Transcript Lifestyle ,smoking and statins

Smoking, lipids and lifestyle
Dr Shirley Copland
Associate Specialist
Normal heart and coronary artery
Diseased coronary artery
Diabetes and cardiovascular risk
• Adults with diabetes have a reduced life
expectancy of some 5-10 years
• Most deaths are due to circulatory diseases
• Heart attacks rates are 3 -5 fold increased
• Stroke risk is increased 2-3 fold
• After 15 years duration of type 2 diabetes more
than 20% of patients have had a heart attack ( UK
prospective diabetes study)
DIABETES AND CARDIVASCULAR
DISEASE
AGE
DIABETES
45-54
55-64
65-74
24.8
37.9
40.5
Incidence of MI per 1000 women
NO DIABETES
4.3
12.6
22.6
Why the excess risk in Diabetes ?
• Thought that raised blood glucose levels are
toxic to the lining of blood vessels
• Vessels are then more susceptible to damage
from all the other risk factors e.g. high blood
pressure, smoking
• Low density lipoprotein (LDL) is more densely
packed with triglyceride which is more readily
taken up into the vessel walls causing atheroma
plaques
Coronary Risk Factors
• Modifiable
• Unmodifiable
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Smoking
High blood pressure
Cholesterol levels
Excess weight
Lack of exercise
High glucose levels
Being male *
Family history
Age
Diabetes mellitus
Proteinuria
Risk Factors - Smoking
• Widely recognised to accelerate coronary artery
disease and to increase risks of certain cancers
• Smoking >20 per day more than doubles the
risk of coronary disease
• Scottish Diabetes Survey 2004 showed 18%
patients with diabetes in Grampian remain
smokers
Risk Factors - Smoking
• Simple advice to stop smoking has a small but
significant effect
• Nicotine replacement therapy can double quitting
success rates
• Zyban also helps more people to be successful but
can increase the BP
• No definite evidence for benefit of acupuncture
• Many people need several attempts to stop –
encourage to keep trying!
• Monitor for relapse !
Risk Factor - Lifestyle
• A 10 kg weight loss in obese patients with
diabetes has been shown to reduce mortality by
25%
• Exercise helps control weight, blood pressure and
lowers blood sugar
• In the UK 60-70% of the adult population is
considered to be physically inactive
• Moderate exercise works - taking a brisk walk
most days reduces coronary risk by up to 50%
Risk Factors - Cholesterol
• Cholesterol is essential in the body
• Component of all cell membranes, needed for
manufacture of steroid hormones, used to make
bile salts which are necessary for digestion
• Excess dietary saturated fat increases blood lipids
• Liver is involved in cholesterol manufacture
Risk Factors - Cholesterol
• Cholesterol is carried in the blood in particles
called lipoproteins.
• Lab tests report the total cholesterol (TC) and the
amounts of the component particles:
• HDL ‘the good’
• LDL ‘the bad’
• TC to HDL ratio ‘the ugly’
• In type 2 diabetes the ratio is often raised due to
low HDL
How to reduce Cholesterol
• We all know the healthy eating messages reduced saturated fats, more fruit and veg and
oily fish - emphasis is on a balanced diet.
• Fish oil supplements shown to be cardioprotective in the short term in high risk
patients. No long term overall benefits.
• Benecol and Flora pro-active margarines do
lower the LDL cholesterol - probably beneficial
but no long term studies to date.
How to reduce Cholesterol
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Weight loss
Exercise
Good blood sugar control
Exclude secondary causes e.g. hypothyroidism
• However despite best efforts the cholesterol levels
often remain relatively too high
Heart Protection Study 2002/3
• Major recent trial studying >20,000 subjects aged
over 40 with vascular disease, hypertension or
diabetes
• Patients had ‘normal’ cholesterols at entry
• In diabetes patients taking simvastatin:
• 27% reduction in major coronary events
• 25% reduction in strokes
• Note - need to treat 100 people for 5 years to
prevent 7 events but benefits would accrue
CARDS 2004
• Almost 3000 patients with type 2 DM
• Patients had no known vascular disease but
had either retinopathy, microalbuminuria,
hypertension or were smokers
• LDL < 4.14 on entry
• Showed atorvastatin prevented 37 vascular
events per 1000 people treated for 4 years
Statin drug therapy
• Most effective lipid lowering medications
• Many large studies have now shown consistent
reductions in cardiovascular risks
• Do more than just reduce the cholesterol - protect
the circulation
• Low incidence of side effects in clinical trials
Potential benefits of ‘statins’
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Reduce major coronary events
Reduce stroke risk
Reduce mortality from heart disease
Reduce need for coronary procedures
(angioplasty, coronary artery bypass grafts)
• Reduce total mortality
‘STATINS’
• Simvastatin, pravastatin, atorvastatin, fluvastatin
and most recently rosuvastatin
• Act on the liver enzyme (HMG Co A reductase)
involved in cholesterol synthesis hence lowering
blood levels
• Not used in active liver disease
• Few drug interactions (but avoid combination with
clarithromycin /erythromycin, ketoconazole,
antivirals, ciclosporin)
• Grapefruit juice avoidance with simvastatin
‘STATINS’
• Few side effects
• Most common are GI effects or headache
• Rare side effects include muscle or liver
inflammation (< 1 in 10,000 patient years)
• Liver tests checked before starting treatment
and periodically thereafter and patients are
advised to report any new muscle pain
• Contra -indicated in pregnancy
Guidelines - shifting the goalpost
• Grampian Diabetes Guidelines - Feb 2004
• GP contract targets - April 2004
• Joint British Societies 2 - November 2005
Joint British Societies Guidelines
(JBS 2)
• All patients with diabetes should receive
lifestyle advice and lipids monitored
• All patients with known vascular disease
should be offered statin therapy
• For primary prevention if patients with
diabetes meet the following criteria then
statin therapy should be offered
• Treat to a target of TC  4 and LDL  2
Joint British Societies Guidelines
(JBS 2)
• All patients with diabetes aged  40 years
• Patients with diabetes aged 18-39 years who
have at least one of:
-retinopathy (severe, prolif. or maculopathy)
-nephropathy (incl. microalbuminuira)
-poor glycaemic control (HBA1c >9%)
-hypertension
-TC  6 or features of metabolic syndrome
-FH of premature IHD
Joint British Societies Guidelines
(JBS 2)
• Low dose aspirin :
• All people with type 2 DM aged  50 years
• Younger patients with diabetes with either
-more than 10 years duration
-treatment for hypertension or
-evidence of complications e.g. retinopathy
or nephropathy
Mr JD 69 years
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Type 2 DM onset 2005
Ex smoker 1989 BMI 27 HBA1c 6.9%
BP 158/78
Left calf claudication
No retinopathy MA screen normal
TC 5.2 LDL 2.9
Rx Metformin
Mr JD 69 years
• Encourage activity increase within limits
• Update on foot self care and refer to
podiatry
• Aspirin
• Statin - simvastatin 40 mgs
• Ace inhibitor as first line anti-hypertensive
Mrs SD 38 years
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Type 2 DM onset 2001
Smoker BMI 33 HBA1c 7.2%
BP 140/86
Check out assistant
No retinopathy MA screen normal
TC 4.2 LDL 2.3 TRIGs 1.2
Rx Metformin
Mrs SD 38 years
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Smoking cessation support
Reinforce dietary advice
Consider Xenical
?Exercise class
Mr J S 38 years
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Type 2 DM onset 2000
Ex smoker BMI 35 HBA1c 8.5%
On anti-hypertensive Rx BP 148/78
Erectile dysfunction 2003
No retinopathy MA screen normal
TC 4.8 LDL 2.6
Rx Insulin, metformin, ramipril, sildenafil
Mr J S 38 years
• Review advice on weight reduction and
activity level
• Insulin and metformin
• Ace inhibitor and other agent to lower BP
• Sildenafil
• Statin
• Aspirin
Mr AF 49 years
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Type 1 DM since 1994
Non smoker BMI 27 HBA1c 8.5%
BP 128/76
Fit joiner
No retinopathy MA screen normal
TC 4.3 LDL 2.5
Rx Basal bolus insulin regime
Mr AF 49 years
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Basal bolus insulin regime
Review education
Simvastatin 20 mgs
Aspirin (nearly 50 years)
Miss C D 34 years
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Type 1 DM since 1980
Smoker BMI 27 HBA1c 7.5%
BP 135/78
Moderate retinopathy
Microalbuminuria present
TC 4.8 LDL 2.7
Miss C D 34 years
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Basal bolus regime of insulin
Support re smoking cessation
Ace inhibitor
Statin
Aspirin
Contraception!