Professional Documents
Culture Documents
Pugud Samodro
Lab/SMF Ilmu Penyakit Dalam FK Unsoed/RSUD Prof.Margono
Soekarjo
Purwokerto
Diabetes characteristic in
Indonesia
2007 - 2013
Source : Source :
Riskesdas 2007 Riskesdas 2013
The Cardiovascular Continuum of Events
ACS
Coronary
Secondary Arrhythmia and
prevention
Thrombosis Stroke
Loss of Muscle
Myocardial Remodeling
Ischemia
Ventricular
CAD Dilatation
Atherosclerosis Congestive
Heart Failure
Primary
prevention Risk Factors End-stage
Heart Disease
( Dyslipidemia, BP, DM,
Insulin Resistance, Platelets,
Adapted from
Fibrinogen, etc)
Dzau et al. Am Heart J. 1991;121:1244-1263
Atherothrombosis: A Generalized
and Progressive Process
Unstable
angina ACS
MI
Ischemic
stroke/TIA
Critical leg
ischemia
Cardiovascularde
ath
Atherosclerosis Atherothrombosis
Stable angina
Intermittent claudication
Adapted from Stary HC et al. Circulation. 1995; 92: 135574, and Fuster V et al. Vasc Med.
1998; 3: 2319.
What are the CHD risk
Factors?
Gender
Smoking
Age
BP control
Race
Lipid management
Family history
Physical activity
Weight
Diabetes
CV Risk Factors in
Diabetes
12
10.0
10
8
Odds Ratio
6.5
6
3.2
4
2.3
2
0
Microalbuminuria Smoking Diastolic BP Cholesterol
11
DM Strongest RF for CVD
DM = CHD
12
ACS and Diabetes Up to 1 Year
25
P<0.0001
No Diabetes
20 21.3
% of patients
N = 3429
Diabetes P<0.0001
15 N = 1149
14.4 14.1
P=0.035
10
8.9 7.
P<0.0001 7.
5 1
9
3.9
1.8
0
In-Hospital Non-fatal MI 1-y All-Cause 1-y
Mortality Mortality Mortality/MI
29%
24%
21%
15%
Harris,Setal.;Type2DiabetesandAssociatedComplicationsinPrimaryCarein
Canada:TheImpactofDurationofDiseaseonMorbidityLoad.CDA2003.
Duration of DM - CV Mortality
3
2.5
2
1.5
1
0.5
0
<5 6 to 10 11 to 15 16 to 25 26 +
Years
DM
90 No DM 1600
80 1400
70 1200
60 Diabetes
1000 No Diabetes
50
800
40
600
30
400
20
10 200
0 0
Men Women Mortality rate/100,000
14
12
10
8
%
6
4
2
0
CV Death MI Stroke Dialysis
HOPE/MICROHOPE.Lancet2000;355:253.
OASIS Study: Total
0.25
Mortality
Diabetes/CVD +, (n = 1148)
RR = 2.88 (2.37-3.49)
Diabetes/CVD -, (n = 569)
0.20 No Diabetes/CVD +, (n = 3503)
No Diabetes/CVD -, (n = 2796)
Event rate
0.05
RR=1.00
0.0
Months 3 6 9 12 15 18 21 24
A: HbA1c <7%
B: BP <140/85 mmHg
C: LDL Cholesterol <70 mg/dL
*These targets should be applied with individual needs taken into account
http:www.escardio.org/GUIDELINES-SURVEYS/ESC-GUIDELINES/Pages/diabetes.aspx
WHAT IS ABC
CONTROL ???
A = A1C = Glycemic control
B = Blood pressure control
C = Cholesterol-LDL control
These ABC,
major and modifiable risk factor
the primary target goals for the
prevention of
CVD
MANAGING HIDDEN CARDIOVASCULAR
RISK IN DIABETES MELLITUS
OLD agents:
Metfromin, Sulfonilurea, a-glucosidase
inhibi-tor, TZDs/Piogtazone
NEW agents:
DPP-4 inhibitors, SGLT2 inhibitors, GLP-
1recep-
tor agonist, insulin analog
The implementation strategies: ADA-
EASD 2015
A Patient-Centered Approach
ADA EASD
PATIENT CENTERED
HEALTHY, EATING, WEIGHT CONTROL, INCREASED PHYSICAL ACTIVITY
Initial drug
monotherapy Metfomin
If needed to reach individualized HbA1c target after 3 months, proceed to two-drug combination (order not
meant to denote any specific preference)
Prevalence
of
hypertensio 50
n
(%)
225
Without
CV mortality rate/ 10.000
diabetes
200
With
diabetes
175
person-years
150
125
100
7
5
5
0
2
5
0
< 120- 140- 160- 180- >
120 139 159 179 199 200
Systolic blood pressure
(mmHg)
Association of systolic blood pressure and CV death
in type 2 diabetes The Lancet 2000; 36: 1955 -
BLOOD PRESSURE (B) CONTROL ADA
2015
BP should be measured at EVERY
routine visit
The target goals:
Systolic BP < 140 mmHg
Diastolic BP < 130 mmHg
Lower BP, systolic < 130 mmHg,
diastolic < 80 mmHg
for younger patients
Pharmacologic therapy:
either ACE inhibitors or ARB
multiple drug combination is generally
required
BLOOD PRESSURE (B) CONTROL ADA
2015
Intensive BP target (upper limit of Syst < 130
and Diast < 80 mmHg) vs Standard BP target
(upper limit Syst 140-160, Diast 85-100
mmHg:
- no significant reduction in mortality or
non-fatal MI
BUT statistically reduction in stroke
ACCORD study, SBP < 120 mmHg compared to
SBP 130-140 mmHg, no benefit
ADVANCE study, BP 136/73, 6 yr follow up,
significant reduction of death any cause, and
CVD
CHOLESTEROL LDL (C)
CONTROL AND CVD IN
DIABETIC PATIENTS
Paradigm shift from:
Treat - to -Target
to
Intensive Statin Therapy
(Gupta A: Endocrinol Metab Clin N Am 2014;43:869-892)
NCEP ATP III LIPID GUIDELINE LDL-C GOALS FOR
DIFFERENT RISK CATEGORIES : TREAT TO TARGET
Risk category LDL goal LDL level at LDL level
at which
(mg/dL) which to initiate to consider
drug
therapeutic life therapy (mg/dL)
style changes
(mg/dL)
0-1 risk factor < 160 > 160 > 190 (160-
189: LDL-lowering
drug optional)
CHD or CHD risk < 100 > 100 > 100 (100-
129:
Gupta A, et al. Endocrinology and drug
equivalents metabolism clinics of North America
optional)
2014; 869-912
(10-y risk > 20%)
The ACC/AHA Guidelines,
November 2013
Group 1 Group 2
Group 3 Group 4
Group 3 Group 4
Trials: Trials:
CARDS-Atorva ASCOT LLA-
Diabetes ASCVD risk 7.5%
TNT*-Atorva Atorva
HPS*-Simva mellitus No diabetes HPS-Simva
+ age of 4075 years JUPITER-Rosuva
+ age of 4075 years + LDL-C 70189 mg/dL
+ LDL-C 70189 mg/dL
* Subgroup analysis
Stone NJ, et al. J Am Coll Cardiol 2013 Nov 7. Epub
AMERICAN COLLEGE OF CARDIOLOGY
AND AMERICAN HEART ASSOCIATION
(ACC-AHA), 13 November 2013
The guideline focuses on: Treatment of blood
cholesterol
to reduce atherosclerotic cardiovascular disease
(ASCVD)
What is new in the ACC-AHA:
1. Identification of 4 Statin Benefit Groups
- Individuals with clinical ASCVD
- Individuals with primary elevation of LDL-C
> 190
mg/dL
- Individuals 40-75 years of age with diabetes
with
LDL-C 70-189 mg/dL
- Individuals without clinical ASCVD or
AMERICAN COLLEGE OF CARDIOLOGY
AND AMERICAN HEART ASSOCIATION
(ACC-AHA), 13 November 2013
Type 1 or 2 diabetes
No Consider statin
Age 4075 years
individually
Yes
High-intensity Moderate-intensity
statin* statin
Lovastatin 40 mg Pitavastatin 1 mg
Fluvastatin XL 80 mg
Fluvastatin 40 mg BID
Pitavastatin 24 mg
*LDL-C reduced by 50%; Reprinted from J Am Coll Cardiol, ePub ahead of print, Stone NJ, Robinson J, Lichtenstein AH,
LDL-C reduced 3050%; Bairey Merz CN, et al., 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce
Atherosclerotic Cardiovascular Risk in Adults: A Report of the American College of
LDL-C reduced <30% Cardiology/American Heart Association Task Force on Practice Guidelines. Copyright (2013), with
BID, 43
twice daily dosing permission
Adapted from Stone NJ, et al. J Am Coll Cardiol 2013 Nov from Elsevier
7. Epub ahead
of print
Recommendations for Nonstatin Drugs
Recommendations for statin treatment and lipid monitoring were revised after consideration of 2013
ACC/AHA guidelines on the treatment of blood cholesterol
In light of this fact, the 2015 ADA Standards of Care have been revised to recommend when to initiate
and intensify statin therapy (high versus moderate) based on risk profile
Treatment initiation (and initial statin dose) is now driven primarily by risk status rather than LDL
cholesterol level