Diabetes and Cardiovascular Risk

Dr S C Sinha MD DM FACC FSCAI

WHO: 2012

CHD Risk Equivalent

• Clinical Coronary Artery disease

• Symptomatic Carotid artery disease

• Peripheral artery disease

• Abdominal aortic aneurysm

• Diabetes Mellitus

• Chronic kidney disease

PREVALENCE OF RISK FACTORS IN OURPOPULATION (CAD)

0

10

20

30

40

50

60

HT DM Sm FH

ACS Control

P= .000

P=0.000

54.0%51.6%

44.0%

22.4%

33.8%

5.7%12.5%

3.5%

ACS N= 981

Control N = 882

P=0.287

P=0.000

LIPID PROFILE IN DM PATIENTS WITH ACS

DM (mg/dl) Non-DM (mg/dl)

T. Cholesterol 170.20± 42.82 167.72± 41.21

Triglyceride 165.83± 82.31 142.55± 78.76

LDL-C 98.90± 39.81 99.23± 38.33

HDL-C 38.47 ±7.74 40.55± 12.47

CAG IN DM WITH ACS

0

5

10

15

20

25

30

35

40

45

50

SVD DVD TVD

DM Non DM

33.6% 42.9%

22.7%21.2% 22.5%

12.6%

OUTCOME

DM Non-DM

LV EF (%) 51.83± 12.65 52.53± 12.81

Alive at discharge(%) 97.9 97.8

Death at discharge(%) 2.1 2.2

DM VS NON-DM WITH ACS

0

10

20

30

40

50

60

70

80

90

Male Female <55y >55y

DM Non-DM

71.5%81.2%

28.5% 18.8%

57.8%

42.3%42.2%

57.8%

• IN INDIA, IT IS ESTIMATED THAT MORE THAN HALF OF

ALL DEATHS IN 2005 WERE DUE TO CHRONIC DISEASE. IF

THE CURRENT TREND CONTINUES CHRONIC DISEASE

DEATHS ARE PROJECTED TO INCREASE BY 18% IN THE

NEXT TEN YEARS. MOST MARKEDLY, DEATHS FROM

DIABETES IN INDIA WILL INCREASE BY 35%.

RISK OF CARDIOVASCULAR EVENTS IN DIABETICS FRAMINGHAM

STUDYAGE-ADJUSTED

BIENNIAL RATE AGE-ADJUSTED

PER 1000 RISK RATIO

CARDIOVASCULAR EVENT MEN WOMEN MEN WOMEN

CORONARY DISEASE 39 21 1.5** 2.2***

STROKE 15 6 2.9*** 2.6***

PERIPHERAL ARTERY DIS. 18 18 3.4*** 6.4***

CARDIAC FAILURE 23 21 4.4*** 7.8***

ALL CVD EVENTS 76 65 2.2*** 3.7***

SUBJECTS 35-64 36-YEAR FOLLOW-UP **P<.001,***P<.0001

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_________________________________________________________________

CARDIOVASCULAR DISEASE AND DIABETES

PROBABILITY OF DEATH FROM CHD IN PATIENTS WITH TYPE 2 DIABETES WITH OR

WITHOUT PREVIOUS MI

FRAMINGHAM HEART STUDY 30-YEAR FOLLOW-UP:

CVD EVENTS IN PATIENTS WITH DIABETES (AGES 35-64)

109

20

11

9 63819

3*

30

0

2

4

6

8

10

Age-adjusted annual rate/1,000

Men Women

Total

CVD

CHD 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.

REVISED ATP III METABOLIC SYNDROME OCT 2005

*Diagnosis is established when 3 of these risk factors are present.†Abdominal obesity is more highly correlated with metabolic risk

factors than is BMI. ‡Some men develop metabolic risk factors when circumference is only

marginally increased.

<40 mg/dL<50 mg/dL or Rx for ↓ HDL

MenWomen

>102 cm (>40 in)>88 cm (>35 in)

MenWomen

100 mg/dL or Rx for ↑ glucoseFasting glucose

130/85 mm Hg or on HTN Rx

Blood pressure

HDL-C

150 mg/dL or Rx for ↑ TGTG

Abdominal obesity†

(Waist circumference‡)

Defining LevelRisk Factor

International Diabetes Federation Definition:

Abdominal obesity plus two other components:

elevated BP, low HDL, elevated TG, or impaired

fasting glucose

Cardiovascular Disease (CVD) and Total Mortality:

US Men and Women Ages 30-74(age, gender, and risk-factor adjusted Cox regression) NHANES II Follow-

Up (n=6255)(Malik and Wong, et al., Circulation 2004; 110: 1245-1250)

0

1

2

3

4

5

6

7R

ela

tive R

isk

CHD Mortality CVD Mortality Total Mortality

None

MetS

Diabetes

CVD

CVD+Diabetes

* p<.05, ** p<.01, **** p<.0001 compared to none

*

***

***

***

**

***

***

***

***

***

***

Aspirin : ADA 2014 Recommendations

• Consider aspirin therapy (75–162 mg/day) as a primary

prevention strategy in those with type 1 or type 2 diabetes at

increased cardiovascular risk (10-year risk >10%). This includes

most men aged >50 years or women aged >60 years who have

at least one additional major risk factor (family history of CVD,

hypertension, smoking, dyslipidemia, or albuminuria). C

• In patients in these age-groups with multiple other risk factors

(e.g.,10-year risk 5–10%), clinical judgment is required. E

Aspirin : ADA 2014 Recommendations

• Aspirin should not be recommended for CVD prevention

for adults with diabetes at low CVD risk (10-year CVD risk

< 5%, such as in men aged <50 years and women aged <60

years with no major additional CVD risk factors), since the

potential adverse effects from bleeding likely offset the

• potential benefits. C

Aspirin : ADA 2014 Recommendations

• For patients with CVD and documented aspirin allergy,

• clopidogrel (75 mg/day) should be used. B

• Dual antiplatelet therapy is reasonable for up to a year after

an acute coronary syndrome. B

Statins : ADA 2014 Recommendations

• Statin therapy should be added to lifestyle therapy, regardless of

baseline lipid levels, for diabetic patients:

with overt CVD

without CVD who are over the age of 40 years and

have one or more other CVD risk factors (family

history of CVD, hypertension, smoking,

dyslipidemia, or Albuminuria).

Statins : ADA 2014 Recommendations

• For lower-risk patients than the above (e.g., without overt

CVD and under the age of 40 years), statin therapy should

be considered in addition to lifestyle therapy if LDL

cholesterol remains above 100 mg/dL or in those with

multiple CVD risk factors. C

• In individuals without overt CVD, the goal is LDL

cholesterol <100 mg/dL.

Statins : ADA 2014 Recommendations

• In individuals with overt CVD, a lower LDL cholesterol

goal of < 70 mg/dL (1.8 mmol/L), with a high dose of a

statin, is an option. B

• If drug-treated patients do not reach the above targets on

maximum tolerated statin therapy, a reduction in LDL

cholesterol of >30–40% from baseline is an alternative

therapeutic goal. B

Statins : ADA 2014 Recommendations

• Triglyceride levels <150 mg/dL (1.7 mmol/L) and HDL cholesterol

>40 mg/dL (1.0 mmol/L) in men and >50 mg/dL (1.3 mmol/L) in

women are desirable. C However, LDL cholesterol–targeted statin

therapy remains the preferred strategy. A

• Combination therapy has been shown not to provide additional

cardiovascular benefit above statin therapy alone and is not

generally recommended. A

• Statin therapy is contraindicated in pregnancy. B

IMMUNIZATION: ADA 2014 Recommendations

• Annually provide an influenza vaccine to all diabetic patients > 6 months of

age. C

• Administer pneumococcal polysaccharide vaccine to all diabetic patients >2

years of age. A one-time revaccination is recommended for individuals >65

years of age who have been immunized >5 years ago.Other indications for

repeat vaccination include nephrotic syndrome, chronic renal disease, and other

immunocompromised states,such as after transplantation. C

• Administer hepatitis B vaccination to unvaccinated adults with diabeteswho

are aged 19–59 years. C

• Consider administering hepatitis B vaccination to unvaccinated adults

with diabetes who are aged>60 years. C

Point Designation based on predictors for 8-Year

Risk of Type 2 Diabetes in Middle-aged Adults

(45- 64 yr)Points

Fasting glucose level 100-126 mg/dL 10

BMI 25.0-29.9 2

BMI >30.0 5

HDL-C level <40 mg/dL in men or <50 mg/dL in women 5

Parental History of diabetes mellitus 3

Triglyceride level >150 mg/dL 3

Blood pressure >130/85 mmHg or receiving treatment 2

Total Points8 Year Risk,

%

≤10 <3

11 4

12 4

13 5

14 6

15 7

16 9

17 11

18 13

19 15

20 18

21 21

22 25

23 29

24 33

≥25 >35

Risk Of Development of Type 2 DM

Primary Prevention of Type 2 Diabetes

• Among individuals at high risk for developing type 2 diabetes,

structured programs that emphasize lifestyle changes that include

moderate weight loss (7% of body weight) and regular physical

activity (150 min/week), with dietary strategies including reduced

calories and reduced intake of dietary fat, can reduce the risk for

developing diabetes and are therefore recommended. A

• Individuals at high risk for type 2 diabetes should be encouraged to

achieve dietary fiber (14 g fiber/1,000 kcal) and foods containing

whole grains (one-half of grain intake). B

RECOMMENDATIONS FOR CHECK-UP IN DMPERSONS