The updated NICE guideline NG28 on type 2 diabetes management now recommends a risk-based approach focusing on both glycemic control and cardiorenal risk reduction, in light of evidence that SGLT2 inhibitors reduce cardiovascular and kidney outcomes. Previously, guidelines focused primarily on glycemic targets, but trials showed SGLT2is reduced heart failure events, kidney function decline, and mortality, regardless of baseline blood sugar levels. The update advises assessing cardiovascular status to help determine appropriate treatments, with some patients now requiring initial therapy with SGLT2is and metformin to control both blood sugar and reduce cardiorenal risk.
This document discusses diabetes, including types, screening recommendations, treatment goals, and management strategies. It notes that 30.3 million Americans have diabetes, which poses significant health and economic burdens. Screening is recommended for those over 35 who are overweight or obese, and those of any age with risk factors. Treatment involves lifestyle changes, medications like metformin, and possibly insulin to control blood glucose and prevent complications. The goals are to reduce HbA1c levels while avoiding hypoglycemia.
John B. Buse, MD, PhD; David Cherney, MD, PhD, FRCP(C); and Mikhail Kosiborod, MD, FACC, FAHA, prepared useful Practice Aids pertaining to SGLT2 inhibitors for this CME activity titled “Complex Cases in Contemporary Practice: Applying New Evidence for SGLT2 Inhibitors in the Management of Patients With Comorbid Cardiometabolic Diseases.” For the full presentation, monograph, complete CME information, and to apply for credit, please visit us at https://bit.ly/3dFKZhs. CME credit will be available until July 22, 2021.
This document discusses timely insulin initiation and overcoming clinical inertia in the management of type 2 diabetes (T2D). It notes that the global prevalence of diabetes is increasing rapidly and is projected to affect 700 million people by 2045. In Africa, it is estimated that the number of adults with diabetes will rise from 19 million currently to 47 million by 2045. The document summarizes studies from Uganda finding low rates of recommended screening and care processes among diabetic patients. It emphasizes the benefits of early intensive glycemic control, as shown in studies like the UKPDS, and indications for insulin therapy in T2D. The document outlines the physiological insulin secretion pattern and roles of basal and bolus insulin in mimicking this pattern.
This document provides information on an academic detailing session for health care professionals on medications for type 2 diabetes, specifically SGLT2 inhibitors and GLP1 agonists. It summarizes clinical trial evidence on empagliflozin, semaglutide, and canagliflozin that shows reductions in cardiovascular outcomes and death. It also reviews dosage, costs, ongoing trials, and clinical considerations for safe use of SGLT2 inhibitors.
Dapagliflozin is an SGLT2 inhibitor that has shown benefits in managing type 2 diabetes and reducing cardiovascular outcomes. The document summarizes results from several key studies on dapagliflozin. The DECLARE-TIMI trial showed that dapagliflozin reduced the risk of cardiovascular death or hospitalization for heart failure compared to placebo in patients with type 2 diabetes with high cardiovascular risk. The DAPA-HF trial found that dapagliflozin reduced the risks of worsening heart failure or cardiovascular death compared to placebo in patients with heart failure regardless of diabetes status. Dapagliflozin also improved outcomes related to heart failure in the DEFINE-HF trial.
This document discusses guidelines for managing chronic complications of diabetes, including microvascular and macrovascular complications. It provides an overview of the pathogenesis and risk factors for complications and reviews current guidelines from the American Diabetes Association (ADA) for screening, treating, and setting goals for hypertension, dyslipidemia, and cardiovascular disease in patients with diabetes. The guidelines recommend treating hypertension to a goal of <140/90 mmHg, prescribing statin therapy for diabetic patients above a certain age or risk level, and using antiplatelet agents for secondary prevention of cardiovascular events.
This document discusses diabetes, including types, screening recommendations, treatment goals, and management strategies. It notes that 30.3 million Americans have diabetes, which poses significant health and economic burdens. Screening is recommended for those over 35 who are overweight or obese, and those of any age with risk factors. Treatment involves lifestyle changes, medications like metformin, and possibly insulin to control blood glucose and prevent complications. The goals are to reduce HbA1c levels while avoiding hypoglycemia.
John B. Buse, MD, PhD; David Cherney, MD, PhD, FRCP(C); and Mikhail Kosiborod, MD, FACC, FAHA, prepared useful Practice Aids pertaining to SGLT2 inhibitors for this CME activity titled “Complex Cases in Contemporary Practice: Applying New Evidence for SGLT2 Inhibitors in the Management of Patients With Comorbid Cardiometabolic Diseases.” For the full presentation, monograph, complete CME information, and to apply for credit, please visit us at https://bit.ly/3dFKZhs. CME credit will be available until July 22, 2021.
This document discusses timely insulin initiation and overcoming clinical inertia in the management of type 2 diabetes (T2D). It notes that the global prevalence of diabetes is increasing rapidly and is projected to affect 700 million people by 2045. In Africa, it is estimated that the number of adults with diabetes will rise from 19 million currently to 47 million by 2045. The document summarizes studies from Uganda finding low rates of recommended screening and care processes among diabetic patients. It emphasizes the benefits of early intensive glycemic control, as shown in studies like the UKPDS, and indications for insulin therapy in T2D. The document outlines the physiological insulin secretion pattern and roles of basal and bolus insulin in mimicking this pattern.
This document provides information on an academic detailing session for health care professionals on medications for type 2 diabetes, specifically SGLT2 inhibitors and GLP1 agonists. It summarizes clinical trial evidence on empagliflozin, semaglutide, and canagliflozin that shows reductions in cardiovascular outcomes and death. It also reviews dosage, costs, ongoing trials, and clinical considerations for safe use of SGLT2 inhibitors.
Dapagliflozin is an SGLT2 inhibitor that has shown benefits in managing type 2 diabetes and reducing cardiovascular outcomes. The document summarizes results from several key studies on dapagliflozin. The DECLARE-TIMI trial showed that dapagliflozin reduced the risk of cardiovascular death or hospitalization for heart failure compared to placebo in patients with type 2 diabetes with high cardiovascular risk. The DAPA-HF trial found that dapagliflozin reduced the risks of worsening heart failure or cardiovascular death compared to placebo in patients with heart failure regardless of diabetes status. Dapagliflozin also improved outcomes related to heart failure in the DEFINE-HF trial.
This document discusses guidelines for managing chronic complications of diabetes, including microvascular and macrovascular complications. It provides an overview of the pathogenesis and risk factors for complications and reviews current guidelines from the American Diabetes Association (ADA) for screening, treating, and setting goals for hypertension, dyslipidemia, and cardiovascular disease in patients with diabetes. The guidelines recommend treating hypertension to a goal of <140/90 mmHg, prescribing statin therapy for diabetic patients above a certain age or risk level, and using antiplatelet agents for secondary prevention of cardiovascular events.
Diabetes mellitus (DM) is a significant public health problem associated with many debilitating health conditions
This presentation will briefly tackle management of Diabetes
This document discusses hypertension guidelines and management. It covers the epidemiology of hypertension, guidelines for classification and treatment targets, detection of white coat and masked hypertension, and management of hypertension in patients with comorbidities like chronic kidney disease. Proper control of hypertension is important for reducing cardiovascular and renal risks. Treatment involves lifestyle changes and antihypertensive medications, with certain drugs offering additional organ protective effects. Management is more complex in patients on dialysis or after kidney transplantation.
RIESGO CARDIOVASCULAR EN EL PACIENTE DIABETICO J GONZALEZ JUANATEYOmarMedina18478
1) The document discusses evaluating cardiovascular risk in diabetic patients, including pathophysiology linking diabetes and cardiovascular/renal disease.
2) Clinical evaluation of basic cardiovascular and renal risk in diabetics includes assessing risk factors, laboratory and imaging tests, and estimating kidney risk based on eGFR and albuminuria levels.
3) Multifactorial intervention is emphasized for optimal reduction of cardiovascular and kidney risks, including treatment of hyperglycemia, dyslipidemia, hypertension, and other factors.
This document discusses the role of glyptins (DPP-4 inhibitors) in the management of type 2 diabetes mellitus (T2DM) and chronic kidney disease (CKD). It notes that T2DM is a leading cause of CKD globally and that strict glycemic control is important for treating diabetic nephropathy. However, patients with CKD are at higher risk of hypoglycemia from antidiabetic medications. The document examines whether glyptins may be renoprotective and safer to use in CKD patients compared to other drugs due to their low risk of hypoglycemia. It reviews studies on the use of sitagliptin and other glyptins in T2
This document discusses the potential benefits of combining a SGLT-2 inhibitor (SGLT2i) and DPP-4 inhibitor (DPP4i) for treatment of type 2 diabetes. It notes that SGLT2is increase glucagon levels while DPP4is inhibit glucagon release, providing a counteracting effect. The combination addresses multiple metabolic abnormalities and has synergistic effects on glycemic control, cardiovascular risk reduction, renal protection, and other benefits. Clinical evidence suggests this combination may be preferred over other therapies for patients with diabetes and cardiovascular or renal complications.
SGLT2I The paradigm change in diabetes managementPraveen Nagula
Just like ARNI, SGLT2I have changed the face of diabetes management and they have a good profile in multimodality management because of pleiotropic effects
The document discusses diabetes, including the different types of diabetes, risk factors, complications, and findings from major clinical trials on diabetes control and treatment. It summarizes results from studies like the Diabetes Control and Complications Trial (DCCT) and United Kingdom Prospective Diabetes Study (UKPDS) which showed that intensive glucose control can reduce diabetes complications. More recent trials found benefits but also risks of intensive control, depending on individual patient factors. The National Diabetes Education Program (NDEP) provides public education materials on diabetes control and management.
Diabetes mellitus and vascular disease 2022 FINALD.pptxhospital
Diabetes is strongly linked to cardiovascular disease through several mechanisms. It increases the risk of both macrovascular and microvascular complications. Treatment aims to control blood sugar and modify risk factors like smoking, physical inactivity, and high cholesterol to prevent vascular disease and related mortality. For those with existing vascular problems, medications that have shown cardiovascular benefits like SGLT2 inhibitors and GLP1 agonists may be recommended. Lifestyle changes and medical therapies can both help reduce cardiovascular risks in people with diabetes.
Dapagliflozin demonstrated clear treatment benefits for cardiovascular, kidney, and mortality outcomes in patients with chronic kidney disease (CKD), regardless of the presence of diabetes. It provides glomerular protection, limits proteinuria and kidney damage, and slows the decline of glomerular filtration rate in CKD patients. The DAPA-CKD trial found that dapagliflozin reduced the risk of end-stage renal disease or death from renal causes compared to placebo in CKD patients with and without type 2 diabetes. Dapagliflozin is indicated for the treatment of CKD up to stage III and was well tolerated with a low rate of treatment discontinuation.
1) The document discusses guidelines for initiating basal insulin therapy in patients with type 2 diabetes, including benefits such as lowering HbA1c and reducing cardiovascular risk.
2) It compares different basal insulin options like glargine, detemir, and NPH insulin, finding that the long-acting analogs glargine and detemir have advantages like lower rates of hypoglycemia and weight gain compared to NPH.
3) Studies show that early initiation of basal insulin can help preserve beta-cell function and provide better long-term glycemic control for patients with type 2 diabetes.
This document discusses the benefits of early initiation of basal insulin in managing type 2 diabetes. It recommends starting with low doses of long-acting basal insulin, which can help lower HbA1c and reduce complications by providing consistent insulin levels throughout the day. Basal insulin is preferred over premix insulins when first adding insulin. Clinical guidelines support initiating basal insulin when oral medications fail to control blood sugar levels. Studies show basal insulin improves beta-cell function and glycemic control long-term compared to late insulin initiation.
This document discusses diabetic kidney disease (DKD). It provides information on the epidemiology, clinical presentation, pathogenesis, standard of care, and pharmacological interventions to reduce cardiorenal risk in patients with type 2 diabetes. Regarding standard of care, it outlines glycemic and blood pressure targets, the use of RAAS inhibitors and statins, and glucose-lowering medications. It then discusses how SGLT2 inhibitors have shown benefits in reducing cardiovascular, renal, and heart failure outcomes as well as slowing kidney disease progression in patients with DKD and type 2 diabetes.
Slidedeck of the presentation I gave during the East by Southwest conference, co-organized by the Division of Nephrology (UNM) and the Renal and Electrolyte Division (UPMC)
Anti-Diabetics For Cardiac Patients The Proper Selectionmagdy elmasry
Cardiovascular Disease and Type 2 Diabetes.Tight glycaemic control can reduce microvascular complications of T2DM, but does not lower CV risk sufficiently.
Multifactorial intervention, comprising of lowering lipid levels and BP, and use of aspirin, has been shown to reduce vascular complications and mortality.Shifting the Paradigm in Diabetes Care
Treating Diabetes Beyond A1C :Considerations for Cardiovascular Protection.
The document provides an overview of the Standards of Care in Diabetes - 2023 guidelines. It includes 17 sections that cover various aspects of diabetes care, treatment goals, and quality evaluation tools. The sections include classification and diagnosis of diabetes, prevention or delay of type 2 diabetes, medical evaluation and assessment of comorbidities, facilitating positive health behaviors, glycemic targets, pharmacologic treatment approaches, management of cardiovascular disease and other complications, and more. The guidelines are intended to provide clinicians, patients, and other stakeholders with an evidence-based framework for diabetes care and management.
Deciphering The Lipid Profile Report in Diabetes! - ver 2.pptxAmeetRathod3
This document summarizes key points about lipid profile management in patients with diabetes. It discusses how diabetic dyslipidemia is characterized by high total cholesterol, high triglycerides, low HDL cholesterol, and increased small dense LDL. It also notes that lipid abnormalities vary across groups and that abnormal lipid levels reflect diabetes risk. Guidelines for lipid targets in diabetes are presented from organizations like the Polish Lipid Association, which classify all diabetic patients as high or very high cardiovascular risk. The principles of striving for lower lipid levels earlier and maintaining them for optimal risk reduction are also covered.
2019 Update to: Management of Hyperglycemia in Type 2 Diabetes, 2018. A Conse...Mgfamiliar Net
The American Diabetes Association and the European Association for the Study of Diabetes have briefly updated their 2018 recommendations on management of hyperglycemia, based on important research findings from large cardiovascular outcomes trials published in 2019. Important changes include: 1) the decision to treat high-risk individuals with a glucagon-like peptide 1 (GLP-1) receptor agonist or sodium–glucose cotransporter 2 (SGLT2) inhibitor to reduce major adverse car- diovascular events (MACE), hospitalization for heart failure (hHF), cardiovascular death, or chronic kidney disease (CKD) progression should be considered independently of baseline HbA1c or individualized HbA1c target; 2) GLP-1 receptor agonists can also be considered in patients with type 2 diabetes without established cardiovascular disease (CVD) but with the presence of specific indicators of high risk; and 3) SGLT2 inhibitors are recommended in patients with type 2 diabetes and heart failure, particularly those with heart failure with reduced ejection fraction, to reduce hHF, MACE, and CVD death, as well as in patients with type 2 diabetes with CKD (estimated glomerular filtration rate 30 to £60 mL min–1 [1.73 m]–2 or urinary albumin-to-creatinine ratio >30 mg/g, particularly >300 mg/g) to prevent the progression of CKD, hHF, MACE, and cardiovascular death.
share - Lions, tigers, AI and health misinformation, oh my!.pptxTina Purnat
• Pitfalls and pivots needed to use AI effectively in public health
• Evidence-based strategies to address health misinformation effectively
• Building trust with communities online and offline
• Equipping health professionals to address questions, concerns and health misinformation
• Assessing risk and mitigating harm from adverse health narratives in communities, health workforce and health system
Diabetes mellitus (DM) is a significant public health problem associated with many debilitating health conditions
This presentation will briefly tackle management of Diabetes
This document discusses hypertension guidelines and management. It covers the epidemiology of hypertension, guidelines for classification and treatment targets, detection of white coat and masked hypertension, and management of hypertension in patients with comorbidities like chronic kidney disease. Proper control of hypertension is important for reducing cardiovascular and renal risks. Treatment involves lifestyle changes and antihypertensive medications, with certain drugs offering additional organ protective effects. Management is more complex in patients on dialysis or after kidney transplantation.
RIESGO CARDIOVASCULAR EN EL PACIENTE DIABETICO J GONZALEZ JUANATEYOmarMedina18478
1) The document discusses evaluating cardiovascular risk in diabetic patients, including pathophysiology linking diabetes and cardiovascular/renal disease.
2) Clinical evaluation of basic cardiovascular and renal risk in diabetics includes assessing risk factors, laboratory and imaging tests, and estimating kidney risk based on eGFR and albuminuria levels.
3) Multifactorial intervention is emphasized for optimal reduction of cardiovascular and kidney risks, including treatment of hyperglycemia, dyslipidemia, hypertension, and other factors.
This document discusses the role of glyptins (DPP-4 inhibitors) in the management of type 2 diabetes mellitus (T2DM) and chronic kidney disease (CKD). It notes that T2DM is a leading cause of CKD globally and that strict glycemic control is important for treating diabetic nephropathy. However, patients with CKD are at higher risk of hypoglycemia from antidiabetic medications. The document examines whether glyptins may be renoprotective and safer to use in CKD patients compared to other drugs due to their low risk of hypoglycemia. It reviews studies on the use of sitagliptin and other glyptins in T2
This document discusses the potential benefits of combining a SGLT-2 inhibitor (SGLT2i) and DPP-4 inhibitor (DPP4i) for treatment of type 2 diabetes. It notes that SGLT2is increase glucagon levels while DPP4is inhibit glucagon release, providing a counteracting effect. The combination addresses multiple metabolic abnormalities and has synergistic effects on glycemic control, cardiovascular risk reduction, renal protection, and other benefits. Clinical evidence suggests this combination may be preferred over other therapies for patients with diabetes and cardiovascular or renal complications.
SGLT2I The paradigm change in diabetes managementPraveen Nagula
Just like ARNI, SGLT2I have changed the face of diabetes management and they have a good profile in multimodality management because of pleiotropic effects
The document discusses diabetes, including the different types of diabetes, risk factors, complications, and findings from major clinical trials on diabetes control and treatment. It summarizes results from studies like the Diabetes Control and Complications Trial (DCCT) and United Kingdom Prospective Diabetes Study (UKPDS) which showed that intensive glucose control can reduce diabetes complications. More recent trials found benefits but also risks of intensive control, depending on individual patient factors. The National Diabetes Education Program (NDEP) provides public education materials on diabetes control and management.
Diabetes mellitus and vascular disease 2022 FINALD.pptxhospital
Diabetes is strongly linked to cardiovascular disease through several mechanisms. It increases the risk of both macrovascular and microvascular complications. Treatment aims to control blood sugar and modify risk factors like smoking, physical inactivity, and high cholesterol to prevent vascular disease and related mortality. For those with existing vascular problems, medications that have shown cardiovascular benefits like SGLT2 inhibitors and GLP1 agonists may be recommended. Lifestyle changes and medical therapies can both help reduce cardiovascular risks in people with diabetes.
Dapagliflozin demonstrated clear treatment benefits for cardiovascular, kidney, and mortality outcomes in patients with chronic kidney disease (CKD), regardless of the presence of diabetes. It provides glomerular protection, limits proteinuria and kidney damage, and slows the decline of glomerular filtration rate in CKD patients. The DAPA-CKD trial found that dapagliflozin reduced the risk of end-stage renal disease or death from renal causes compared to placebo in CKD patients with and without type 2 diabetes. Dapagliflozin is indicated for the treatment of CKD up to stage III and was well tolerated with a low rate of treatment discontinuation.
1) The document discusses guidelines for initiating basal insulin therapy in patients with type 2 diabetes, including benefits such as lowering HbA1c and reducing cardiovascular risk.
2) It compares different basal insulin options like glargine, detemir, and NPH insulin, finding that the long-acting analogs glargine and detemir have advantages like lower rates of hypoglycemia and weight gain compared to NPH.
3) Studies show that early initiation of basal insulin can help preserve beta-cell function and provide better long-term glycemic control for patients with type 2 diabetes.
This document discusses the benefits of early initiation of basal insulin in managing type 2 diabetes. It recommends starting with low doses of long-acting basal insulin, which can help lower HbA1c and reduce complications by providing consistent insulin levels throughout the day. Basal insulin is preferred over premix insulins when first adding insulin. Clinical guidelines support initiating basal insulin when oral medications fail to control blood sugar levels. Studies show basal insulin improves beta-cell function and glycemic control long-term compared to late insulin initiation.
This document discusses diabetic kidney disease (DKD). It provides information on the epidemiology, clinical presentation, pathogenesis, standard of care, and pharmacological interventions to reduce cardiorenal risk in patients with type 2 diabetes. Regarding standard of care, it outlines glycemic and blood pressure targets, the use of RAAS inhibitors and statins, and glucose-lowering medications. It then discusses how SGLT2 inhibitors have shown benefits in reducing cardiovascular, renal, and heart failure outcomes as well as slowing kidney disease progression in patients with DKD and type 2 diabetes.
Slidedeck of the presentation I gave during the East by Southwest conference, co-organized by the Division of Nephrology (UNM) and the Renal and Electrolyte Division (UPMC)
Anti-Diabetics For Cardiac Patients The Proper Selectionmagdy elmasry
Cardiovascular Disease and Type 2 Diabetes.Tight glycaemic control can reduce microvascular complications of T2DM, but does not lower CV risk sufficiently.
Multifactorial intervention, comprising of lowering lipid levels and BP, and use of aspirin, has been shown to reduce vascular complications and mortality.Shifting the Paradigm in Diabetes Care
Treating Diabetes Beyond A1C :Considerations for Cardiovascular Protection.
The document provides an overview of the Standards of Care in Diabetes - 2023 guidelines. It includes 17 sections that cover various aspects of diabetes care, treatment goals, and quality evaluation tools. The sections include classification and diagnosis of diabetes, prevention or delay of type 2 diabetes, medical evaluation and assessment of comorbidities, facilitating positive health behaviors, glycemic targets, pharmacologic treatment approaches, management of cardiovascular disease and other complications, and more. The guidelines are intended to provide clinicians, patients, and other stakeholders with an evidence-based framework for diabetes care and management.
Deciphering The Lipid Profile Report in Diabetes! - ver 2.pptxAmeetRathod3
This document summarizes key points about lipid profile management in patients with diabetes. It discusses how diabetic dyslipidemia is characterized by high total cholesterol, high triglycerides, low HDL cholesterol, and increased small dense LDL. It also notes that lipid abnormalities vary across groups and that abnormal lipid levels reflect diabetes risk. Guidelines for lipid targets in diabetes are presented from organizations like the Polish Lipid Association, which classify all diabetic patients as high or very high cardiovascular risk. The principles of striving for lower lipid levels earlier and maintaining them for optimal risk reduction are also covered.
2019 Update to: Management of Hyperglycemia in Type 2 Diabetes, 2018. A Conse...Mgfamiliar Net
The American Diabetes Association and the European Association for the Study of Diabetes have briefly updated their 2018 recommendations on management of hyperglycemia, based on important research findings from large cardiovascular outcomes trials published in 2019. Important changes include: 1) the decision to treat high-risk individuals with a glucagon-like peptide 1 (GLP-1) receptor agonist or sodium–glucose cotransporter 2 (SGLT2) inhibitor to reduce major adverse car- diovascular events (MACE), hospitalization for heart failure (hHF), cardiovascular death, or chronic kidney disease (CKD) progression should be considered independently of baseline HbA1c or individualized HbA1c target; 2) GLP-1 receptor agonists can also be considered in patients with type 2 diabetes without established cardiovascular disease (CVD) but with the presence of specific indicators of high risk; and 3) SGLT2 inhibitors are recommended in patients with type 2 diabetes and heart failure, particularly those with heart failure with reduced ejection fraction, to reduce hHF, MACE, and CVD death, as well as in patients with type 2 diabetes with CKD (estimated glomerular filtration rate 30 to £60 mL min–1 [1.73 m]–2 or urinary albumin-to-creatinine ratio >30 mg/g, particularly >300 mg/g) to prevent the progression of CKD, hHF, MACE, and cardiovascular death.
Similar to ZEN0224_Slide narrative_hosted version_reapproval_APPROVED-1.pptx (20)
share - Lions, tigers, AI and health misinformation, oh my!.pptxTina Purnat
• Pitfalls and pivots needed to use AI effectively in public health
• Evidence-based strategies to address health misinformation effectively
• Building trust with communities online and offline
• Equipping health professionals to address questions, concerns and health misinformation
• Assessing risk and mitigating harm from adverse health narratives in communities, health workforce and health system
Promoting Wellbeing - Applied Social Psychology - Psychology SuperNotesPsychoTech Services
A proprietary approach developed by bringing together the best of learning theories from Psychology, design principles from the world of visualization, and pedagogical methods from over a decade of training experience, that enables you to: Learn better, faster!
These lecture slides, by Dr Sidra Arshad, offer a quick overview of the 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 lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
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. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
8 Surprising Reasons To Meditate 40 Minutes A Day That Can Change Your Life.pptxHolistified Wellness
We’re talking about Vedic Meditation, a form of meditation that has been around for at least 5,000 years. Back then, the people who lived in the Indus Valley, now known as India and Pakistan, practised meditation as a fundamental part of daily life. This knowledge that has given us yoga and Ayurveda, was known as Veda, hence the name Vedic. And though there are some written records, the practice has been passed down verbally from generation to generation.
Our backs are like superheroes, holding us up and helping us move around. But sometimes, even superheroes can get hurt. That’s where slip discs come in.
Cell Therapy Expansion and Challenges in Autoimmune DiseaseHealth Advances
There is increasing confidence that cell therapies will soon play a role in the treatment of autoimmune disorders, but the extent of this impact remains to be seen. Early readouts on autologous CAR-Ts in lupus are encouraging, but manufacturing and cost limitations are likely to restrict access to highly refractory patients. Allogeneic CAR-Ts have the potential to broaden access to earlier lines of treatment due to their inherent cost benefits, however they will need to demonstrate comparable or improved efficacy to established modalities.
In addition to infrastructure and capacity constraints, CAR-Ts face a very different risk-benefit dynamic in autoimmune compared to oncology, highlighting the need for tolerable therapies with low adverse event risk. CAR-NK and Treg-based therapies are also being developed in certain autoimmune disorders and may demonstrate favorable safety profiles. Several novel non-cell therapies such as bispecific antibodies, nanobodies, and RNAi drugs, may also offer future alternative competitive solutions with variable value propositions.
Widespread adoption of cell therapies will not only require strong efficacy and safety data, but also adapted pricing and access strategies. At oncology-based price points, CAR-Ts are unlikely to achieve broad market access in autoimmune disorders, with eligible patient populations that are potentially orders of magnitude greater than the number of currently addressable cancer patients. Developers have made strides towards reducing cell therapy COGS while improving manufacturing efficiency, but payors will inevitably restrict access until more sustainable pricing is achieved.
Despite these headwinds, industry leaders and investors remain confident that cell therapies are poised to address significant unmet need in patients suffering from autoimmune disorders. However, the extent of this impact on the treatment landscape remains to be seen, as the industry rapidly approaches an inflection point.
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
1. AN UPDATE TO NICE GUIDELINE NG28
This is an AstraZeneca promotional material for UK healthcare professionals only.
Prescribing information for can be found here.
GB-38766 | October 2022
Visit the See Beyond Sugar webpage to learn more about managing
cardiorenal risk in type 2 diabetes and improving patient outcomes >
Adverse events should be reported. Reporting forms and information can be found at
www.mhra.gov.uk/yellowcard. Adverse events should also be reported to AstraZeneca by visiting
https://aereporting.astrazeneca.com or by calling 0800 783 0033.
CARDIORENAL PROTECTION:
A RISK-BASED APPROACH TO MANAGING TYPE 2 DIABETES
IN ADDITION TO GLYCAEMIC CONTROL
2. FORXIGA® (dapagliflozin) | Therapeutic indication
Type 2 diabetes mellitus
FORXIGA is indicated in adults and children aged 10 years and above for the treatment of insufficiently controlled
type 2 diabetes mellitus as an adjunct to diet and exercise
• as monotherapy when metformin is considered inappropriate due to intolerance.
• in addition to other medicinal products for the treatment of type 2 diabetes.
For study results with respect to combination of therapies, effects on glycaemic control, cardiovascular events, and
the populations studied, see sections 4.4, 4.5 and 5.1. of the summary of product characteristics
Heart failure
FORXIGA is indicated in adults for the treatment of symptomatic chronic heart failure with reduced ejection fraction.
Chronic kidney disease
FORXIGA is indicated in adults for the treatment of chronic kidney disease
FORXIGA® (dapagliflozin) Indication:
Summary of key data
3. Finding your way
(a)CV(D) = (atherosclerotic) cardiovascular (disease); CKD = chronic kidney disease; HF = heart failure; NG28 = NICE guideline 28; NICE = National Institute for Health and Care Excellence;
SGLT2i(s) = sodium-glucose cotransporter-2 inhibitor(s); T2D = type 2 diabetes.
Welcome and introduction
• Recognise the burden and consequences of cardiorenal disease (HF, aCVD, renal impairment leading
to CKD) as early complications in T2D
• Examine the SGLT2i class in terms of cardiorenal benefit
• Understand the NG28 guideline update ‒ from primarily addressing blood glucose control to a risk-
based approach in T2D
• Review implementation of risk assessment in existing- and newly-diagnosed patients to optimise their
T2D treatment
• Identify which patients require first-line treatment with an SGLT2i in combination with metformin
Key objectives
This presentation examines the optimal drug treatment for T2D, supported
by the 2022 NICE guideline NG28 update
• Clinical trials showed that SGLT2is reduced the risk of CKD progression, mortality and CV events
in T2D
• The NICE committee agreed that it is important to assess CV status to help determine suitable
treatments; NG28 recommendations have been updated to reflect this
SGLT2i Prescribing considerations Guidelines Summary
T2D burden
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Clinical practice points highlight
practical advice related to
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4. The burden of cardiorenal disease and T2D
Cardiorenal diseases account for 60% of first comorbidities in T2D:1–3
CKD = chronic kidney disease; HF = heart failure; LV = left ventricular; MI = myocardial infarction; PAD = peripheral arterial disease; T2D = type 2 diabetes.
1. NHS. End of life care in heart failure. https://www.england.nhs.uk/improvement-hub/wp-content/uploads/sites/44/2017/11/heart-failure.pdf Accessed April 2022; 2. Kidney Care UK. Facts and Stats.
https://www.kidneycareuk.org/news-and-campaigns/facts-and-stats/ Accessed April 2022; 3. Birkeland KI et al. Diabetes Obes Metab. 2020;22:1607–1618; 4. Diabetes UK. Diabetes diagnoses double in the last 15
years. https://www.diabetes.org.uk/about_us/news/diabetes-diagnoses-doubled-prevalence-2021 Accessed April 2022; 5. Lawson CA et al. JAMA Netw Open 2019;2:e1916447; 6. Parving HH et al. Kidney Int
2006;69:2057–2063.
HF
2021 UK
prevalence1
~900,000
CKD
2021 UK
prevalence2
~3M
58% of people with T2D
will develop CKD
(N=24,151)6
24% of HF patients in
a UK primary care
cohort had T2D
(N=87,709)5
2021 UK
prevalence4
~4.9M
Diabetes can affect the
heart and kidneys
simultaneously and is an
independent predictor of
worsening function
Diabetes
Renal impairment (leading
to CKD) and HF are
interrelated and lead to a
vicious circle of cardiac,
renal and metabolic risk
Cardiorenal
diseases
(HF or CKD)
60%3
Prescribing considerations Guidelines
SGLT2i
Home T2D burden Summary
7. In a systematic review of 57 studies (N=4,549,481), CVD
affected 32% overall, specifically:2
Cardiorenal disease is the most frequent first
comorbidity in T2D1
NICE define established aCVD as coronary heart disease, acute coronary syndrome, previous MI, stable angina, prior coronary or other revascularisation, cerebrovascular disease (ischaemic stroke and transient
ischaemic attack) and peripheral arterial disease3
(a)CV(D) = (atherosclerotic) cardiovascular (disease); CKD = chronic kidney disease; eGFR = estimated glomerular filtration rate; HF = heart failure; MACE = major adverse cardiovascular event;
MI = myocardial infarction; T2D = type 2 diabetes.
1. Birkeland KI et al. Diabetes Obes Metab 2020;22:1607–1618; 2. Einarson TR et al. Cardiovasc Diabetol 2018;17:83; 3. Hill CJ et al. Diabet Med 2014;31:448–454 4. Kidney Disease: Improving Global Outcomes
(KDIGO). KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. Kidney Int 2013;3:1–150.
Adapted from Einarson TR et al. 20182
In the UK National Diabetes Audit (N=868,616),
42% of patients with T2D had renal impairment
(normal function: eGFR >60 mL/min/1.73 m2 + normal albumin:
creatinine ratio)3
CV death risk
Stage of CKD
(eGFR mL/min/1.73 m2)
Up to 4.3x greater 3a (45–60)
Up to 5.2x greater 3b (30–45)
Up to 14x greater 4 (15–30)
Adapted from KDIGO 20124
CV mortality risk compared to an eGFR baseline of 90–105 mL/min/1.73 m2 and ACR
<10. CV mortality ranges: Stage 3a (1.5 to 4.3), Stage 3b (2.2 to 5.2), Stage 4 (4.8 to
14.0) per year4
Atherosclerosis
HF
Angina
MI
Stroke
Rate
(%)
Prescribing considerations Guidelines
SGLT2i
Home T2D burden Summary
Declining eGFR strongly correlates with MACE and
CV death4
CV outcome
29
15 15
10
8
0
5
10
15
20
25
30
8. In T2D, even early decline of eGFR (≤75 mL/min/1.73 m2)
is associated with an increased risk of death
eGFR = estimated glomerular filtration rate; T2D = type 2 diabetes.
Fox C et al. Lancet 2012;380:1662–1673.
Risk of all-cause mortality according to eGFR in patients with T2D
Prescribing considerations Guidelines
SGLT2i
Home T2D burden Summary
9. (a)CV(D) = (atherosclerotic) cardiovascular (disease); ARR = absolute risk reduction; CANVAS = Canagliflozin Cardiovascular Assessment Study; CANVAS-R = Canagliflozin Cardiovascular Assessment Study-
Renal; CI = confidence interval; CREDENCE = Canagliflozin and Renal Events in Diabetes with Established Nephropathy Clinical Evaluation; DECLARE-TIMI 58 = Dapagliflozin Effect on Cardiovascular Events–
Thrombolysis in Myocardial Infarction 58; EMPA-REG-OUTCOME = Empagliflozin Cardiovascular Outcome Event Trial in Type 2 Diabetes Mellitus Patients; HF = heart failure;
hHF = hospitalisation for HF; HR = hazard ratio; MACE = major adverse cardiovascular event; MI = myocardial infarction; SGLT2i(s) = sodium-glucose cotransporter-2 inhibitor(s);
VERTIS CV = Cardiovascular Outcomes Following Ertugliflozin Treatment in Type 2 Diabetes Mellitus Participants With Vascular Disease.
McGuire DK et al. JAMA Cardiol 2021;6:148–158.
Cardiorenal benefits demonstrated in meta-analysis
of SGLT2i trials assessing CV and kidney outcomes
• A meta-analysis of six SGLT2i trials (EMPA-REG OUTCOME, CANVAS, CANVAS-R, DECLARE-TIMI 58, CREDENCE,
VERTIS CV) (N=46,969; 66.2% with aCVD; 7.4%–59.8% with baseline eGFR <60 mL/min/1.73 m2; 10.0%–23.7% with history of
HF) reported favourable CV and kidney outcomes
10% hazard reduction
HR 0.90 (95% CI 0.85–0.95)
22% hazard reduction
HR 0.78 (95% CI 0.73–0.84)
4931 MACE
(MI, stroke and CV death)
3154 CV deaths/hHF 1426 renal composite outcomes
38% hazard reduction
HR 0.62 (95% CI 0.56–0.70; p<0.0001)
0.4% ARR 1.3% ARR 1.4% ARR
• Presence or absence of aCVD did not modify the above treatment outcomes
SGLT2i Prescribing considerations Guidelines
Home T2D burden Summary
10. Dapagliflozin addresses the cardiorenal burden
across HF and CKD
ACEi = angiotensin-converting-enzyme inhibitor; ARB = angiotensin receptor blocker; ARR = absolute risk reduction; CI = confidence interval; CKD = chronic kidney disease; CV = cardiovascular; DAPA-CKD = Dapagliflozin
and Prevention of Adverse Outcomes in Chronic Kidney Disease; DAPA-HF = Dapagliflozin and Prevention of Adverse Outcomes in Heart Failure; eGFR = estimated glomerular filtration rate; DECLARE = Dapagliflozin
Effect on Cardiovascular Events; ESKD = end-stage kidney disease; GLT = glucose-lowering therapy; HF = heart failure; hHF = hospitalisation for heart failure; HR = hazard ratio; MACE = major adverse CV events;
RRR = relative risk reduction; T2D = type 2 diabetes.
1. Wiviott SD et al. N Engl J Med 2019;380:347–357; 2. Mosenzon O et al. Lancet Diabetes Endocrinol 2019;7:606–617; 3. McMurray JJV et al. N Engl J Med 2019;381:1995–2008; 4. Petrie MC et al. JAMA
2020;323:1353–1368; 5. Docherty KF et al. Article and supplementary material. Diabetes Care 2020;43:2878–2881; 6. Heerspink HJL et al. N Engl J Med 2020:383;1436–1446.
Dapagliflozin vs placebo
Dapagliflozin vs placebo
(+ device therapy, HF- and
other glucose-lowering
medications)
Dapagliflozin vs placebo
(± ACEi or ARB)
SGLT2i Prescribing considerations Guidelines
Home T2D burden Summary
11. Dapagliflozin has shown an overall consistent safety
profile in patients with T2D, CKD and HFrEF
*Acute kidney injury in DECLARE-TIMI 58; †Definite or probable; ‡Leading to discontinuation of the trial regimen or considered to be serious adverse events.
CKD = chronic kidney disease; DAPA = dapagliflozin; DAPA-CKD = Dapagliflozin and Prevention of Adverse Outcomes in Chronic Kidney Disease; DAPA-HF = Dapagliflozin and Prevention of Adverse Outcomes in
Heart Failure; eGFR = estimated glomerular filtration rate; DECLARE-TIMI 58 = Dapagliflozin Effect on Cardiovascular Events–Thrombolysis in Myocardial Infarction 58; DKA = diabetic ketoacidosis;
HFrEF = heart failure with reduced ejection fraction; N/A = not available; T2D = type 2 diabetes.
1. Wiviott SD et al. Article and supplementary material. N Engl J Med 2019;380:347–357; 2. Heerspink HJL et al. N Engl J Med 2020:383:1436–1446; 3. McMurray JJV et al. Article and supplementary material. N
Engl J Med 2019;381:1995–2008; 4. In House Data, AstraZeneca Pharmaceuticals LP. Clinical study report D1699C00001.
All values are % unless otherwise stated
Note: Adverse event rates should not be compared across the 3 trials due to the different patient populations and follow-up durations.
SGLT2i Prescribing considerations Guidelines
Home T2D burden Summary
DECLARE-TIMI 581 DAPA-CKD2 DAPA-HF3,4
Adverse event, %
DAPA 10 mg
(N=8574)
Placebo
(N=8569)
DAPA 10 mg
(N=2149)
Placebo
(N=2149)
DAPA 10 mg
(N=2368)
Placebo
(N=2368)
Volume depletion 2.5 2.4 5.9 4.2 7.5 6.8
Renal adverse event* 1.5 2.0 7.2 8.7 6.5 7.2
Fracture 5.3 5.1 4.0 3.2 2.1 2.1
Amputation 1.4 1.3 1.6 1.8 0.5 0.5
Major hypoglycaemia 0.7 1.0 0.7 1.3 0.2 0.2
Diabetic ketoacidosis† 0.3 0.1 0 <0.1 0.1 0
Genital infection‡ 0.9 0.1 NA NA 0.3 <0.1
Urinary tract infection‡ 1.5 1.6 NA NA 0.8 0.9
Fournier’s gangrene, n 1 5 0 1 0 1
12. Prescribing considerations in T2D
DKA = diabetic ketoacidosis; eGFR = estimated glomerular filtration rate; GI = gastrointestinal; SGLT2i(s) = sodium-glucose cotransporter-2 inhibitor(s); SU = sulphonylurea.
Electronic Medicines Compendium. Dapagliflozin Summary of Product Characteristics. May 2022. https://www.medicines.org.uk/emc/product/7607/smpc#gref Accessed September 2022.
Observation Action
Rare cases of DKA, including life-threatening and fatal cases, have
been reported in patients treated with SGLT2is, including dapagliflozin
If DKA is suspected or diagnosed, dapagliflozin treatment should be stopped
immediately
Insulin and SUs cause hypoglycaemia A lower dose of insulin/SU may be required to reduce the risk of
hypoglycaemia when used in combination with dapagliflozin
There is limited experience with initiating dapagliflozin in patients with
eGFR <25 mL/min/1.73 m2, and no experience with initiating treatment
in patients with eGFR <15 mL/min/1.73 m2
It is not recommended to initiate dapagliflozin in patients with eGFR
<15 mL/min/1.73 m2
Whilst cardiorenal protection is maintained, glycaemic efficacy is
reduced in patients with eGFR <45 mL/min/1.73 m2
Additional glucose lowering treatment should be considered if eGFR drops
below 45 mL/min/1.73 m2
Volume depletion may be exacerbated in patients on diuretics,
antihypertensives or the elderly
Exercise caution in these patients and consider adjusting the dose of diuretic
medication if needed
Intercurrent conditions may lead to volume depletion (e.g. GI illness) Careful monitoring of volume status (e.g. physical examination, blood pressure
measurements, laboratory tests) is recommended
Interrupt therapy/withhold in patients with confirmed volume depletion, until
volume depletion is corrected
Please refer to the product Summary of Characteristics for full details
Prescribing considerations
Home T2D burden Guidelines
SGLT2i Summary
13. NICE GUIDELINE NG28 NOW
RECOMMENDS FIRST-LINE
SGLT2i + METFORMIN ON A
RISK-BASED APPROACH
ADOPT AN INDIVIDUALISED APPROACH TO T2D CARE:
INCLUDE CVD STATUS AND RISK ASSESSMENT
CVD = cardiovascular disease; NG28 = NICE guideline 28; NICE = National Institute for Health and Care Excellence; SGLT2i(s) = sodium-glucose cotransporter-2 inhibitor(s); T2D = type 2 diabetes.
Click here to take a closer look at the
NG28 guideline
Guidelines
Home T2D burden SGLT2i Summary
Prescribing considerations