The document discusses diabetes care and management strategies. It covers several key points:
1. The Alphabet Strategy outlines evidence-based targets for diabetes care including advice, blood pressure, cholesterol, diabetes control, eye exams, foot exams, and medications.
2. Studies show tight control of blood pressure and cholesterol significantly reduces cardiovascular risks for those with diabetes.
3. The UKPDS trial demonstrated that intensive glucose control can reduce microvascular complications, though the effects on macrovascular disease are less certain. Maintaining an A1c below 7% is a recommended target.
Atorvastatin: Statins in CVD management. Is just lipid lowering enough Dr Vivek Baliga
When it comes to management of cardiovascular diseases, are achieving lipid lowering targets sufficient. Here Dr Vivek Baliga, Consultant Internal medicine discusses the additional benefits of statins in CVD in India.
http://www.theheart.org/web_slides/1283563.do
A study on Anglo-Scandinavian Cardiac Outcomes--Lipid Lowering Arm (ASCOT-LLA) designed to assess the effect on risk of normal MI and fatal CHD of two treatment strategies.
Atorvastatin: Statins in CVD management. Is just lipid lowering enough Dr Vivek Baliga
When it comes to management of cardiovascular diseases, are achieving lipid lowering targets sufficient. Here Dr Vivek Baliga, Consultant Internal medicine discusses the additional benefits of statins in CVD in India.
http://www.theheart.org/web_slides/1283563.do
A study on Anglo-Scandinavian Cardiac Outcomes--Lipid Lowering Arm (ASCOT-LLA) designed to assess the effect on risk of normal MI and fatal CHD of two treatment strategies.
http://www.theheart.org/web_slides/1135309.do
A study on Effects of a fixed combination of perindopril and indapamide on macrovascular and microvascular outcomes in patients (ADVANCE)
Dyslipidemia management an evidence based approachDr Vivek Baliga
How is dyslipidemia managed in clinical practice? Here is a short review on how current guidelines are shaping clinical practice, and how saroglitazar is playing a role in it.
Mubashar A Choudry MD | Effects of statin or usual care on outcomesMubashar A Choudry MD
Here, Dr. Mubashar A Choudry MD is explaining about effects of statin or usual care on outcomes. Dr. Mubashar Choudry is a respected cardiologist in Washington.
El Prof. Alberico L. Catapano, profesor de Farmacología en la Facultad de Farmacia de la Universidad de Milán (Italia) y presidente de la European Atherosclerosis Society (EAS), participa en la sesión 'Nuevos enfoques y evidencias cone statinas en ECV y control lipídico', perteneciente a la 'Jornada Galáctica sobre Guías de Lípidos y objetivos a alcanzar en los pacientes de más alto riesgo cardiovascular' (Málaga, 4-5 abril, 2014).
Accede a la jornada completa en http://guiaslipidos.secardiologia.es
http://www.theheart.org/web_slides/1135309.do
A study on Effects of a fixed combination of perindopril and indapamide on macrovascular and microvascular outcomes in patients (ADVANCE)
Dyslipidemia management an evidence based approachDr Vivek Baliga
How is dyslipidemia managed in clinical practice? Here is a short review on how current guidelines are shaping clinical practice, and how saroglitazar is playing a role in it.
Mubashar A Choudry MD | Effects of statin or usual care on outcomesMubashar A Choudry MD
Here, Dr. Mubashar A Choudry MD is explaining about effects of statin or usual care on outcomes. Dr. Mubashar Choudry is a respected cardiologist in Washington.
El Prof. Alberico L. Catapano, profesor de Farmacología en la Facultad de Farmacia de la Universidad de Milán (Italia) y presidente de la European Atherosclerosis Society (EAS), participa en la sesión 'Nuevos enfoques y evidencias cone statinas en ECV y control lipídico', perteneciente a la 'Jornada Galáctica sobre Guías de Lípidos y objetivos a alcanzar en los pacientes de más alto riesgo cardiovascular' (Málaga, 4-5 abril, 2014).
Accede a la jornada completa en http://guiaslipidos.secardiologia.es
Achieving Hba1c targets: Strategies For Initiating and Intensifying Diabetes ...Nemencio Jr
This module highlights the appropriate HbA1c targets that reduce microvascular and macrovascular complications in appropriate populations and how to safely achieve them with current anti-hyperglycemic agents
Management of coronary disease in diabetes - Is it different?Dr Vivek Baliga
The management of diabetes and coronary artery disease go hand in hand. This presentation by Dr Vivek talks on whether it varies from usual management.
Diabetes and acute coronary syndrome
Diabetic patients as compared to non diabetics withacute cornary syndrome (ACS) at 2 years showed a
1.8 fold increase in cardiovascular deaths
1.4 fold increase in myocardial infarctions (MI)
www.srisriholistichospitals.com
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
HOT NEW PRODUCT! BIG SALES FAST SHIPPING NOW FROM CHINA!! EU KU DB BK substit...GL Anaacs
Contact us if you are interested:
Email / Skype : kefaya1771@gmail.com
Threema: PXHY5PDH
New BATCH Ku !!! MUCH IN DEMAND FAST SALE EVERY BATCH HAPPY GOOD EFFECT BIG BATCH !
Contact me on Threema or skype to start big business!!
Hot-sale products:
NEW HOT EUTYLONE WHITE CRYSTAL!!
5cl-adba precursor (semi finished )
5cl-adba raw materials
ADBB precursor (semi finished )
ADBB raw materials
APVP powder
5fadb/4f-adb
Jwh018 / Jwh210
Eutylone crystal
Protonitazene (hydrochloride) CAS: 119276-01-6
Flubrotizolam CAS: 57801-95-3
Metonitazene CAS: 14680-51-4
Payment terms: Western Union,MoneyGram,Bitcoin or USDT.
Deliver Time: Usually 7-15days
Shipping method: FedEx, TNT, DHL,UPS etc.Our deliveries are 100% safe, fast, reliable and discreet.
Samples will be sent for your evaluation!If you are interested in, please contact me, let's talk details.
We specializes in exporting high quality Research chemical, medical intermediate, Pharmaceutical chemicals and so on. Products are exported to USA, Canada, France, Korea, Japan,Russia, Southeast Asia and other countries.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
Anti ulcer drugs and their Advance pharmacology ||
Anti-ulcer drugs are medications used to prevent and treat ulcers in the stomach and upper part of the small intestine (duodenal ulcers). These ulcers are often caused by an imbalance between stomach acid and the mucosal lining, which protects the stomach lining.
||Scope: Overview of various classes of anti-ulcer drugs, their mechanisms of action, indications, side effects, and clinical considerations.
Factory Supply Best Quality Pmk Oil CAS 28578–16–7 PMK Powder in Stockrebeccabio
Factory Supply Best Quality Pmk Oil CAS 28578–16–7 PMK Powder in Stock
Telegram: bmksupplier
signal: +85264872720
threema: TUD4A6YC
You can contact me on Telegram or Threema
Communicate promptly and reply
Free of customs clearance, Double Clearance 100% pass delivery to USA, Canada, Spain, Germany, Netherland, Poland, Italy, Sweden, UK, Czech Republic, Australia, Mexico, Russia, Ukraine, Kazakhstan.Door to door service
Hot Selling Organic intermediates
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
Follow us on: Pinterest
Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
4. 50% of newly presenting patients with type 2 diabetes already have one or more complications at diagnosis . Retinopathy: 21% Hypertension: 35% Stroke or TIA: 1% Absent foot pulses: 13% Intermittent claudication: 3% Ischaemic skin changes to feet: 6% Erectile dysfunction: 20% Plasma creatinine >120 mol/l: 3% Myocardial Infarction: 1% Abnormal ECG: 18% UKPDS Group. Diabetes Research 1990;13:1–11. Complications at diagnosis in the UKPDS
5. Goodkin G. Journal of Occupational Medicine 1975;17(11): 716–721. Donnelly R, et al. British Medical Journal 2000; 320: 1062–1066. Life expectancy and diabetes 40 45 50 55 60 65 70 75 80 85 15-19 20-29 30-39 40-49 50-59 60-70 Life expectancy (yrs) Diabetics Non Diabetics Age at diagnosis (yrs)
6. Diabetes in the UK Indo - Asian community Asian European Men Women Age groups 20–39 40–59 60–79 20–39 40–59 60–79 30% 25% 20% 15% 10% 5% 0%
7. U.K. economic costs Diabetes UK. May 2000. Year 2000 projected NHS diabetes expenditure ( 9% ) : £4,878,000,000 Equivalent to: per week £93,807,692 per day £13,401,098 per hour £ 558,379 per minute £ 9,306 per second £ 155 50% of Costs are due to premature complications
8.
9. GMS Contract NICE National Service Framework Guidelines Increasing prevalence Evidence base User expectations
11. “ Excellence requires that important, simple things are done right all the time . ” National Service Framework for Coronary Heart Disease
12. Patel V, Morrissey J The Alphabet Strategy British Journal of Diabetes & Vascular Disease, 2002: 2: 1: 58-59
13.
14.
15.
16.
17.
18. Prevention of progression of IGT to diabetes Finnish Diabetes Prevention Study Intensive lifestyle intervention reduced progression to diabetes by 58%. Diabetes Prevention Program Intensive lifestyle management reduced diabetes by 58%. Standard lifestyle advice plus metformin reduced diabetes by 31% Incidence of diabetes was 11, 7.8 and 4.8 cases per 100 person years with placebo, metformin and intensive lifestyle intervention respectively.
19.
20. UKPDS design Adapted from UK Prospective Diabetes Study (UKPDS) Group Lancet 1998;352:837-853; Turner R et al Ann Intern Med 1996;124(1 pt 2):136-145. Aim To determine whether intensified blood glucose control , with either sulphonylurea or insulin , reduces the risk of macrovascular or microvascular complications in type 2 diabetes. To determine the effect of aggressive blood pressure control . Study Population 3867 newly diagnosed type 2 diabetic patients who were asymptomatic after 3 months of diet ; fasting glucose 6.1–15 mmol/l (110–270 mg/dl) ; treat for 10 years .
21.
22. UKPDS : diabetes-related deaths 0% 5% 10% 15% 20% 0 3 6 9 % of patients with events Years from randomisation Tight blood pressure control (758) Less tight blood pressure control (390) Risk reduction 32% ( p=0.019 )
23. UKPDS : microvascular endpoints Risk reduction 37% ( p=0.0092 ) 0% 5% 10% 15% 20% 25% 0 3 6 9 % patients with event Years from randomisation Tight Blood Pressure Control (758) Less Tight Blood Pressure Control (390)
24. UKPDS blood pressure control study In 1148 type 2 diabetic patients a tight blood pressure control policy which achieved blood pressure of 144 / 82 mm Hg gave reduced risk for : Any diabetes-related endpoint 24% p=0.0046 Diabetes-related deaths 32% p=0.019 Stroke 44% p=0.013 Microvascular disease 37% p=0.0092 Heart failure 56% p=0.0043 Retinopathy progression 34% p=0.0038 Deterioration of vision 47% p=0.0036
25.
26.
27.
28. SIMVASTATIN: CAUSE-SPECIFIC MORTALITY Risk ratio and 95% CI STATIN PLACEBO Cause of death (10269) (10267) STATIN better STATIN worse CHD 577 701 Other vascular 214 242 ALL VASCULAR 791 943 (7.7%) (9.2%) 17% SE 4.4 reduction (2P<0.0002) Neoplastic 352 337 Respiratory 93 111 Other medical 76 91 Non-medical 16 21 ALL NON-VASCULAR 537 560 (5.2%) (5.5%) 5% SE 5.9 reduction ALL CAUSES 1328 1503 (12.9%) (14.6%) 12% SE 3.5 reduction (2P<0.001) 0.4 0.6 0.8 1.0 1.2 1.4
29. SIMVASTATIN: MAJOR VASCULAR EVENTS Risk ratio and 95% CI STATIN PLACEBO Vascular event (10269) (10267) STATIN better STATIN worse Total CHD 914 1234 Total stroke 456 613 Revascularisation 926 1185 ANY OF ABOVE 2042 2606 (19.9%) (25.4%) 24% SE 2.6 reduction (2P<0.00001) 0.4 0.6 0.8 1.0 1.2 1.4
30. SIMVASTATIN: VASCULAR EVENT by PRIOR DISEASE STATIN worse Risk ratio and 95% CI STATIN PLACEBO Baseline feature (10269) (10267) STATIN better STATIN worse Previous MI 1007 1255 Other CHD (not MI) 452 597 No prior CHD CVD 182 215 PVD 332 427 Diabetes 279 369 ALL PATIENTS 2042 2606 (19.9%) (25.4%) 24% SE 2.6 reduction (2P<0.00001) 0.4 0.6 0.8 1.0 1.2 1.4
33. CARDS Collaborative Atorvastatin Diabetes Study Helen Colhoun, John Betteridge, Paul Durrington, Graham Hitman, Andrew Neil, Shona Livingstone, Margaret Thomason, Michael Mackness, Valentine Menys, John Fuller on behalf of the CARDS Investigators Presented at ADA 2004
34. Primary prevention diabetes patients with one other risk factor (hypertension, smoker, micro-albuminuria, retinopathy) CARDS Design Placebo Atorvastatin 10mg Placebo 2838 patients
35. Treatment effect on the primary endpoint 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 * 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
37. CHD prevention trials with statins in diabetes : CHD Endpoints: † HPS = first major vascular event; †† CARE = absolute risk of coronary events; ** CARDS: Acute Coronary Events ‡ 4S = major CHD events; ‡‡ 4S reanalysis = major coronary events. Cohorts: *HPS = risk reduction for the entire cohort (nondiabetics and patients with diabetes). Footnote: NS = results not statistically significant. 1. HPS Collaborative Group. Lancet. 2002;360:7-22. 2. Goldberg RB, Mellies MJ, Sacks FM, et al. Circulation. 1998;98:2513-2519. 3. Py ö r ä l ä K, Pedersen TR, Kjekshus J, et al. Diabetes Care. 1997;20:614-620. 4. Haffner SM, Alexander CM, Cook TJ, et al. Arch Intern Med. 1999;159:2661-2667. CARDS Study ADA 2004. GREACE Study Secondary Prevention Primary Prevention 12% NS 24%* 3051 Simvastatin HPS 1 42% 32% 483 Simvastatin 4S reanalysis 4 ‡‡ 55% 59% 32% 202 313 Simvastatin Atorvastatin 24mg 4S 3 ‡ GREACE 25% 23% 586 Pravastatin CARE 2 †† 37%** 26 -33 % 25%* 2838 2912 Atorvastatin 10mg Simvastatin 40mg CARDS HPS 1 † CHD risk red n Diabetes CHD risk red n Nondiabetics Number of patients Drug Study
38. Cholesterol Treat all d iabetes patients with statins! (evidence if total cholesterol greater than 3.5 mmol/l) Alphabet t arget : t otal cholesterol <4 . 0 LDL <2 HDL ≥ 1.0: GMS t arget : t otal cholesterol <5 . 0
39.
40.
41.
42. UKPDS : any diabetes related endpoint 0% 20% 40% 60% 0 3 6 9 12 15 % of patients with an event Years from randomisation Intensive (2729) Conventional (1138) Risk reduction 12%
55. HOPE: Heart Outcomes Prevention Evaluation Study: Micro-HOPE sub study Effects of ramipril on cardiovascular and microvascular outcomes in people with diabetes mellitus Lancet 2000; 355: 253 - 59
56. HOPE : MI rate - ramipril vs placebo in diabetics 0.00 0.02 0.04 0.06 0.08 0.10 0.12 0.14 0.16 0 500 1000 1500 2000 Days of Follow-up Kaplan-Meier Rates ramipril Placebo RRR = 22% (6 - 36) p= 0.01
57. HOPE : stroke rate - ramipril vs placebo in diabetics 0.00 0.02 0.04 0.06 0.08 0 500 1000 1500 2000 Days of Follow-up Kaplan-Meier Rates ramipril Placebo RRR = 33% (10 - 50) p=0.0074
58. HOPE : CV death - ramipril vs placebo in diabetics 0.00 0.02 0.04 0.06 0.08 0.10 0.12 0 500 1000 1500 2000 Days of Follow-up Kaplan-Meier Rates ramipril Placebo RRR = 37% (21 - 51) p=0.0001
59.
60. LIFE : losartan intervention for endpoint reduction in hypertension study Lancet 2002 ; 359 : 995 - 1003
61. LIFE : total mortality – diabetes subgroup Study Month 0 6 12 18 24 30 36 42 48 54 60 66 Proportion of patients, % 24 20 16 12 8 4 0 RRR = 39%; p=0·002 Losartan Atenolol
62. LIFE : new onset diabetes by treatment group Study Month 0 6 12 18 24 30 36 42 48 54 60 66 0 2 4 6 8 10 Proportion of patients, % Atenolol Losartan
63.
64.
65.
66.
67. POEM 400 : heart disease risk score UKPDS: T0 vs. Tfu p=NS Tadj vs. Tfu p<0.001 n=315
68. Pulling it all together : the Steno 2 Study Multifactorial intervention in high-risk individuals with type 2 diabetes Gaede P et al (2003) N Eng J Med 348:5 p383
69.
70. Steno-2 : objective To compare the effect of a targeted , intensified, multifactorial intervention with that of conventional treatment on modifiable risk factors for cardiovascular disease in patients with type 2 diabetes and microalbuminuria.
71.
72. Steno-2 vs Alphabet Strategy : targets Annually Annually F eet UKPDS risk Events H eart disease Most All ACEI / AIIA Most All G uardians : aspirin Annually Annually E yes 7.0 6.5 D iabetes Control : HbA1c% 5.0 4.5 C holesterol 140 / 80 130 / 80 (140 / 85) B lood Pressure Standard Standard A dvice Alphabet Strategy Steno-2 intensive cohort
73. Steno-2 intensive cohort : results 28 AIIA use 79 ACEI use 85 Statin use 87 Aspirin use 15 HbA1c% =< 6.5 72 Total cholesterol =< 4.5 70 Diastolic BP =< 80 54 Systolic BP =< 130 % Target
74. Steno-2 : CVD event reduction 33 events in 19 patients 85 events in 35 patients 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 Cardiovascular Death Intensive Conventional Event
76. 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%.”