Transcript عوارض قلبی دیابت

‫عوارض قلبی دیابت‬
‫دکتر شهرام مظاهری تهرانی‬
‫بورد تخصصی قلب و عروق‬
ATHEROSCLEROSIS
Pations with diabetes have two to eightfold higher rates of future
cardiovascular events as compared with
age and ethinicity-matched nondiabetic
individuals
patients with diabetes have worse
CVD outcomes after ACS events.
Worse prognosis with higher
glucose level
SILENT MI
In addition to CHD, diabetes increases the
risks of stroke and peripheral arterial
disease. The diagnosis of diabetes
portends a twofold increased stroke risk
compared with nondiabetic individuals
Abnormalities in lipid metabolism also
contribute to the increased atherosclerotic
risk associated with diabetes
Diabetic dyslipidemia is characterized by
high triglyceride levels, low HDL
concentration, and increased atherogenic
small dense LDL particles, each of which
is likely to contribute to the accelerated
development and progression of
atherosclerosis
METABOLIC SYNDROME
At least 3 of following 5 critria
1-waist circumference larger than 102 cm in men
and 88 cm in women
2-TG at least 150 mg/dl
3-HDL less than 40 mg/dl in men and less than 50
mg/dl in women
4-BP of at least 130/85
5- FBS at least 110 mg/dl
Therapeutic lifestyle interventions remain the
cornerstone of prevention of the
atherosclerotic complications associated with
diabetes
include smoking abstinence, at least 150
minutes of moderate-intensity aerobic activity
weekly, and medical nutrition therapy
recommendations for weight control and
dietary composition
Beyond lifestyle, a number of
pharmacologic strategies have proven
effective for CVD risk reduction in
diabetes and are recommended for
routine prescription for patients with
diabetes
Such interventions include intensive blood
pressure and lipid management,
consideration for angiotensin-converting
enzyme (ACE) inhibitors independent of
blood pressure, and daily antiplatelet therapy
for patients with prevalent CVD or increased
primary risk
Aspirin Therapy
The ADA and AHA presently recommend daily
aspirin (75 to 162 mg/day) for all patients with
diabetes who have prevalent CVD or for primary
prevention in all patients older than 40 years
with additional CVD risk factors or younger in
the presence of prevalent CVD risk
LIPID CONTROL
considering diabetes as a coronary disease
risk equivalent, an optional target for LDL
cholesterol of <70 mg/dL should be
considered for patients with diabetes
Contemporary guidelines for the
management of diabetic dyslipidemia focus
on the use of statin medications
Once LDL cholesterol targets have been
achieved through lifestyle modification and
statin therapy, the principal secondary
therapeutic lipid target for patients with
diabetes who have persistent fasting
triglyceride elevation >200 mg/dL
The preferred method to achieve the
secondary target is by intensification of
statin monotherapy as tolerated, with the
secondary option to add another lipidmodifying agent such as niacin, ezetimibe,
bile acid binders, or fibric acid derivatives
HYPERTENSION
Hypertension affects
approximately 70% of
diabetic patients
Given the potent benefits for both
macrovascular and microvascular
disease complications, blood
pressure management is of principal
importance in this high-risk
population
Blood pressure targets for patients with
diabetes are more aggressive than for
the overall population, with a goal of
<130/80 mm Hg most patients requiring
a combination of multiple blood pressure
medications to achieve such targets
ACE inhibitors and angiotensin II receptor
blockers (ARBs) have become keystones of
therapy for hypertension in diabetes because
of their broadly demonstrated favorable
effects on diabetic nephropathy and CVD
outcomes, as well as their modest favorable
effects on measures of glucose metabolism
ACE inhibitors are the first-line
treatment for hypertension in the
setting of diabetes and should be
considered for all diabetic patients
with prevalent CVD or a clustering of
CVD risk factors
ARBs should be considered
second-line therapy, and their use
reserved for those patients who
cannot tolerate ACE inhibitors
because of cough, angioedema,
or rash
Calcium Channel Blockers
Dihydropyridine calcium channel
blockers, such as nifedipine,
nitrendipine, nisoldipine, and
amlodipine, are well tolerated and
effective at lowering blood pressure
BETA BLOCKERS
beta blockers are another key
component of effective CVD risk
reduction in diabetes.
Early in the course of clinical use, beta
blockers were considered relatively
contraindicated in the setting of diabetes
because of concerns about masking
hypoglycemia symptoms and adverse effects
on glucose and lipid metabolism. These
concerns have been mitigated by the results
of CVD outcomes trials supporting the benefit
of beta blockers for patients with diabetes
Thiazide Diuretics
Concern about the adverse glycometabolic
effects of the thiazide diuretic class of
medication has resulted in some degree of
hesitancy to use these medications in the
setting of diabetes or in patients at
increased risk for development of diabetes
However, randomized trials of thiazide
diuretics that included substantial
numbers of patients with diabetes
have consistently demonstrated CVD
benefits despite their adverse
metabolic effects
Heart Failure in the Patient with Diabetes
diabetes associates independently with a
twofold to fivefold increased risk of heart
failure compared with those without
diabetes, comprising both systolic and
diastolic heart failure
once HF is present, diabetes portends
especially adverse prognosis for
subsequent morbidity and mortality
In general, drug therapies for HF
evaluated in the overall population of
patients with risk and disease generally
have similar if not better efficacy in
patients with diabetes compared with
those without diabetes
ACE inhibitors should be firstline therapy for the prevention
and treatment of HF in patients
with diabetes