Cardiovascular Risk in Diabetes

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Cardiovascular Risk in Diabetes

  1. 1. Cardiovascular Risk and Diabetes<br />DR. S. ASWINI KUMAR. MD<br />Professor of Medicine<br />Medical College Hospital<br />Thiruvananthapuram<br />1<br />
  2. 2. New definition for Diabetes<br />Type 2 diabetes is a condition of premature cardiovascular complications in the setting of chronic hyperglycaemia<br />2<br />
  3. 3. Cardiometabolic Risk<br />A patient with diabetes<br />Normal person with MI<br />3<br />Consider yourself having a heart attack already, when you develop diabetes<br />
  4. 4. Diabetes as a new risk factor for cardiovascular mortality<br />4<br />Diabetes<br />
  5. 5. Framingham Heart Study 30-Year Follow-Up:CVD Events in Patients With Diabetes (Ages 35-64)<br />10<br />10<br />9<br />Men<br />Women<br />8<br />11<br />Risk<br />ratio<br />6<br />30<br />19<br />4<br />9<br />6<br />38<br />20<br />3*<br />2<br />0<br />Total Cardiac and vascular events<br />Coronary Heart Disease<br />Cardiac Failure<br />Stroke<br />Intermittent Claudication<br />Age-adjusted annual rate/1,000<br />P&lt;0.001 for all values except *P&lt;0.05.<br />Wilson PWF, Kannel WB. In: Hyperglycemia, Diabetes and Vascular Disease.<br />Ruderman N et al, eds. Oxford; 1992.<br />5<br />
  6. 6. Coronary Heart Disease - Mortality<br />Male<br />60<br />50<br />40<br />30<br />20<br />10<br /> 0<br />With Diabetes*<br />Female<br />Without Diabetes<br />CHD Mortality/1,000<br />Male<br />Female<br /> 0-3 4-7 8-11 12-15 16-19 20-23 <br />Duration of Follow-up (yrs)<br />* Diagnosed between 35 and 65 years of age<br />Am J Med 90(2A): 56S-61S,1991<br />6<br />
  7. 7. What if a diabetic had a coronary event?<br />7<br />Coronary Events<br />Multivessel disease<br />Complications<br />PC Interventions<br />Diabetic ketosis<br />Bypass surgery<br />
  8. 8. Natural History of Type2 Diabetes<br />8<br />
  9. 9. The continuum of Cardiovascular Risk in Diabetes<br />9<br />
  10. 10. Diabetes and Cardiovascular risk<br />Endothelialdysfunction<br />Dyslipidemia<br />Total-C <br />LDL-C <br />Triglycerides <br />Apo-B <br />HDL-C <br />AdvancedGlycationProducts<br />Type 2Diabetes<br />ProthrombosisFibrinogen <br />PAI-1 <br />Hypertension<br />10<br />
  11. 11. Diabetes and Endothelial Dysfunction<br />11<br />
  12. 12. Relationship between obesity, insulin resistance and dyslipidemia<br />12<br />
  13. 13. Diabetic vascular pathology<br />13<br />
  14. 14. Common pathways of diabetic complications<br />14<br />Glucose<br />Peripheral & Autonomic Neuropathy<br />Polyol<br /> Pathway<br />Hexosamine<br />Pathway<br />AGE Formation<br />Nephropathy<br />Oxidative<br />Stress<br />Cellular<br />Dysfunction<br />ROS<br />Vascular Damage<br />Coronary Artery Disease<br />Cell<br />Damage<br />Different complications (eye, kidney, nerve, blood vessels) arise from limited number of triggers perturbing a limited number of metabolic pathway(s)(Brownlee, 2001)<br />Retinopathy<br />
  15. 15. Cardiovascular risk factors specific for diabetes<br />15<br />Microalbuminuria<br />Massive proteinuria<br />Abn. Platelet function<br />Microalbuminuria<br />Fibrinogen levels<br />Serum insulin<br />PAI-1<br />
  16. 16. Accelerated CAD progression in Diabetes - Summary<br />16<br />
  17. 17. Can you prevent the premature Cardiovascular Events in Diabetes?<br />Optimal control of glycemia, BP, lipids, regimens<br />optimized to reverse LVH, dysfunction & plaque<br />17<br />
  18. 18. DCCT and other studies<br />Research studies between 1970 and 2000 showed that complications could be prevented by lowering high glucose levels<br />Studies<br />DCCT 1984-1992<br />EDIC 1996<br />UKPDS 1978-1998<br />Kumamoto 1992-2000<br />Results<br />Better health<br />Fewer complications<br />Sense of well-being<br />More flexible lifestyle<br />18<br />GOAL: A1c &lt; 6.5%<br />HB Mortensen et al: Diabetes Care. 1997 May;20(5):714-20<br />Diabetes Care. 1997 May;20(5):714-20<br />Horm Res 1998;50:107–140<br />
  19. 19. UKPDS Findings<br />19<br />16%<br />19%<br />37%<br />43%<br />Micro-vascular Disease<br />PVD<br />Heart Failure<br />Cataract Extraction<br />Risk reduction with 1% decline in annual mean A1C<br />P &lt;.0001<br />P = .035<br />P = .021<br />P = .0001<br />0%<br />12%<br />14%<br />15%<br />30%<br />45%<br />MI<br />Stroke<br />Stratton IM, et al. BMJ. 2000;321:405-412.<br />
  20. 20. EDIC Findings: Cardiovascular Events<br />20<br />Cumulative Incidence of First of Any Event<br />0.12<br />0.10<br />Risk reduction:42% <br />95% CI: 9% to 63%<br />P = 0.02<br />Conventional<br />0.08<br />Cumulative Incidence <br />0.06<br />0.04<br />Intensive<br />0.02<br />0.00<br />0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21<br />Years from Study Entry<br />DCCT/EDIC N Engl J Med 2005: 353:2643-2653.<br />
  21. 21. AHA/ACC 2006 Secondary prevention guidelines: Risk factor modification in diabetic patients<br />21<br />
  22. 22. Diet and Diabetes – A days menu<br />06.30 am Tea without<br />08.30am Break fast<br />10.30am Snack<br />01.30pm Lunch<br />02.30pm Fruits<br />04.30pm Tea without<br />08.30pm Dinner<br />06.30pm Green salad<br />22<br />
  23. 23. Diet and Diabetes – What not to eat<br />Vada<br />Sweets<br />Pastry<br />Sugar<br />Mutton<br />Beef fry<br />Colas<br />Chips<br />23<br />
  24. 24. Benefits of 10% Weight Loss<br />24<br />20% fall in total mortality<br />30% fall in diabetes related death<br />40% fall in obesity related death<br />20% fall in Systolic BP<br />10% fall in Diastolic BP<br />50% fall Fasting Glucose<br />10% fall in Total Cholesterol<br />15% fall in LDL<br />8% increase in HDL<br />30% fall in Triglyceride<br />
  25. 25. Exercise in Diabetes<br />25<br />Calories spent /minute<br /><ul><li>Lying down, sleeping, sitting 1
  26. 26. Standing, desk work, driving 2
  27. 27. Level walking, level bicycling 3
  28. 28. Social doubles badminton 4
  29. 29. Social singles badminton 5
  30. 30. Gardening , swimming 6
  31. 31. Competitive badminton 7
  32. 32. Jogging 8
  33. 33. Basketball 9
  34. 34. Running 1km in 1hr 10 </li></li></ul><li>Exercise in Diabetes<br />26<br />
  35. 35. *<br />Exercise Guidelines<br />Medical evaluation for CAD, PVD, and neuropathy<br />Choose activity patient enjoys<br />Walking - minimum 20 min 5x/wk<br />Five minutes warm up<br />Five minutes cool down<br />Educate on hypoglycemia<br />Proper foot care and footwear<br />RBS monitoring - pre and post<br />Insulin or carbohydrate adjustments<br />Medical Identity card<br />27<br />
  36. 36. Use of Aspirin in Diabetes Mellitus for prevention of Cardiovascular events<br />25<br />22%<br />20<br />18%<br />PatientsExperiencingCardiovascularEvents(%)<br />15<br />12%<br />10%<br />10<br />9%<br />5<br />4%<br />0<br />Placebo<br />Placebo<br />Placebo<br />ASA<br />ASA<br />ASA<br />US MDs*<br />APT†<br />ETDRS‡<br />* Physician’s Health Study (US MDs); relative risk (RR) = 0.39 (NS), NEJM 1989<br />†AntiplateletTrialists’ Collaboration (APT); 2 P &lt; 0.002, BMJ 1994<br />‡ Early Treatment Diabetes Retinopathy Study (ETDRS); relative risk (RR) = 0.83 (P= 0.04), JAMA 1992<br />28<br />
  37. 37. How do treat hypertension in association with DM in order to reduce cardiac risk?<br />29<br />Thiazide diuretics<br />Captopril<br /> Blockers<br />↑ IR ↑ LDL HDL ↓ slightly<br />↓IR ↓ LDL HDL↑ slightly<br />Beta blockers<br />Calcium channel blockers<br />↓IR ↓ LDL HDL↑ slightly<br />Glucose & lipid neutral<br />↑ IR ↑ LDL HDL ↓ slightly<br />
  38. 38. Travelling with cholesterol<br />30<br />HDL seeks out excess cholesterol and cholesterol & prevents CAD<br />HDL returns excess cholesterol to liver to be converted to bile acids<br />Excess cholesterol deposited in arterial walls to form plaques<br />Saturated and trans fat in the diet act on the liver to increase excess LDL cholesterol in blood<br />LDL delivers cholesterol throughout the body<br />Liver regulates production of cholesterol<br />Liver packages TG & TC into VLDL and sends to blood<br />VLDL broken down to LDL and TG. TG is used as energy and stored <br />
  39. 39. How do treat dyslipidemia in association with DM in order to reduce cardiac risk?<br />31<br />High levels of TG<br />Low levels of HDL<br />Preponderance of small dense LDL<br />Absolute LDL normal<br />HDL is lower in men and women with diabetes<br />Increase in TG predicts heart disease morbidity and mortality in diabetes<br />Diabetes Atherosclerosis Intervention study<br />Fenofibrate reduced atherosclerosis by 40% and deaths by 23% <br />
  40. 40. ADA recommendations: Lipid lowering drugs by treatment goal<br />32<br />
  41. 41. The Polypill concept<br />Aspirin<br />Ramipril<br />Atorvostatin<br />Beta blocker<br />Thiazide<br />Folic acid<br />Dr. Nicholas Wald<br />33<br />
  42. 42. Rimonobant in Type2 Diabetes – The SERENADE Study<br />34<br />
  43. 43. Having diabetes is as bad as having an acute myocardial infarction<br />Death in diabetic patient is usually due to acute coronary event<br />Insulin resistance plays a vital role in the pathogenesis of increased risk<br />Coronary event are more extensive in presence of diabetes<br />Management of patients with acute MI are no different in DM patients<br />PCI in diabetic patients have unfavourable outcomes<br />CABG may be preferred in diabetic patients<br />Dietary & life style modifications are vital in reducing cardiovascular risk<br />Hypertensive medications are to be chosen with care in diabetics<br />Lipid management is slightly different from non-diabetic patients<br />Summary<br />35<br />
  44. 44. 36<br />

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