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Prevention of cardiovascular risk in diabetes

Prevention of cardiovascular risk in diabetes. Applying evidence based medicine to clinical care. Cardiovascular disease is the biggest killer in UK. Number of deaths (000’s). 124,037. 60,666. 18,165. 33,634. 16,216. 12,762. 103,431. 19,996. 96,195.

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Prevention of cardiovascular risk in diabetes

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  1. Prevention of cardiovascular risk in diabetes Applying evidence based medicine to clinical care

  2. Cardiovascular disease is the biggest killer in UK Number of deaths (000’s) 124,037 60,666 18,165 33,634 16,216 12,762 103,431 19,996 96,195 National Institute for Health and Clinical Excellence, 2005

  3. Leading causes of death and disability in UK Disabilityadjustedlifeyears 1990 2020 Rank Cause % Rank Cause % National Institutefor Health and ClinicalExcellence, 2005

  4. Patients with one CV risk factor are likely to have additional risk factors +1 RF 27% +2 RFs 24% +1 RF 26% +2 RFs 25% No additional RF 17% +3 RFs 22% +3 RFs 20% No additional RF 19% + ≥ 4 RFs 12% + ≥ 4 RFs 8% Men Women Kannel WB. Am J Hypertens 2000; 13: 3S-10S

  5. SBP (mm Hg) 50 44% 110 150 120 160 40 130 170 33% 140 180 5-year CVD risk per 100 people 30 24% 18% 20 12% 10 6% 3% <1% 0 HDL = 39 mg/dL Male Reference TC = 270 mg/dL Smoker Diabetes 60 yearsof age TC = total cholesterol Additive risk factors Synergistic interaction of traditional multiple risk factors on CVD risk Jackson R et al. Lancet. 2005;365:434-41

  6. None Hypertens + diabetes Dyslipidaemia + hypertens +/- diabetes Diabetes only Dyslipidaemia Hypertension only Prevalence (%): 54.9 22.9 2.6 2.3 9.4 8.0 PROCAM: Combination of risk factors increases risk of MI Assmann G, Schulte H. Am Heart J 1988;116:1713-24

  7. Patients with Type 2 diabetes are a high cardiovascular risk group Nondiabeticpatients 50 Patientswith type 2 diabetes 45 40 35 -MI: no prior myocardialinfarction / +MI: prior myocardialinfarction 30 25 7-year incidence of cardiovascualrevents (%) 20 15 10 5 0 -MI +MI -MI +MI -MI -MI +MI -MI +MI +MI -MI +MI Myocardial infarction Cardiovascular death Stroke Haffner SM et al. NEJM 1998; 339: 229-34

  8. Nondiabetic Diabetic Dyslipidaemia Hypertension Obesity CHD deaths/ 1000 patient-years Serum cholesterol (mmol/L) SBP (mmHg) BMI (kg/m2) Cardiovascular risk factors in type 2 diabetes Adlerberth AM et al. Diabetes Care 1998;21:539-45 Eschwege E. Diabetes Metab 2003;29:6S19-27

  9. 0.25 diabetes + CVD (n=1448) 0.20 Event rate (Total mortality) diabetes + no CVD (n=569) 0.15 no diabetes + CVD (n=3503) 0.10 no diabetes/CVD (n=2796) 0.05 0 0 3 6 9 12 15 18 21 24 Months follow-up Diabetes is a CHD risk equivalent Malmberg K et al. OASIS. Circulation 2000;102:1014–1019

  10. Diabetesprevalence~171 million in 2000 ~366 million in 2030 140 155% 120 100 99% 102% Diabetes prevalence (in millions) 80 44% 180% 60 40 160% 20 0 W Pacific Africa Americas E Medit Europe SE Asia 2000 2030 Worldwide prevalenceofdiabetesexpectedtoincrease World Health Organization. www.who.org.

  11. 60 50 Myocardial 40 infarction % Incidence/1000 patient-years 30 Microvascular disease 20 10 0 <6 6-<7 7-<8 8-<9 9-<10 10+ Updated HbA1C (%) Hyperglycaemia and vascular complications in type 2 diabetes Stratton IM et al. BMJ 2000;321:405-12

  12. Type 2 diabetes:Vascularcomplications By 10 years: Microvascular 23% have had a significant microvascular complication (mainly retinal or macular) • Macrovascular • 28% have died from a diabetes related cause • 27% have had a myocardial infarction • 10% have had a stroke Marshall SM, Flyvbjerg A. BMJ 2006 333: 475-480 Johansen OE, Birkeland KI . Am J Cardiovasc Drugs. 2003: 283-97

  13. Diabetes No diabetes 100 90 80 70 60 50 40 100 90 80 70 60 50 40 Men Women n=1628 n=568 Survival (%) Survival (%) n=228 0 10 20 30 40 50 60 Months Post-MI Months Post-MI Post-MI survival n=156 0 10 20 30 40 50 60 Sprafka JM et al. Diabetes Care 1991;14:537–543.

  14. CABG PTCA 35 30 25 20 5-years mortality (%) 15 10 5 0 No diabetes (n=1476) Diabetes (n=353) Mortality after coronary intervention BARI Investigators. N Engl J Med 1996:335:217–225.

  15. Sources of excess mortality in diabetes NHANES I cohort Age-standardised mortalityper 100,000 person-years Death from Gu K et al. Diabetes Care 1998;21:1138-45

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