Transcript Cardiac Complications of Diabetes

Aggressive treatment of risk factors to prevent cardiovascular
complications of Diabetes
Ms. Kristin L. Eckland, RN, MSN,
ACNP-BC
Duke University Health System
Cardiothoracic Surgery
Cardiac Complications
Overview
of Diabetes
Diabetes is a complicated, complex multi-systen disease!
 Diabetic complications primarily affect the cardiovascular
system (heart and blood vessels)
 result of inflammatory damage and accelerated
atherosclerosis (plaque formation)
 This is part of the effects seen on kidneys, eyes, and feet.
Cardiovascular System
Atherosclerosis
(plaque formation)
Incidence & Implications
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Diabetes is epidemic worldwide, but huge numbers of
people remain undiagnosed (and thus untreated.)
Among diagnosed Diabetes the rate of complications
remains frighteningly high due to poor glucose
control, failure to address modifiable risk factors and
poor adherence to therapies.
International Diabetes Federation, 2009.
Scope of Problem – United States
Local Diabetes incidence,
2005 data
CDC, 2005 - * Does not factor pre-diabetes, undiagnosed disease.
Danville city 11.5 %
Pittslyvania county 10.2%
So what?
Source: Haffner SM et al. N Engl J Med. 1998;339:229-234. “Impact of Diabetes
and Hypertension on Cardiovascular Risk”
Evidence based outcomes
Steno-2 study showed that by controlling the five factors
mentioned here –
Cardiovascular and microvascular outcomes reduced by
50% (over 9 years) with a 57% reduction in mortality
over 13 years.
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Another large study showed that after 3 years of intensive
treatment - 79% of diabetic patients no longer
demonstrated silent ischemia. (Note – study was in
asymptomatic patients).
Incidence & Implications
Diagnosis of Diabetes is cardiac equivalent to a small
heart attack.
 Heart disease defined as ‘heart failure & heart attack’
is the number one cause of death among diabetics.
 A glycosolated hemoglobin A1c greater than 7.0% is
indicative of increased risk of cardiovascular events
(heart attack, stroke).**
** further discussion on future slides
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Pharmacological
Management
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All treatment regimens should be discussed with your
primary care provider.
Medical therapies should be individualized.
This presentation is not a substitute for regular checkups and examinations with your primary care provider.
These are recommendations/ explanations of existing
therapies/ current guidelines ONLY.
Risk Factors for MI (heart attack)
1. Dyslipidemia (abnormal lipids)
Diabetes changes the way lipids are processed by the body,
leading to abnormal / increased plaque (blockage)
formation.
These changes also decrease the amount of HDL produced.
THIS IS GREATLY WORSENED BY SMOKING!
Guidelines for Treatment:
LDL (bad cholesterol) LESS than 70
HDL (good cholesterol) GREATER than 50.
For every 1% LDL is reduced, cardiac events decrease 1%. For HDL: every 1% increase equals 3%
decrease in cardiac events (Bell, 2008). Based on the article, “A cardiac condition manifesting as
Hyperglycemia: Risk factors for Myocardial infarction.” Medscape, October 2009.
Dyslipidemia
Treatment Guidelines:
-All type 2 diabetics (with no contraindications) should be
prescribed a ‘statin’ drug. (pravastatin*, lovastatin*,
atorvastatin, simvastatin)
Statins work two ways:
-reduce plague formation
-reduce epithelial inflammation
Statins primarily work on lowering LDL.
* Available of the $4 plan of many pharmacies
Dyslipidemia - continued
-Exercise: at least 150 minutes per week.
Exercise lowers circulating glucose levels,
and RAISES HDL.
-fibrates (Gemfibrozil)
Works on triglycerides, and with some increase in HDL,
modest decrease in LDL.
Recently FDA approved as adjuvant treatment for
diabetes – improves glucose control.
Hyperglycemia
- Hyperglycemia!! – not diagnosis of Diabetes!!
-This includes people in ‘at risk’ catagories that are often
undertreated such as “pre-diabetes.”
-It’s not the label that matters – it’s the glucose level.
**No hyperglycemia should be treated with diet and
exercise alone – this is a recipe for failure!
>95% of ‘pre-diabetics’ become diabetics*
-New & existing data confirms that diabetic
complications are occurring at this stage!
* when treated with diet and exercise alone.
Hyperglycemia
-Postprandial (after eating) glucose elevates earlier during
disease process (5 to 7 years earlier). During this early
period, organ damage is occurring.
-Postprandial glucose (PPG) is a better marker of glucose
control, compared to fasting glucose.
-Hemoglobin A1c for global view of glucose control. Test
provides 3 month overview of glucose.
Hemoglobin A1c
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Important tool for diabetes care.
Research suggests A1c & postprandial glucose testing
more accurate for diagnosing diabetes. Currently
under review for revision of endocrinology guidelines.
Ideal results: 4.6 – 5.7% - this is what we should be
striving for.
Treatment strategies should be based on A1c.
“Glycemia in nondiabetics linked with silent cardiovascular disease”.
Diabetes Care, 2009;32: 1712-1733.
“ADA 2009: Expert committee recommends use of hemoglobin A1c for
diagnosis of Diabetes. American Diabetes Association (ADA) 69th
Scientific Sessions, June 2009.
A1c results:
Hemoglobin A1c
Average glucose
Comment
4.6 – 5.7
70 - 110
Normal/ optimal
6.0
135
Abnormal..
7.0
170
8.0
205
At increased cardiac
risk!!
Add insulin to
current meds
9.0
240
Poorly controlled
10
275
At very high risk for
11
310
CV events
Cardiac risk predicted by ACCORD, UKPDS studies.
Evidence-based treatment
New
recommendations: ADA 2009
guidelines
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for elevated PPG, or hemoglobinA1c greater than 5.9
– 7.9: start METFORMIN, and /or sulfonylureas
(glipizide).
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For A1c greater than 7.9: Metformin + basal insulin
(lantus or levemir)
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For grossly uncontrolled diabetes: Metformin, basal
insulin and mealtime insulin regimens.
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Evidence-based treatment
Latest research shows little support for alternative oral
guidelines
diabetic agents. Use as second line only.
Metformin as superior agent to other therapies, with
limited side effects and several additional benefits (in
addition to glucose control.)
New guidelines recommend continuing metformin
when transitioning/ continuing insulin therapy.
Note: Metformin use may be limited by poor renal
function/ lung function in some individuals.
** Metformin available as $4 medication.
Hypertension Management
Research indicates that people with diabetes need tighter
blood pressure control than previously recommended.
-This often requires a step by step approach using
multiple medications.
Goals:
Systolic blood pressure less than 130. (top number)
Diastolic blood pressure less than 80.
Hypertension
Note:
Many drugs that are used for hypertension (high blood
pressure) are also used for other reasons, particularly
in diabetic individuals.
These medications are often prescribed even when blood
pressure is normal.
For example: Lisinopril (ace-inhibitor) is used to slow the
progression of kidney disease in Diabetics, and reduce
cardiac workload in patients after a heart attack, or in
congestive heart failure.
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Endothelial inflammation/
Hyperglycemia
= Endothelial inflammation/
damage,
Antiplatelet
Therapy
leading to increasing thrombus/ clot formation.
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Recommendations: if no contraindications
Aspirin 81mg (baby) every evening*
Aspirin 325mg if heart history
Add clopidogrel if other indications; ie. history of previous
stent, medical management of diagnosed CAD, PVD.
No specific brand of Aspirin has been shown to be superior to any other.
Microalbuminuria
Early indicator of diabetic nephropathy (diabetic damage
to kidneys).
This is the presence of small particles of protein in the
urine. Passage of protein through the glomeruli (or
filtering units of the kidney, damages the kidney.)
-Detected in urinalysis (UA)
-Presence of microalbuminuria indicates 16.5X
increased risk of cardiovascular mortality over 3.6
years (Bell, 2009).
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Microalbuminuria Control of serum
glucose/ hyperglycemia
Treatment
Additional of an ace-inhibitor, “prils”
(lisinopril, fosinopril, enalapril, etc.)
Note: Medications help treat all of these conditions, not
cure.
Glucose control most important factor for preventing
additional damage.
Case Study #1
Ms. M is a 43 y.o overweight woman who presents to her
MD for routine check up.
Ht 5’2” wt. 155 (6 pound increase in 6 mo.) BMI 28
B/P 142/86 (136/90, 140/90 on previous checks) Heart
rate: 76 R- 12 T 98.2
Labs:
Fasting glucose 105 A1c: 6.4%
UA: + microalbuminuria
Chl: 230 Tri 130 HDL: 25 LDL: 120
What should we be looking at? How many risk factors does
she have?
Case Study – evaluation
Risk Factors:
-Overweight (BMI greater than 25, recent wt gain)*
-elevated B/P on last three checks
-Hyperglycemia (fasting greater than 100, A1C elevated)
-Dylipidemia
-Microalbuminuria
* Secondary risk factor for HTN, DM
What are YOUR recommendations?
Case Study - Treatment
Nonpharmacological:
-Diet modification
-exercise program (walking 150+ minutes/
week)
-diabetes teaching
Ms. M also to learn how to check her blood
sugar, and blood pressure and record for
follow up visits.
Case Study - Treatment
Pharmacological:
-Pravastatin (dyslipidemia, endothelial function)
-Metformin (hyperglycemia, endothelial function)
-Lisinopril (for B/P, and microalbuminuria)
-Aspirin (endothelial function)
*Total cost of medications: $14.00/ month
Patient to return in ONE month for re-assessment.
- plan to adjust medications according to B/P readings,
glucose and follow up labs.
Questions?
“I am the master of my fate; I am the
captain of my soul.”
William Ernest Henley