Presentation on theme: "Diabetes and its Cardiovascular Impact Dr Rashid Iqbal Consultant Cardiologist Surrey and Sussex Healthcare NHS Turst St Georges Hospitals NHS Trust Spire."— Presentation transcript:
Diabetes and its Cardiovascular Impact Dr Rashid Iqbal Consultant Cardiologist Surrey and Sussex Healthcare NHS Turst St Georges Hospitals NHS Trust Spire Gatwick Park Hospital
Aims Epidemiology of DM Coronary Artery Disease in Diabetes How to protect Diabetic Heart?
Diabetes Prevalence Worldwide In 2000 2.8% (171 million) By 2030 4.4% (366 million) A 36 % increase in 30 years Wild S et al Diabetes Care 2004;27:1047-53
0 1995200020052010201520202025 2030 100 150 300 350 50 200 250 Diabetes – Prevalence Year 2000: 177 million Year 2030: 370 million. equivalent to 2/3 rd of Europe population
Glycemic disorders Dyslipidemia - Low HDL - Small, dense LDL - Hypertriglyceridemia -Postprandial lipemia Hypertension Impaired thrombolysis - PAI-1, fibrinogen Endothelial dysfunction/ inflammation - CRP, MMP-9, adiponectin Microalbuminuria Visceral Obesity Insulin Resistance Free Fatty Acids Atherosclerosis The Metabolic Syndrome: A Network of Atherogenic Factors Brunzell J, Hokanson J. Diabetes Care. 1999;22(Suppl 3):C10-C13. McFarlane S, et al. J Clin Endocrinol Metab. 2001;86(2):713-718. Frohlich M, et al. Diabetes Care. 2000;23(12):1835-1839. Kuusisto J, et al. Circulation. 1995;91:831-837. Parulkar AA, et al. Ann Intern Med. 2001;134:61-71. Hseuh WA, et al. Diabetes Care. 2001;24(2):392-397. Lebovitz H. Clin Chem. 1999;45(8B):1339-1345.
Cardiovascular Mortality Associated With Metabolic Syndrome Diabetes Care 2001;24:683 p < 0.001
Cardiovascular Disease Early, aggressive interventions for risk reduction New, more effective therapies for treatment of HTN and hyperlipidemia Dramatic improvement in cardiovascular interventions Reduction in smoking ? Yet the increase in prevalence of obesity and diabetes is epidemic, with CVD the leading complication of DM
ACS Treatment STMI- Aim for PPCI NSTMI- Aim to catheterise within 72hours Secodary prevention: DAPT, Aspirin for life, Clopidogrel/Prasugrel/Ticagrelol 12 MONTHS High dose Statin +/- Ezatemibe ( In-Practice Study and NICE guidance. Betablocker/ACE Inhibition Smoking cessation Cardiac Rehab
BIP: -Blocker Treatment Improves Survival of Patients With Diabetes
Costs - Fact File Studies have shown that diabetes is a costly disease Type 2 diabetes accounted for between 3% and 6% of total healthcare expenditure in eight European countries Hospital in-patient costs are the largest single contributor to direct healthcare costs
Diabetes-CVD Facts More than 65% of all deaths in people with diabetes are caused by cardiovascular disease. Heart attacks occur at an earlier age in people with diabetes and often result in premature death. 3
Diabetes-CVD Facts Up to 60% of adults with diabetes have high blood pressure. Nearly all adults with diabetes have one or more cholesterol problems, such as: –high triglycerides –low HDL cholesterol –high LDL cholesterol 4
The Good News… By managing the ABCs of diabetes, people with diabetes can reduce their risk for heart disease and stroke. A stands for A1C B stands for Blood pressure C stands for Cholesterol 5
Ask About Your A1C A1C measures average blood glucose over the last three months. Get your A1C checked at least twice a year. A1C Goal = less than 7% 6
Treating Cardiovascular risk factors… Managing the ABCs of diabetes, people with diabetes can reduce their risk for heart disease and stroke. A stands for A1C B stands for Blood pressure C stands for Cholesterol 5
HbA 1c % 7.0% versus 7.9% Reduction in risk by: 25%for eye disease and early kidney disease 16%for Heart Attacks 24%for cataract surgery Reduction in risk by: 25%for eye disease and early kidney disease 16%for Heart Attacks 24%for cataract surgery
Risk Reduction With a 1% Reduction in HbA 1c : Any lower is therefore better! 16% Heart failure 43% Amputation / death from leg vessel problems 37% Eye and early kidney disease 12%Stroke 14% Heart Attacks 21% Deaths related to diabetes
Pharmacotherapy of Hypertension Aim for 125/75-80 ACE inhibitors and ARBs have a favorable effect on renal and cardiovascular systems. ß-blockers along with ACE inhibitors help in reducing myocardial infarction and heart failure. Calcium channel blockers in combination with ACE inhibitors, ß-blockers, and diuretics help in controlling blood pressure. Diuretics are recommended when BP control is still uncontrolled.
Cholesterol lowering reduces Heart Disease in Patients with Diabetes by up to 55% ! 1234560 0 20 40 60 80 100 Risk reduction reduction 55% Diabetic,simvastatin Diabetic, placebo Years since randomisation Patients with heart disease (%)
Plaque Disruption & Thrombosis Journal of medicine
Atherothrombotic plaque in diabetic patients More in number More likely to rupture More likely to have existing surface thrombus
Antiplatelets Aspirin 75mg once daily : Aspirin 75mg once daily : Diabetes UK advises aspirin treatment in all patients with diabetes over the age of 30 years with any of the following: Diabetes UK advises aspirin treatment in all patients with diabetes over the age of 30 years with any of the following: previous MI, angina, HT, diabetic eye disease, PVD, early kidney disease, raised cholesterol, family history of heart disease, obesity, south Asians smokers, DM duration > 10 years. Clopidogrel can be used as an alternative.
DES in Diabetes Both Sirolimus- and Paclitaxel-eluting stents substantially reduce angiographic and clinical restenosis compared with BMS DES have not eliminated the excess risk of restenosis in diabetics c/w non-diabetics
CABG: the “diabetic disadvantage” Society of Thoracic Surgeons database of 1.37 million patients undergoing cardiac surgery (1990-2000). Diabetic patients had higher rates of: 30 day mortality and deep sternal wound infections stroke longer hospital stay two-fold worse 10 year survival (36835 pts) Brown et al Semin Thorac Cardiovasc Surg 2006;18:281
PCI v CABG( SYNTAX) No mortality difference at 1 year Higher incidence of CVA after CABG More frequent angina after PCI More frequent angiography and repeat revascularisation after PCI
Reducing risk in patients undergoing PCI – what can we do? Tight glycaemic control (HbA1c ≤7) pre and post procedure ( Corpus et al JACC 2004;43:8 ) Thiazolidinediones – may reduce neointimal proliferation and restenosis in T2DM receiving BMS Antithrhrombotic therapy Drug eluting stents
Conclusion Diabetic patients are different 1.Epidemiology: increasing prevalence worldwide 2.Pathology: their vasculature is different - plaques more frequent and more prone to rupture. 3.Outcomes: for patients with type 2 diabetes sustaining an acute myocardial infarction is poor particularly if they have documented coronary artery disease. 4.Treatment: Modern therapies have a favourable effect but there remains a residual risk not addressed by these therapies.