An update for Northern diabetes educators Cardiovascular
disease: the long-term complication with Diabetes Mellitus November
20 th, 2014 Brian Butkus, PA-C,. MS. AACC Physician assistant, St.
Lukes Hospital Depart: Cardiology/Electrophysiology
[email protected]
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Presenters Disclosures
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Heart Disease: Atherosclerosis Slow progressive disease which
begins in childhood. Plaque in the artery wall forms as a response
to injury to the endothelium. Artery narrows and symptoms begin
when >50% blocked.
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Diabetes mellitus: A state of premature cardiovascular death
which is associated with chronic hyperglycemia. Fisher BM. Diabetes
Mellitus and myocardial infarction: a time to act or a time to
wait? Diabetes Medicine. 1998, 15: 275
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The State of Risk 2 out of 3 Americans are overweight or obese
More than 70 million (nearly 1 in 4) Americans have varying degrees
of insulin resistance There are an estimated 54 million (more than
1 in 6) Americans with prediabetes Nearly 1 in 4 U.S. adults has
high cholesterol 1 in 3 American adults has high blood pressure 2
out of 3 Americans are overweight or obese More than 70 million
(nearly 1 in 4) Americans have varying degrees of insulin
resistance There are an estimated 54 million (more than 1 in 6)
Americans with prediabetes Nearly 1 in 4 U.S. adults has high
cholesterol 1 in 3 American adults has high blood pressure
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Direct and Indirect Cost of CVD and Diabetes $296 billion$152
billion $116 billion$58 billion $412 billion$210 billion *Note:
these figures may not account for potential overlap. Sources: 2008
statistics from the American Diabetes Association and American
Heart Association. Cardiovascular Disease Diabetes TOTAL Estimated
Direct Medical Costs Estimated Indirect Costs (disability, work
loss, premature mortality)
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Heart disease strikes people with DM twice as often than those
without. Diabetics are 2-4x more likely to suffer strokes after
having had a stroke. By far the greatest cause of death in people
with diabetes is CVD. Deaths from heart disease in men with
diabetes have decreased by only 13% compared to a 36% decreased in
number without diabetes. Why the diff? In people with
Diabetes:
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DM and all CV-events according to the Framingham study
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Can a Hba1c Predict a MI in Type 2 Diabetes??
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UKPDS 35--Study
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So does this mean we should treat everyone to the lowest
attainable hemoglobin A1c Goal?
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Despite clear epidemiology, controversy continues regarding the
role of glucose lowering to prevent coronary events This is the
position statement by the ADA on glycemia and CVD--2010
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--11,140 patients randomized. --Followed 5.9 years. --There was
no evidence that intensive glucose (Hga1
Cholesterol Management For patients >20 years of age,
cholesterol should be checked every 5 years Ordering a fasting
lipid panel is preferred to gauge the patients total cholesterol,
LDL-C, HDL-C and triglycerides New guidelines based on ASCVD risk
score vs ATPIII guidelines based on treating to targets. For
patients >20 years of age, cholesterol should be checked every 5
years Ordering a fasting lipid panel is preferred to gauge the
patients total cholesterol, LDL-C, HDL-C and triglycerides New
guidelines based on ASCVD risk score vs ATPIII guidelines based on
treating to targets.
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New Recommendations for Diabetics and statins (LDL:70-189).
--Age 40-75(no CAD): Mod-intens statin. --Age 40-75(CAD):
High-intens statin. 2013 ACC/AHA LIPID GUIDELINES
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Statins???
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Do statins cause diabetes ? It is clear that statins can
prevent future major cardiovascular events!!!!!!!! Trials do show
that Statins can modestly raise blood sugars. In 1 study, diabetes
mellitus was diagnosed in 27% more patients receiving a statin
(rosuvastatin) compared with patients receiving placebo (an
identical appearing pill that does not contain medication), but
patients receiving the statin had a significant 54% lower risk of
heart attack, 48% lower risk of stroke, and 20% lower risk of death
from any cause.
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of Min LDL cholesterol) from a meta-analysis of 14 clinical
trials risk of experiencing a cardiac event or death by diabetes
status (for a near 40 mg/dL reduction in LDL cholesterol) from a
meta-analysis of 14 clinical trials of statin therapy. Shah R V,
and Goldfine A B Circulation. 2012;126:e282- e284 Copyright
American Heart Association, Inc. All rights reserved.
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So how much does a statin increase your glucose? Non- diabetics
Fasting sugars are increased by 3mg/dl Diabetics Increased
hemoglobin A1c by 0.3% Simsek S, Schalkwijk C, Wolffenbuttel B.
Effects of rosuvastatin and atorvastatin on glycemic control in
type 2 diabetes: the Corall Study. Diabet Med. 2012;29:628
631.
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Diabetes and heart failure: Numerous trials (HOPE,SOLVD) have
found DM as a major risk factor for the development of heart
failure. DM: can cause heart failure independent of CAD or HTN, via
the development of diabetic cardiomyopathy.
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Relation of glucose tolerance to LV Left ventricular size
increases with worsening glucose tolerance especially in women.
Multiple mechanisms have been implicated in this cause of CHF.
Henry RMA et al. Diabetes care. 2004; 27:522 -529.
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--AF is the most common arrhythmia in the world. --AF is likely
multifactorial and the mechanism is elusive. --Population based
studies suggest DM is an independent risk factor for AF. --Most
importantly is the fact that DM and AF are predictors for
stroke!!!!!!!! Link between DM and Atrial fibrillation cause or
correlation?
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Age (years) Prevalence % PREVALENCE OF AF 0.5 1.8 4.8 8.8 0 2 4
6 8 10 50-5960-6970-7980-89
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Priorities in the Management of A FIB The Patient Care Pathway
Rhythm Control Prevention of Thromboembolism Rate Control
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C CHF = 1 H Hypertension = 1Hypertension A Age >75 years = 1
D Diabetes = 1Diabetes S Prior Stroke or TIA = 2StrokeTIA Gage et
al. Validation of Clinical Classification Schemes for Predicting
Stroke. JAMA 2001: 285: 22 (2864-2870).
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Antithrombotic Therapy ACC/AHA/ESC Guidelines 2006 Risk Factor
Recommended Therapy No risk factors CHADS 2 = 0 Aspirin, 81-325 mg
qd One moderate risk factor CHADS 2 = 1 Aspirin, 81-325 mg/d or
Warfarin (INR 2.0-3.0, target 2.5) Any high risk factor or >1
moderate risk factor CHADS 2 >2 or Mitral stenosis Warfarin (INR
2.0-3.0, target 2.5) Prosthetic valve Warfarin (INR 2.5-3.5, target
3.0)
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Case - Mr. Martin Ms. Anderson 57-year-old female, hasnt seen
doctor in years Works as a driver, eats mostly fast food Smokes 1
pack per day At health fair found to have BP = 146/86, total
cholesterol = 210 Weight = 200 lbs; Family history of HTN and
diabetes Ms. Anderson 57-year-old female, hasnt seen doctor in
years Works as a driver, eats mostly fast food Smokes 1 pack per
day At health fair found to have BP = 146/86, total cholesterol =
210 Weight = 200 lbs; Family history of HTN and diabetes
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Chief Complaint: -SOB -Jaw discomfort when walking out in the
cold -Fatigue
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46 yo female transferred to SLH by Life Flight with Chest
Discomfort. -Admits to being diabetic but is on no medications.
-HTN -Smokes 1-pack cigarrettes -unknown lipid status --under
initial circumstances, difficult to obtain medical hx. Ms.
Johnson
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Ms Johnson Her Hemoglobin A1c 8.4%
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Risk factors(modifiable) for the prevention and management of
cardiovascular disease: 1. Hypertension 2. Dyslipidemia 3. Smoking
cessation 4. Hyperglycemia
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Patients with blood pressure >120/80 mmHg should be advised
on lifestyle changes to reduce blood pressure. Patients with
confirmed blood pressure higher than 140/80 mmHg should, in
addition to lifestyle therapy, have prompt initiation and timely
subsequent titration of pharmacological therapy to achieve blood
pressure goals. Recommendations: Hypertension/Blood Pressure
Control ADA. VI. Prevention, Management of Complications. Diabetes
Care 2014;37(suppl 1):S36
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Recommendations: Hypertension/Blood Pressure Control Lifestyle
therapy for elevated blood pressure Weight loss if overweight
DASH-style dietary pattern including reducing sodium, increasing
potassium intake Moderation of alcohol intake Increased physical
activity
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Antiplatelet and Diabetics Consider aspirin therapy (75162
mg/day) As a primary prevention strategy in those with type 1 or
type 2 diabetes at increased cardiovascular risk (10- year risk
>10%) Includes most men >50 years of age or women >60
years of age who have at least one additional major risk factor
Family history of CVD Hypertension Smoking Dyslipidemia Albuminuria
2010, a position statement of the ADA, the American Heart
Association (AHA), and the American College of Cardiology
Foundation (ACCF)
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Aspirin continued Aspirin should not be recommended for CVD
prevention for adults with diabetes at low CVD risk, since
potential adverse effects from bleeding likely offset potential
benefits --Low risk: 10-year CVD risk