Cardiovascular Risk in Diabetes

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Presentation at Calicut Endocrinology Club

Comments

By: syssm (100 month(s) ago)

A good PPT,but the contents was not so intensive.

By: cardioaldia (102 month(s) ago)

I completely agree with Callegold: What is the point of not allowing th download of his excellent EDUCATIONAL material. Ia am a cardiologist from a very poor Rain forest area in a country in Central America. Last year students and residentswould be delighted to see this. Dr. S Aswini Kumar, do you think I am going to get a prize showing your material, or steal it from you for other purposes???. How about blocking your title and whatever is in your mind that could compromise sharing. If your ppt presentation is not allowed to de downloaded, then what is the matter Sir, in showing it here. I am a Cardiologist of a very POOR country as your's. Think it over. My name is Dr. Mario R. Lambour E Cardiologist Guatemala cardioaldia@gmail.com

By: CALLEGOLD (121 month(s) ago)

what is the point of putting this presentation online and then stopping people from downloading it? The more information you can give and share with others can save many lives! If you want to keep it private,...don't post!

Presentation Transcript

Cardiovascular Risk and Diabetes : 

Cardiovascular Risk and Diabetes DR. S. ASWINI KUMAR. MD Professor of Medicine Medical College Hospital Thiruvananthapuram 1

New definition for Diabetes : 

New definition for Diabetes Type 2 diabetes is a condition of premature cardiovascular complications in the setting of chronic hyperglycaemia 2

Cardiometabolic Risk : 

Cardiometabolic Risk A patient with diabetes Normal person with MI 3 Consider yourself having a heart attack already, when you develop diabetes

Diabetes as a new risk factor for cardiovascular mortality : 

Diabetes as a new risk factor for cardiovascular mortality 4 Diabetes

Framingham Heart Study 30-Year Follow-Up:CVD Events in Patients With Diabetes (Ages 35-64) : 

Framingham Heart Study 30-Year Follow-Up:CVD Events in Patients With Diabetes (Ages 35-64) 10 9 20 11 9 6 38 19 3* 30 0 2 4 6 8 10 Age-adjusted annual rate/1,000 Men Women Total Cardiac and vascular events Coronary Heart Disease Cardiac Failure Intermittent Claudication Stroke Risk ratio P<0.001 for all values except *P<0.05. Wilson PWF, Kannel WB. In: Hyperglycemia, Diabetes and Vascular Disease. Ruderman N et al, eds. Oxford; 1992. 5

Coronary Heart Disease - Mortality : 

Coronary Heart Disease - Mortality 6 60 50 40 30 20 10 0 0-3 4-7 8-11 12-15 16-19 20-23 Duration of Follow-up (yrs) CHD Mortality/1,000 With Diabetes* Without Diabetes Male Male Female Female Am J Med 90(2A): 56S-61S,1991 * Diagnosed between 35 and 65 years of age

What if a diabetic had a coronary event? : 

What if a diabetic had a coronary event? 7 Coronary Events Multivessel disease Complications PC Interventions Diabetic ketosis Bypass surgery

Natural History of Type2 Diabetes : 

Natural History of Type2 Diabetes 8

The continuum of Cardiovascular Risk in Diabetes : 

The continuum of Cardiovascular Risk in Diabetes 9

Diabetes and Cardiovascular risk : 

Diabetes and Cardiovascular risk Type 2Diabetes AdvancedGlycationProducts Dyslipidemia Total-C  LDL-C  Triglycerides  Apo-B  HDL-C  Hypertension Endothelialdysfunction ProthrombosisFibrinogen  PAI-1  10

Diabetes and Endothelial Dysfunction : 

Diabetes and Endothelial Dysfunction 11

Relationship between obesity, insulin resistance and dyslipidemia : 

Relationship between obesity, insulin resistance and dyslipidemia 12

Diabetic vascular pathology : 

Diabetic vascular pathology 13

Common pathways of diabetic complications : 

Common pathways of diabetic complications 14 Oxidative Stress Cellular Dysfunction Polyol Pathway AGE Formation Cell Damage Hexosamine Pathway ROS Glucose Peripheral & Autonomic Neuropathy Nephropathy Coronary Artery Disease Vascular Damage Different complications (eye, kidney, nerve, blood vessels) arise from limited number of triggers perturbing a limited number of metabolic pathway(s)(Brownlee, 2001) Retinopathy

Cardiovascular risk factors specific for diabetes : 

Cardiovascular risk factors specific for diabetes 15 Microalbuminuria Microalbuminuria Massive proteinuria Abn. Platelet function Serum insulin PAI-1 Fibrinogen levels

Accelerated CAD progression in Diabetes - Summary : 

Accelerated CAD progression in Diabetes - Summary 16

Can you prevent the premature Cardiovascular Events in Diabetes? : 

Can you prevent the premature Cardiovascular Events in Diabetes? Optimal control of glycemia, BP, lipids, regimens optimized to reverse LVH, dysfunction & plaque 17

DCCT and other studies : 

DCCT and other studies Research studies between 1970 and 2000 showed that complications could be prevented by lowering high glucose levels Studies DCCT 1984-1992 EDIC 1996 UKPDS 1978-1998 Kumamoto 1992-2000 Results Better health Fewer complications Sense of well-being More flexible lifestyle 18 HB Mortensen et al: Diabetes Care. 1997 May;20(5):714-20 Diabetes Care. 1997 May;20(5):714-20 Horm Res 1998;50:107–140 GOAL: A1c < 6.5%

UKPDS Findings : 

UKPDS Findings 19 Stratton IM, et al. BMJ. 2000;321:405-412. P <.0001 P = .035 P = .021 P = .0001 Risk reduction with 1% decline in annual mean A1C 0% 45% 15% 30% 14% 12% MI Stroke

EDIC Findings: Cardiovascular Events : 

EDIC Findings: Cardiovascular Events 20 Cumulative Incidence Years from Study Entry Cumulative Incidence of First of Any Event 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 Risk reduction:42% 95% CI: 9% to 63% P = 0.02 0.12 0.10 0.08 0.06 0.04 0.02 0.00 Conventional Intensive DCCT/EDIC N Engl J Med 2005: 353:2643-2653.

AHA/ACC 2006 Secondary prevention guidelines: Risk factor modification in diabetic patients : 

AHA/ACC 2006 Secondary prevention guidelines: Risk factor modification in diabetic patients 21

Diet and Diabetes – A days menu : 

Diet and Diabetes – A days menu 06.30 am Tea without 08.30am Break fast 10.30am Snack 01.30pm Lunch 02.30pm Fruits 04.30pm Tea without 06.30pm Green salad 08.30pm Dinner 22

Diet and Diabetes – What not to eat : 

Diet and Diabetes – What not to eat Sugar Sweets Pastry Vada Mutton Beef fry Chips Colas 23

Benefits of 10% Weight Loss : 

Benefits of 10% Weight Loss 24 20% fall in total mortality 30% fall in diabetes related death 40% fall in obesity related death 20% fall in Systolic BP 10% fall in Total Cholesterol 15% fall in LDL 8% increase in HDL 30% fall in Triglyceride 50% fall Fasting Glucose 10% fall in Diastolic BP

Exercise in Diabetes : 

Exercise in Diabetes 25 Calories spent /minute Lying down, sleeping, sitting 1 Standing, desk work, driving 2 Level walking, level bicycling 3 Social doubles badminton 4 Social singles badminton 5 Gardening , swimming 6 Competitive badminton 7 Jogging 8 Basketball 9 Running 1km in 1hr 10

Exercise in Diabetes : 

Exercise in Diabetes 26

Exercise Guidelines : 

Exercise Guidelines Medical evaluation for CAD, PVD, and neuropathy Choose activity patient enjoys Walking - minimum 20 min 5x/wk Five minutes warm up Five minutes cool down Educate on hypoglycemia Proper foot care and footwear RBS monitoring - pre and post Insulin or carbohydrate adjustments Medical Identity card 27

Use of Aspirin in Diabetes Mellitus for prevention of Cardiovascular events : 

Use of Aspirin in Diabetes Mellitus for prevention of Cardiovascular events PatientsExperiencingCardiovascularEvents(%) * Physician’s Health Study (US MDs); relative risk (RR) = 0.39 (NS), NEJM 1989 † Antiplatelet Trialists’ Collaboration (APT); 2 P < 0.002, BMJ 1994 ‡ Early Treatment Diabetes Retinopathy Study (ETDRS); relative risk (RR) = 0.83 (P = 0.04), JAMA 1992 25 20 15 10 5 0 10% Placebo ASA 4% 22% Placebo ASA 18% Placebo 12% ASA 9% US MDs* APT† ETDRS‡ 28

How do treat hypertension in association with DM in order to reduce cardiac risk? : 

How do treat hypertension in association with DM in order to reduce cardiac risk? 29 Thiazide diuretics ↑ IR ↑ LDL HDL ↓ slightly Captopril ↓IR ↓ LDL HDL↑ slightly ↓IR ↓ LDL HDL↑ slightly Calcium channel blockers  Blockers Glucose & lipid neutral Beta blockers ↑ IR ↑ LDL HDL ↓ slightly

Travelling with cholesterol : 

Travelling with cholesterol 30 Liver regulates production of cholesterol Liver packages TG & TC into VLDL and sends to blood VLDL broken down to LDL and TG. TG is used as energy and stored LDL delivers cholesterol throughout the body Excess cholesterol deposited in arterial walls to form plaques HDL seeks out excess cholesterol and cholesterol & prevents CAD HDL returns excess cholesterol to liver to be converted to bile acids Saturated and trans fat in the diet act on the liver to increase excess LDL cholesterol in blood

How do treat dyslipidemia in association with DM in order to reduce cardiac risk? : 

How do treat dyslipidemia in association with DM in order to reduce cardiac risk? 31 High levels of TG Low levels of HDL Preponderance of small dense LDL Absolute LDL normal HDL is lower in men and women with diabetes Increase in TG predicts heart disease morbidity and mortality in diabetes Diabetes Atherosclerosis Intervention study Fenofibrate reduced atherosclerosis by 40% and deaths by 23%

ADA recommendations: Lipid lowering drugs by treatment goal : 

ADA recommendations: Lipid lowering drugs by treatment goal 32

The Polypill concept : 

The Polypill concept Dr. Nicholas Wald 33 Aspirin Ramipril Atorvostatin Beta blocker Thiazide Folic acid

Rimonobant in Type2 Diabetes – The SERENADE Study : 

Rimonobant in Type2 Diabetes – The SERENADE Study 34

Summary : 

Summary Having diabetes is as bad as having an acute myocardial infarction Death in diabetic patient is usually due to acute coronary event Insulin resistance plays a vital role in the pathogenesis of increased risk Coronary event are more extensive in presence of diabetes Management of patients with acute MI are no different in DM patients PCI in diabetic patients have unfavourable outcomes CABG may be preferred in diabetic patients Dietary & life style modifications are vital in reducing cardiovascular risk Hypertensive medications are to be chosen with care in diabetics Lipid management is slightly different from non-diabetic patients 35

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