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Diabetic macrovascular disease

(atherosclerotic cardiovascular
disease in diabetic patients)
Assist. lect. dr. Ariel Florentiu

MICROVASCULAR COMPLICATIONS

in adults1

Diabetic
nephropathy
Leading cause of
endstage renal
disease2

Diabetic
neuropathy
Leading
cause of nontraumatic
lower
extremity
amputations2

Stroke
Two- to four-fold
increase in CV
mortality and
stroke2

Cardiovascul
ar disease
65%of
individuals with
diabetes die
from CV events2

Peripheral
arterial Disease
Prevalence of 29% in
diabetic people
> 50 years3

MACROVASCULAR COMPLICATIONS

Diabetic
retinopath
Leading cause
y
of blindness

Most complications arise from damage to small blood vessels and narrowing of
large arteries (atherosclerosis) associated with chronic hyperglycaemia.
Tight control of glycaemia may prevent these complications.

Cardiovascular risk
evaluation and primary
cardiovascular prevention
in diabetic patients

The concept of risk


Risk: the probability a (healthy) person will be

afected by a certain condition over a period of


time (short-term<10 yrs, long-term>10 yrs)
Absolute risk
Relative risk:

expressed as a ratio of the


persons
absolute
risk
to
a
certain
baseline/comparator

Residual risk: the persistent risk after maximal

treatment of modifiable risk factors

Cardiovascular risk factors


Characteristics (variables) present in the healthy

population that are independently and nonrandomly associated with the risk of developing
cardiovascular disease
Examples

Anthropometric determinations (e.g. weight, waist

circumference)
Diseases (e.g. arterial hypertension, diabetes)
Life style factors (e.g. smoking)

Genetic or environmental
The purpose of indentifying risk factors is to

modify them in order to prevent disease

Modifiable risk factors


Diabetes mellitus/prediabetes
Insulin resistance
Arterial hypertension
Hyperlipidemia
Obesity
Smoking
Sedentary lifestyle
Nutritional factors

Non-modifiable risk factors


Age
Male sex
Family history of premature cardiovascular

disease (genetic background)


Diabetes duration

Novel cardiovascular risk


factors
Abdominal obesity
Microalbuminuria
Reduced renal function (glomerular filtration rate)
Endothelial dysfunction
Biomarkers of chronic low-grade inflamation and

plasmatic viscosity (e.g. hsCRP)

Identification of risk factors and


risk estimation
History taking (including family history,

hystory of smoking, duration of diabetes)


Physical examination (including BMI, waist
circumference, BP)
Biochemistry: blood lipids, HbA1c, serum
creatinine (eGFR), albuminuria
Absolute risk estimation using risk
scores/engines

Framingham risk score


American population
Takes into account 6 risk factors: sex, age,

smoking, total and HDL-cholesterol, SBP


Estimates the absolute 10-yrs risk of coronary
death and non-fatal MI
Risk:
low(<10%);
moderate (10-20%);
high(>20%)

Years
20-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75-79

Points
-7
-3
0
3
6
8
10
12
14
16

Step 2: Total Cholesterol

15

SCORE risk diagrams


European population, low and high-risk

diagrams (high-risk for Romania)


5 risk factors: sex, age, smoking, total
cholesterol, SBP
Estimates the absolute 10-yrs risk of CV
death
Risk:
low(<1%);
moderate (1-5%);
high (>5%)

SCORE diagram

UKPDS risk engine


Type 2 diabetes specific
10 risk factors
Estimates the absolute 10-yrs risk of coronary and

cerebrovascular morbidity and mortality


Risk:
low (<15%),
moderate (15-30%)
high (30%)

UKPDS risk engine

Therapeutic means for preventing


macrovascular disease in diabetes
Lowering LDL-C with statin treatment (primary

prevention in all diabetic patients >40 yrs)


Lowering BP to <140/90 mmHg (using ACEi or ARBs as
first line agents)
Stoping smoking
Lowering HbA1c<7% (in most patients)
Other desirable lipid targets (HDL-C>40 mg/dl in men
and >50 mg/dl in women, TG<150 mg/dl)
Aspirin/clopidogrel for primary prevention (if 10-yrs risk
>10%)

Cardiovascular disease
characteristics in
diabetes

Introduction
2-3 fold increase in diabetic patients

compared to the general population


First cause of death in diabetes (65%);
2-4 fold increase in mortality rate of
established CV disease in diabetes as
compared to general population
The relative increase in risk from diabetes is
greater in premenopausal women than in
men
Atherosclerotic lesions histology in diabetes
is identical to non-diabetic patients. The
lesions often appear at an earlier age,
progress more quickly and are more diffuse

Coronary heart disease


Manifests at a younger age (7-10 yrs earlier)
Lesions are often diffuse (proximal and distal) with

involvement of all coronary arteries, with more


calcification and poorer collateral circulation
Frequent silent ischemia or atypical angina (in
patients with long-standing diabetes complicated
by autonomic neuropathy)

Acute coronary syndromes


More frequent
Sometimes with atypical or no pain
At the same extension of infarction diabetic

patients have an increased mortality


(secondary to acute HF and rhythm
disturbances)
30% of patients presenting with an ACS have
diabetes. Antecedent MI is an indication for
diabetes screening

What about RCA?

66 yr, , inferolateral STEMI


D1 culprit?...or LAD or OM

Peripheral arterial disease


2 fold increase in risk in diabetic patients
Typical lesions are diffuse, situated below the

knee on the medium calibre arteries (calf


trunks). Diabetes does not cause obligatory
diffuse disease of the small vessels
Sometimes with no intermitent claudication
(in diabetic patients that also have peripheral
polineuropathy)
Diabetes is the leading cause of nontraumatic lower-limb amputation

Cerebrovascular
disease
Strokes

are 2-4 times more frequent in


diabetic patients and have a higher mortality
The frequency increases with age and
diabetes duration

Cardiovascular disease management


Risk factor control as in primary prevention,

but often more aggressive


Other specific medical treatments

Antiplatelet treatment for secondary prevention


Beta-blockers at least 2 yrs post-MI

Specific cardiologic and surgical therapeutic

procedures (e.g. revascularisation)

Thank you!