ABC Strategy - Vinod Patel

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  • Overall, HIV/AIDS is the leading cause of death in adults aged 15–59. Ischaemic heart disease is the leading cause of death at older ages Note that 30% of deaths in developing countries occur in young adults – this vast premature adult mortality is a major public health concern
  • Chairman, ladies and gentlemen, this slide serves as a reminder of the many complications of diabetes. Diabetic retinopathy is the commonest cause of blindness in those of working age. The diabetic foot is the commonest cause of non-traumatic amputation. With regard to macrovascular disease, atherosclerosis accounts for most of the excessive mortality in diabetics, conferring a 2-4x increased risk of a heart attack.
  • Diabetes Prevention Program Finnish Diabetes Prevention Study 7% weight loss in the obese > 5% weight loss Avoid excess alcohol Fat intake < 30% of total calories Diet advice Saturated fat < 10% of total calories Smoking advice Fibre intake ≥ 15g per 1000 calories intake 150 mins of moderate exercise per week (mainly walking or cycling) Exercise > 4 hours per week    Other dietary measures: increased vegetables and fruits, decreased sugar, decreased salt
  • In the UKPDS, intensive treatment gave a mean HbA1c of 7.0% compared to and HbA1c of 7.9% in the conventional treatment group. This 0.9% difference was associated with a 25% reduction in diabetes-related deaths, a 7% reduction in all-cause mortality, and an 18% reduction in combined fatal and non-fatal myocardial infarction. UK Prospective Diabetes Study (UKPDS) Group. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with Type 2 diabetes (UKPDS 33). The Lancet 1998; 352 (Sept. 12): 837–853.
  • 3
  • Multi-factorial Interventions in Diabetes Care Most of the trials discussed above looked at the effect of a single intervention on CHD outcomes. Very few well constructed studies on multi-factorial intervention have been published to date. A seminal study in this regard was the Steno-2 study. (16. Steno 2) The Steno 2 Study has provided evidence of the cardiovascular benefits that can accrue multifactorial interventions in diabetes care. 160 patients with type 2 diabetes and microalbuminuria were randomised to receive conventional treatment in accordance to national Danish guidelines or to intensive treatment with stepwise implementation of behaviour modification and pharmacological treatment that targeted hyperglycaemia, hypertension, dyslipidaemia, microalbuminuria (treated with ACE-I or AT II -I) and secondary prevention of cardiovascular disease with aspirin. In this study the men age of the subjects was 55.1 years. Over the average 7.8 years of follow-up there were significant declines in HbA1c%, SBP, DBP, serum cholesterol and triglycerides and urine albumin excretion in comparison to the conventionally treated group. Patients receiving intensive treatment had a significantly lower risk of cardiovascular disease by 53%, nephropathy by 61%, retinopathy by 58% and autonomic neuropathy by 67%. There were 85 cardiovascular events in 35 subjects (44%) in the conventional therapy group but only 33 events in 19 subjects (24%) in the intensive therapy group (Table X). Cardiovascular EventConventional TherapyIntensive Multi-factorial Intervention Cardiovascular death77Myocardial infarction (non-fatal)175CABG Surgery105Percutaneous coronary interventions50Strokes (non-fatal)203Amputations147Peripheral Atherosclerotic Disease surgery 12685 events in 35 subjects (44%)33 events in 19 subjects (24%)P=0.002
  • Multi-factorial Interventions in Diabetes Care Most of the trials discussed above looked at the effect of a single intervention on CHD outcomes. Very few well constructed studies on multi-factorial intervention have been published to date. A seminal study in this regard was the Steno-2 study. (16. Steno 2) The Steno 2 Study has provided evidence of the cardiovascular benefits that can accrue multifactorial interventions in diabetes care. 160 patients with type 2 diabetes and microalbuminuria were randomised to receive conventional treatment in accordance to national Danish guidelines or to intensive treatment with stepwise implementation of behaviour modification and pharmacological treatment that targeted hyperglycaemia, hypertension, dyslipidaemia, microalbuminuria (treated with ACE-I or AT II -I) and secondary prevention of cardiovascular disease with aspirin. In this study the men age of the subjects was 55.1 years. Over the average 7.8 years of follow-up there were significant declines in HbA1c%, SBP, DBP, serum cholesterol and triglycerides and urine albumin excretion in comparison to the conventionally treated group. Patients receiving intensive treatment had a significantly lower risk of cardiovascular disease by 53%, nephropathy by 61%, retinopathy by 58% and autonomic neuropathy by 67%. There were 85 cardiovascular events in 35 subjects (44%) in the conventional therapy group but only 33 events in 19 subjects (24%) in the intensive therapy group (Table X). Cardiovascular EventConventional TherapyIntensive Multi-factorial Intervention Cardiovascular death77Myocardial infarction (non-fatal)175CABG Surgery105Percutaneous coronary interventions50Strokes (non-fatal)203Amputations147Peripheral Atherosclerotic Disease surgery 12685 events in 35 subjects (44%)33 events in 19 subjects (24%)P=0.002
  • Multi-factorial Interventions in Diabetes Care Most of the trials discussed above looked at the effect of a single intervention on CHD outcomes. Very few well constructed studies on multi-factorial intervention have been published to date. A seminal study in this regard was the Steno-2 study. (16. Steno 2) The Steno 2 Study has provided evidence of the cardiovascular benefits that can accrue multifactorial interventions in diabetes care. 160 patients with type 2 diabetes and microalbuminuria were randomised to receive conventional treatment in accordance to national Danish guidelines or to intensive treatment with stepwise implementation of behaviour modification and pharmacological treatment that targeted hyperglycaemia, hypertension, dyslipidaemia, microalbuminuria (treated with ACE-I or AT II -I) and secondary prevention of cardiovascular disease with aspirin. In this study the men age of the subjects was 55.1 years. Over the average 7.8 years of follow-up there were significant declines in HbA1c%, SBP, DBP, serum cholesterol and triglycerides and urine albumin excretion in comparison to the conventionally treated group. Patients receiving intensive treatment had a significantly lower risk of cardiovascular disease by 53%, nephropathy by 61%, retinopathy by 58% and autonomic neuropathy by 67%. There were 85 cardiovascular events in 35 subjects (44%) in the conventional therapy group but only 33 events in 19 subjects (24%) in the intensive therapy group (Table X). Cardiovascular EventConventional TherapyIntensive Multi-factorial Intervention Cardiovascular death77Myocardial infarction (non-fatal)175CABG Surgery105Percutaneous coronary interventions50Strokes (non-fatal)203Amputations147Peripheral Atherosclerotic Disease surgery 12685 events in 35 subjects (44%)33 events in 19 subjects (24%)P=0.002
  • ABC Strategy - Vinod Patel

    1. 1. CVD and Diabetes Care: The Alphabet Strategy   Vinod Patel BSc (Hons) MD FRCP MRCGP DRCOG Consultant Physician, Diabetes and Endocrinology Associate Professor in Clinical Skills University of Warwick Medical School
    2. 2. Leading causes of mortality Adults, 2002 5823 4692 2399 1398 929 754 735 606 496 478 HIV/AIDS Ischaemic heart disease Tuberculosis Road traffic accidents Cerebrovascular disease Self-inflicted injuries Violence Cirrhosis of the liver Lower respiratory infections Chronic obstruc. pulmonary disease 2279 1331 1037 811 783 672 475 382 352 343 Ischaemic heart disease Cerebrovascular disease Chronic obstruc. pulmonary disease Lower respiratory infections Trachea, bronchus, lung cancers Diabetes mellitus Hypertensive heart disease Stomach cancer Tuberculosis Colon and rectal cancers 15–59 60 and over World Health Report 2003 (thousands)
    3. 3. Diabetes Care: The Complications <ul><li>Retinopathy </li></ul><ul><li>Most common cause of blindness in people of working age </li></ul>Nephropathy 16% of all new patients needing renal replacement therapy Erectile dysfunction May affect up to 50% of men with long-standing diabetes Macrovascular disease 2–4 fold increased risk of coronary heart disease and stroke, 75% have hypertension Foot problems Commonest cause of non-traumatic amputation The Audit Commission. Testing Times. A Review of Diabetes Services in England and Wales, 2000.
    4. 4. Diabetes Chronic Disease Management Single Team Public Health & Prevention Primary Experts Secondary care Tertiary Secondary Primary Interface ……… ... Diagnosis ……… . General treatment ……… Review … .… Screening …… Healthy eating …… Exercise …… Weight care Palliative …………………… . …………………… Renal replacement ………………… .. Amputation ………………… . Rehabilitation ………………… PCI / CABG ……………… .. Advanced eye surgery ……………… DKA …………… .. Infections ………… ..... CVD ………… ... CVD Risk ………… ... Insulin start ………… .. Screening eyes ………… . Screening feet ………… . Screening renal …… .…... Complex cases
    5. 5. A POETIC vision of Healthcare <ul><li>P: </li></ul><ul><ul><li>Patient-centred, Patient Safe, Public Health-Driven </li></ul></ul><ul><li>O: </li></ul><ul><ul><li>Objective-clear, what is it that we desire to achieve and why </li></ul></ul><ul><li>E: </li></ul><ul><ul><li>Evidence-based, audit-informed, research will be desirable </li></ul></ul><ul><li>T: </li></ul><ul><ul><li>Team orientated, multidisciplinary, well-trained, validated </li></ul></ul><ul><li>I: </li></ul><ul><ul><li>Integrated, primary, secondary care, schools, community, councils </li></ul></ul><ul><li>C: </li></ul><ul><ul><li>Cost-effective, cost efficient, but clinically governed </li></ul></ul>
    6. 6. Need a Swiss Army Knife Approach!
    7. 7. Alphabet Strategy: QoF Standards <ul><li>Advice: </li></ul><ul><ul><li>exercise, diet, not smoking, regular testing & clinics </li></ul></ul><ul><li>Blood Pressure: </li></ul><ul><ul><li>aim less than 140/80 </li></ul></ul><ul><li>Cholesterol: Creatinine Care </li></ul><ul><ul><li>less than 5 </li></ul></ul><ul><li>Diabetes Control: </li></ul><ul><ul><li>HbA1c% less than 7.5% </li></ul></ul><ul><li>Eyes: </li></ul><ul><ul><li>check yearly at least </li></ul></ul><ul><li>Feet: </li></ul><ul><ul><li>check yearly at least </li></ul></ul><ul><li>Guardian Drugs: </li></ul><ul><ul><li>Aspirin 75mg </li></ul></ul><ul><ul><li>ACE inhibitors, ARBs </li></ul></ul>
    8. 8. Lifestyle changes reducing progression to DM Other measures: increased veg/and fruits, less sugar/salt Exercise > 4 hours per week 150 mins of moderate exercise per week Fibre intake ≥ 15g per 1000 calories intake Smoking advice Saturated fat < 10% of total calories Diet advice Fat intake < 30% of total calories Avoid excess alcohol > 5% weight loss 7% weight loss in the obese Finnish Diabetes Prevention Study Diabetes Prevention Program
    9. 9. Blood Pressure UKPDS 38: 154/87 versus 144/82 UK Prospective Diabetes Study (UKPDS) Group (38). BMJ 1998;317:703–713 -24 Significant -34 Significant -21 Non significant -44 Significant -56 Significant -37 Significant -35 Significant Deaths reduced by 32% MI Microvascular endpoint –34% Heart failure –35% Stroke –37% All macrovascular endpoints –44% Retinal photocoagulation –56% Any diabetes-related endpoint –24% 0 -10 -20 -30 -40 -50 % Reduction in risk
    10. 10. <ul><li>Primary Prevention Diabetes patients with one other risk factor (hypertension, smoker, micro-albuminuria, retinopathy) </li></ul>Cholesterol CARDS Study Placebo Atorvastatin 10mg Placebo 2838 patients
    11. 11. CARDS Study: Treatment Effect s * N (% randomised) .2 .4 .6 .8 1 1.2 Favours Atorvastatin Favours Placebo ** Fatal MI , Other acute CHD death , n on fatal MI , U nstable angina , CABG , F atal stroke , n on fatal stroke 21 (1.5%) 24 (1.7%) 51 (3.6%) 83 (5.8%) Atorva* 48% (11- 69) 39 (2.8%) Stroke 31% (-16- 59) 34 (2.4%) Coronary revascularisation 36% (9- 55) 77 (5.5%) Acute coronary events 37% (17- 52) p=0.001 127 (9.0%) Primary endpoint ** Hazard Ratio Risk Reduction (CI) Placebo* Event
    12. 12. Diabetes Control UKPDS 33: HbA1c% 7.9% versus 7.0% Intensively-treated patients: HbA 1C = 7.0% Conventionally-treated patients: HbA 1C = 7.9% This 0.9% decrease is associated with reduction in risk for: MI: 16% p=0.052 Retinopathy: -21% Cataract extraction: -24% Microvascular endpoint: -25% Albuminuria at 12 years: -34% Any diabetes-related endpoint: -12% Significant Significant Borderline significance Borderline significance Significant Significant -12 -25 -16 -21 -34 -24 0 -10 -20 -30 -40 -50 % Reduction in risk
    13. 13. Risk of diabetes complications The risk of diabetes complication based on the UKPDS Study. From Mogensten C-E . Diabetic nephropathy:evidence for renoprotection and practice. Heart 2000; 84(suppl): i26 -28 . Reproduced with permission from the BMJ Publishing Group.
    14. 14. E is for .... E ye screening <ul><li>Diabetic Maculopathy : Commonest cause of blindness in UK under 65 </li></ul><ul><li>Haemorrhages and/or hard exudates within one disc diameter of the macula, with or without visual loss </li></ul><ul><li>Treatment : clinical risk factors (BP, Glycaemia, cholesterol) and focal laser photocoagulation </li></ul>
    15. 15. F is for ... <ul><li>FOOT SCREENING </li></ul>
    16. 16. G uardian Drugs <ul><li>Aspirin 75mg od: </li></ul><ul><li>JBS 2 (2005) advocates considering aspirin 75mg od against CVD events in: </li></ul><ul><ul><li>Any established atherosclerotic disease </li></ul></ul><ul><ul><li>≥ 50 years, or those younger but have had diabetes for 10 years, or hypertenisve </li></ul></ul><ul><ul><li>Retinopathy or nephropathy </li></ul></ul><ul><ul><li>Once BP <150/90 </li></ul></ul>
    17. 17. <ul><li>ACE-inhibitors and Angiotensin-II Receptor Antagonists have a special role in preventing diabetes complications (MICRO-HOPE , LIFE ) </li></ul><ul><li>ACE-inhibitors and Angiotensin-II Receptor Antagonists may have a special role in preventing diabetes </li></ul><ul><li>Statins are guardian drugs </li></ul>G uardian Drugs
    18. 18. RENAAL Primary Components ESRD ESRD or Death Doubling of Serum Creatinine Months % with event 0 12 24 36 48 0 10 20 30 40 50 751 714 625 375 69 762 715 610 347 42 Months 751 692 583 329 52 762 689 554 295 36 P (+ CT) L (+ CT) Months % with event 0 12 24 36 48 0 10 20 30 P L p=0.010 Risk Reduction: 20% 751 714 625 375 69 762 715 610 347 42 P (+ CT) L (+ CT) % with event p=0.006 Risk Reduction: 25% 0 12 24 36 48 0 10 20 30 P L p=0.002 Risk Reduction: 28% P L P (+ CT) L (+ CT)
    19. 19. B.Dahlof (Co-chair), P.Sever (Co-chair), N. Poulter (Secretary) H. Wedel (Statistician), G. Beevers, M. Caulfield, R. Collins S. Kjeldsen , A. Kristinsson , J. Mehlsen, G. McInnes, M. Nieminen E. O’Brien , J. Östergren , on behalf of the ASCOT Investigators A randomised controlled trial of the prevention of CHD and other vascular events by BP and cholesterol lowering in a factorial study design
    20. 20. Study design atenolol ± bendroflumethiazide amlodipine ± perindopril 19,257 hypertensive patients PROBE design ASCOT-BPLA Investigator-led, multinational randomised controlled trial placebo atorvastatin 10 mg Double-blind ASCOT-LLA 10,305 patients TC ≤ 6.5 mmol/L (250 mg/dL)
    21. 21. Treatment algorithm to BP targets < 140/90 mm Hg or < 130/80 mm Hg in patients with diabetes amlodipine 5-10 mg atenolol 50-100 mg perindopril 4-8 mg bendroflumethiazide-K 1.25-2.5 mg doxazosin GITS 4-8 mg add add add additional drugs, eg, moxonidine/spironolactone add
    22. 22. ASCOT patient population risk factor profile All patients in ASCOT have hypertension plus ≥ 3 risk factors for CHD Patients with risk factor (%) 0 10 20 30 40 50 60 70 80 90 100 Hypertension Age ≥ 55 years Male Microalbuminuria/proteinuria Smoker Family history of CHD Plasma TC:HDL-C ≥ 6 Type 2 diabetes Certain ECG abnormalities LVH Previous cerebrovascular events Peripheral vascular disease 84 77 61 30 27 24 24 14 13 11 6 100
    23. 23. Systolic and diastolic blood pressure mm Hg 60 80 100 120 140 160 180 Time (years) Baseline 0.5 1 1.5 2 2.5 3 3.5 4 4.5 5 5.5 atenolol  thiazide amlodipine  perindopril 137.7 136.1 79.2 77.4 Mean difference 1.9 Last visit Mean difference 2.7 SBP DBP 163.9 164.1 94.8 94.5
    24. 24. Fatal and non-fatal stroke Number at risk Amlodipine  perindopril 9639 9483 9331 9156 8972 7863 Atenolol  thiazide 9618 9461 9274 9059 8843 7720 0.0 1.0 2.0 3.0 4.0 5.0 Years 0.0 1.0 2.0 3.0 4.0 5.0 Amlodipine  perindopril (No. of events 327) Atenolol  thiazide (No. of events 422) HR = 0.77 (0.66­0.89) p = 0.0003 %
    25. 25. CV mortality Number at risk Amlodipine  perindopril 9639 9544 9441 9322 9167 8078 Atenolol  thiazide 9618 9532 9415 9261 9085 7975 0.0 1.0 2.0 3.0 4.0 5.0 Years 0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 Amlodipine  perindopril (No. of events 263) Atenolol  thiazide (No. of events 342) HR = 0.76 (0.65­0.90) p = 0.0010 %
    26. 26. ASCOT: BPLA and LLA combined: Insight into optimal CV prevention Rates / 1000 patient years 44% 48% Relative risk reduction 8.2 4.6 Fatal and non-fatal stroke 9.2 4.8 Fatal MI and non-fatal CHD Atenolol  thiazide + placebo Amlodipine  perindopril + statin Endpoint
    27. 27. Doing all this polypharmacy w ill poison our patients ! Blood pressure, Cholesterol, Diabetes control, ACE-I, Aspirin!
    28. 28. The Steno-2 Study : A Summary Steno Diabetes Centre Copenhagen, Denmark <ul><li>160 with T2D and microalbuminuria </li></ul><ul><li>80 allocated to conventional treatment </li></ul><ul><li>80 allocated to intensive treatment </li></ul><ul><li>Mean age 55.1 years </li></ul><ul><li>Mean follow-up 7.8 years </li></ul>
    29. 29. Steno-2 T argets Annually Annually F eet All most Statins Most All G uardians : aspirin , ACEI / AIIA Annually Annually E yes 7.0 % GMS Audit 7.5% 6.5 % D iabetes Control : Hb A 1 c % 4.0 GMS Audit 5 4.5 C holesterol 140 / 80 Optimal 130/80 GMS Audit 145/80 130 / 80 Earlier 140 / 85 B lood Pressure Standard Standard A dvice JBS/Alphabet Guidelines Steno-2 intensive cohort %
    30. 30. Steno 2: Event Reduction 53 % 61% 58% 67% 0 10 20 30 40 50 60 70 cardiovascular disease nephropathy retinopathy autonomic neuropathy Number of events
    31. 31. Steno-2 : CVD Event Reduction 33 events in 19 patients 24% overall 85 events in 35 patients 44% overall P<0.002 6 12 Revascularisation for PVD 7 14 Amputations 3 20 Stroke : non-fatal 0 5 PCI 5 10 CABG 5 17 MI : non-fatal 7 7 …died earlier! Cardiovascular Death Intensive Conventional Event
    32. 32. Steno-2 : CVD Deaths at 13 years Reduced by 57%! P<0.05 Cardiovascular Deaths Intensive Conventional Event
    33. 33. Steno-2 : 13 years follow up data P<0.05 55% Retinal Laser Rx 1 versus 6 patients End Stage Renal Failure 59% Cardiovascular events 57% Cardiovascular Deaths 46% All Deaths Reduction in Intensive Group Event
    34. 34. Steno-2 : Conclusion “ A target driven, long-term, intensified intervention aimed at multiple risk factors in patients with type 2 diabetes and microalbuminuria reduces the risk of cardiovascular and microvascular events by about 50%.”
    35. 40. Diabetes Passport
    36. 45. Diabetes Polypill? X? Y? Z? A? B? BMJ Polypill Paper
    37. 46. SAMTA Pill S tatin A spirin M etformin T hiazide A CE-I or ARB Diabetes Polypill Approach? Indo-linguistically: “equality” ie in terms of reducing morbidity and mortality esp. CVD
    38. 47. Single approach Guardian Drugs Functional management ESCRD Care ECG , US, ?CT Diabetes control Cholesterol Creatinine Blood Pressure Advice Renal Guardian Drugs Functional disability management ECG and other Investigation Diabetes control Cholesterol Creatinine Blood Pressure Advice Stroke Guardian Drugs Functional status and follow up ECG / ETT / Echocardiography Diabetes control Cholesterol Creatinine Blood Pressure Advice CHD Guardian Drugs Feet Eyes Diabetes control Cholesterol Creatinine Blood Pressure Advice Diabetes G E F D C B A
    39. 48. Alphabet Strategy: QoF Standards <ul><li>Advice: </li></ul><ul><ul><li>exercise, diet, not smoking, regular testing & clinics </li></ul></ul><ul><li>Blood Pressure: </li></ul><ul><ul><li>aim less than 140/80 </li></ul></ul><ul><li>Cholesterol: Creatinine Care </li></ul><ul><ul><li>less than 5 </li></ul></ul><ul><li>Diabetes Control: </li></ul><ul><ul><li>HbA1c% less than 7.5% </li></ul></ul><ul><li>Eyes: </li></ul><ul><ul><li>check yearly at least </li></ul></ul><ul><li>Feet: </li></ul><ul><ul><li>check yearly at least </li></ul></ul><ul><li>Guardian Drugs: </li></ul><ul><ul><li>Aspirin 75mg </li></ul></ul><ul><ul><li>ACE inhibitors, ARBs </li></ul></ul>

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