates that this is the case. Another thing about coronary interventions is also that you do not need to stop metformin before a coronary angiography.  You should follow kidney function in the nearest days and if it is compromised you can stop the drug， but frequently， you will never have to do anything and just continue with that treatment.

　　<International Circulation>:  In regards to the medical therapy， there is for example for the lipid target， there is a difference between your lipid target and the European dyslipidemia management guidelines.

　　Lars Ryden: No actually not.  We already in the previous guidelines recommend the LDL target in people with diabetes with high cardiovascular risk to be less than 1.8 mmol/L.  This is left unchanged because we were by then， one of the very first groups that suggested that we should go below 1.8 mmol/L. We also recommend that you should lower cholesterol even if you are at 2 mmol/L.  I do not think there is much of a difference.

　　<International Circulation>:  In that guideline actually they put all diabetes as very high risk， but in your guidelines for diabetes patients， some are very high， and some are high.

　　Lars Ryden: That is true， if we have patients without coronary artery disease and any other vascular engagement then the LDL-target is set somewhat higher in our guidelines.

　　<International Circulation>:  So how do you explain this discrepancy?

　　Lars Ryden: We looked through available evidence. Even specialists can interpret information differently.  Blood pressure is another interesting issue. We have increased the target to 140/85 from the pervious recommendation of 130/80.  During the last few years evidence has emerged that a too low blood pressure in some patients may actually cause harm rather than benefit. We also know that it is very difficult to get the blood pressure down to below 130 systolic. We hope people will be more prone to adhere to the recommendation of 140/85. If people do that it could be a great benefit for the patients.

　　<International Circulation>:  So what should doctors do to effectively reduce cardiac risk in pre-diabetic patients?

　　Lars Ryden: You have a perfect Chinese example of that in the DA QING study which has been on going for 20 years. They report continued benefits with patients who have IGT and who not develop diabetes by means of lifestyle adjustments including weight loss and physical activity.  In very recent publications the group behind this study released very interesting data on complications noting that serious eye disease was considerably less among people in the lifestyle arm. In additrio0n there are some indication that cardiovascular manifestations like myocardial infarctions may be reduced in people that has been subjected to guideline recommended lifestyle interventions.  So this is the way you should tackle them – lifestyle is the essence.  Otherwise， in people with diabetes or glucose problems， it is very important to understand that it is not only one thing that has to be taken into account. First of all the platform is lifestyle adjustments， then blood pressure， glycemia， platelet stabilization and lipid lowering.  Everything should be taken care of at the same time.

　　<International Circulation>:  Yes but it is so difficult to do lifestyle changes， and you mentioned it should be a systematic way to do the lifestyle change.

　　Lars Ryden: That is why we have added a new chapter on ‘Patient Centered Care’ underlining that patient empowerment and self monitoring， for example， are mandatory for successful managing.  We also have to handle within treatment teams trained in such issues.  The patients should take their own responsibilities in their own hands but get all support they need to be able to accomplish this. I am truly happy with this new and important chapter.

　　<International Circulation>:  Maybe we need another nurse to help.

　　Lars Ryden: Physicians  may know about and aim at recommended life style adjustments. But to get the patients to comply -- smoking cessation， physical activity， eating better –- you need someone who gives structured advice and such advice has been very successfully implemented by nurses in care teams but not only nurses. A team also needs dieticians and physiotherapists and other people as well.

　　<International Circulation>:  What are the general principles to treat diabetic patients with coronary disease?

　　Lars Ryden: It is actually to detect if they have or have not glucose problems. If they have， then you must take that into account by looking at the guidelines and their treatment targets and adhere to them as much as possible.

        Lars Ryden教授  指南联合主席

　　ESC与EASD发布联合指南的目的

　　2013 ESC/EASD糖尿病、糖尿病前期和心血管疾病指南由来自EASD及ESC的专家共同编写，凝聚两个领域医学专家的智慧与经验，是两个领域的合作。以往指南没有针对糖尿病患者的特殊问题进行重点关注；冠状动脉介入治疗指南更多关注介入治疗的细节。糖尿病指南论述哪些患者需要进行血运重建以及糖尿病患者在选择血运重建类型时的注意事项。原则上讲，EASD/ESC联合指南尝试解决糖尿病人群的独特问题，为糖尿病及糖尿病前期患者的管理、诊断及风险评估提供具体指导。

　　联合指南的重点内容

　　第一版指南于2007年编写和发布，2013年新指南的更新有：①诊断流程被简化。我们推荐起始就应用糖化血红蛋白（HbA1c）进行诊断。如果结果为阴性（HbA1c<6.5%），需进行糖耐量试验；但如果HbA1c升高，则可直接确诊糖尿病。对一般人群，可以选用简单的量表评估糖尿病的发生风险。如果评分较高，需测定HbA1c。测定的HbA1c若在正常范围，则无需进行口服葡萄糖耐量试验。后者目前仅被推荐用于高危人群筛查。②危险分层。旧指南联合应用多种变量进行风险评分，评估不同个体的风险水平。新指南则强调：伴有心血管疾病及糖尿病的患者属于极高危，伴有糖尿病但无心血管疾病表现者为高危。这项更新的原因是原有评分系统本身并不胜任评价风险，并且已经过时，不适用于当今的患者群体。③经皮冠状动脉介入治疗（PCI）的更新基于近期发表的一些大型试验如BARI 2D试验及FREEDOM研究的结果。这些试验结果提示：首先，对不太复杂的冠状动脉疾病和心绞痛患者，应优化药物治疗。如果能正确实施优化药物治疗，超过一半的患者无需PCI。其次，对威胁生命的冠状动脉疾病和多支血管病变或复杂病变，应选择冠状动脉旁路移植术（CABG）。与PCI相比，CABG可延长患者预期寿命。最后，仍有心绞痛症状但病变不复杂者通常可选用药物洗脱支架行PCI治疗。SYNTAX评分可评估冠状动脉病变复杂与否，如果超过22分，则提示病变较为复杂。指南还明确指出，冠状动脉造影前无需停用二甲双胍，只需在手术前几天监测肾功能，如果有肾功能受损，则停用二甲双胍，其余情况下可以持续应用。

　　联合指南的血脂和血压目标值

　　存在心血管高危风险的糖尿病患者低密度脂蛋白胆固醇（LDL-C）目标应<1.8 mmol/L，我们是率先提出这样控制目标的学术组织之一。如果患者不伴有冠状动脉疾病及其他血管疾病，其LDL-C控制目标可以适当放宽一些。这是我们对现有证据进行回顾后作出的推荐。血压控制目标由之前的130/80 mm Hg提高到140/85 mm Hg。过去几年间的证据表明，在某些患者中将血压降得过低实际上不仅不能为其带来获益反而对其有害。另外，在临床实践中达到收缩压130 mm Hg以下的目标非常困难，而140/85 mm Hg的降压目标推荐值更易于实现和坚持。将血压控制在140/85 mm Hg以内能为患者带来极大获益。

　　降低糖尿病前期患者心血管风险

　　中国已开展20年的大庆研究是一个非常好的例子。其结果显示，包括减重及体力活动在内的生活方式干预能为糖耐量受损（IGT）患者带来持续获益，延缓糖尿病发生。大庆研究的研究者近期发表数据显示，生活方式干预组的严重眼病显著减少。此外，有迹象表明指南推荐的生活方式干预还能减少心肌梗死等心血管事件。降低糖尿病前期患者心血管风险需综合干预，其中生活方式干预是根本所在，降糖、降压、稳定血小板和调脂应同时进行。

　　以患者为中心的管理

　　新指南添加了“以患者为中心的管理”这一章节。充分尊重患者，强调患者的自我监督是成功管理的必要条件。我们也就此举行专门的治疗团队培训。患者应该承担自己的责任，同时应得到全面支持以实现自我管理。我非常高兴指南中能加入这一新的重要章节。

　　医生可能也知道推荐患者进行生活方式方面的调整。但要想让患者遵医嘱戒烟、增加体力活动、健康饮食，则需其他人来给予更具体的结构化建议。在治疗团队中，护士可成功地完成上述任务，但这项任务并不仅限于护士来执行。一个团队还需要有营养师及理疗师及其他人的共同参与。

                                                                                                                                           （编辑：孙里娜）