1 / 34

CVD Workshop

CVD Workshop. SDPI CVD Risk Reduction Project Meeting #5 Denver, Colorado. Case Study. 62 year old woman presents for her scheduled intake visit for your CVD project She has been overweight most of her adult life and has a BMI of ~32 PMHx: HTN, diet controlled diabetes

walden
Télécharger la présentation

CVD Workshop

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. CVD Workshop SDPI CVD Risk Reduction Project Meeting #5 Denver, Colorado

  2. Case Study • 62 year old woman presents for her scheduled intake visit for your CVD project • She has been overweight most of her adult life and has a BMI of ~32 • PMHx: HTN, diet controlled diabetes • Medication: HCTZ 25 mg Q day

  3. Case Study • SHx: Walks to the bus every day and occasionally walks with friend on the weekend • She smoked ½ pack/day until 2 years ago • FHx: Her sister is overweight, and take metformin for diabetes, her father died from a heart attack, her mother has diabetes

  4. Case Study: Physical Exam • Vitals: Height: 64” Weight: 188 lb BP 140/90 Waist Circumference: 39” • Exam: HEENT WNL, Lungs clear, Heart RRR S1/S2 no murmur, GI obese abdomen, Foot exam: monofilament normal in both feet, pulse and skin normal, no pedal edema, nails mild fungal changes

  5. Case Study: Initial Laboratory • FBS: 165 mg/dl, • A1c 8.1% • TC: 220 mg/dl • TG: 240 mg/dl • HDL-C: 38 mg/dl • LDL-C: 134 mg/dl • Creatinine: 0.6 mg/dl • Urine M/C Ratio: 35

  6. Modifiable Major Risk Factors Hypertension Hypercholesterolemia Smoking Microalbuminurea Hyperglycemia Contributing Causes Obesity, fat distribution Lack of physical exercise Genetic factors Age Disease duration Cardiovascular Risk Assessment: Garber, AJ American Family Practice December 15 2000

  7. 0 -10 -20 -30 -40 -50 United Kingdom Prospective DiabetesStudy (UKPDS): Results BP Control (144/82 vs 154/87 mm Hg) Glucose Control Any diabetes- related endpoint Any diabetes- related endpoint Micro- vascular endpoints Diabetes- related death Diabetes- related death Micro-vascular endpoints Stroke -10% (P=.34) -12% (P<.0001) -25% (P<.005) -25% (P<.01) -32% (P=.019) -37% (P=.009) -44% (P=.013) UK Prospective Diabetes Study Group 38. BMJ. 1998;317:703-713. UK Prospective Diabetes Study Group 33. Lancet. 1998;352:837-853.

  8. STENO-2 Study:Multifactorial Intervention and CVD in Patients with Type 2 Diabetes • Denmark Study: NEJM 1/30/2003 • 160 patients with type 2 diabetes • 8 year study with mean age 55 years • Two study groups: intensive therapy and conventional therapy Gaede P, et al. N Eng J Med. 2003;348:383-393.

  9. STENO-2 Study:Multifactorial Intervention and CVD in Patients with Type 2 Diabetes • Intensive Group: stepwise implementation of behavior modification and pharmacologic therapy targeting: • Hyperglycemia • Hypertension • Dyslipidemia • Microalbuminurea Gaede P, et al. N Eng J Med. 2003;348:383-393.

  10. STENO-2 Study:Multifactorial Intervention and CVD in Patients with Type 2 Diabetes • End point: • Death from cardiovascular causes • Nonfatal myocardial infarction • Stroke • Coronary or peripheral artery revascularization • Amputation as a result of ischemia Gaede P, et al. N Eng J Med. 2003;348:383-393.

  11. STENO-2 Study:Multifactorial Intervention and CVD in Patients with Type 2 Diabetes Macrovascular Complications • Conventional Group: 44% of patient had a primary end point event • Intensive Group: 24% of patients had a primary end point event Primary composite endpoint: Death from CV causes, nonfatal MI, CABG, PCI, nonfatal stroke, amputation, or surgery for peripheral atherosclerotic artery disease. Adapted from Gaede P, et al. N Eng J Med. 2003;348:383-393.

  12. Intensive Multiple Risk Factor Management Patients with Type 2 Diabetes and Macroalbuminuria 60 N=160; follow-up=7.8 years Conventional Therapy 20% Absolute Risk Reduction 40 Primary Composite Endpoint* (%) 20 • Aggressive treatment of†: • Microalbuminuria with • ACEIs, ARBs, or combination • Hypertension • Hyperglycemia • Dyslipidemia • Secondary prevention of CVD Intensive Therapy† 12 24 36 48 60 72 84 96 Months of Follow-Up Primary composite endpoint: conventional therapy (44%) and intensive therapy (24%). *Death from CV causes, nonfatal MI, CABG, PCI, nonfatal stroke, amputation, or surgery for peripheral atherosclerotic artery disease. †Behavior modification and pharmacologic therapy. Adapted from Gaede P, et al. N Eng J Med. 2003;348:383-393.

  13. Smoking Cessation Hyperglycemia CVD Risk Reduction Lifestyle Changes Weight loss, healthy foods, Increased activity Daily Aspirin Lipid Control Hypertension Control

  14. Hypertension

  15. JNC 7 “Failure to titrate or combine medications, despite knowing the patient is not at goal BP, represents clinical inertia and must be overcome.” Chobanian A, et al. JAMA. 2003;289:2560-2572.

  16. Treatment of Hypertension in Diabetes Diagnosis of Hypertension BP>130/80 mm Hg Non-Pharmacologic Therapies Drug Therapies ACE based regimes preferred Multi-drug therapy often needed Target BP <130/85

  17. Step-wise progression to controlling Blood pressure ACE & ARBS Limits nephropathy and Lower CVD risk  Blocker Ca++CB Thiazide -Blocker*

  18. Average Number of Antihypertensive Agents Needed Per Patient to Achieve Target BP Trail Target BP mm Hg Number of Antihypertensive Agents UKPDS DBP<85 ABCD DBP<75 VDRD MAP<92 HOT DBP<80 AASK MAP<92

  19. SUMMARYTreatment of Hypertension in Diabetes • Blood pressure goal in diabetes = 130/85 • Level of blood pressure more important that type of therapy • Reduces rates of both micro and macrovascular disease • ACE based therapies: 1st Line Choice • Reduces CVD complication and offers reno-protection • Multi-drug therapy often needed • Aggressive treat essential, if CVD and renal disease present ideal goal: 125/80 (?) Arch Intern Med, Vol160, Sep 11, 2000, 2447-2452

  20. Hypercholesterol

  21. Prevalence of Dyslipidemia in Type 2 Diabetes • Most common pattern is elevated triglycerides and low HDL • TC & LDL concentration is often the same as non-diabetic individuals • However, LDL particles are smaller, denser and more atherogenic

  22. Goals for Control • LDL < 100 • HDL> 45* in men, HDL> 55 in women • Lipid panel annually • Consider direct LDL if TG >250 or if specimen is non-fasting • All patients with LDL > 100 need medical, dietary and lifestyle intervention

  23. Considerations in Therapy • Diet and exercise are key • Hyperglycemia itself will lead to increased TG: try to improve sugars first • Metformin will decrease LDL • Glitazones will decrease TG, increase HDL • Check TFTs in initial work-up • Metamucil, increased dietary fiber

  24. Microalbuminuria and CVD in Diabetes

  25. Microalbuminuria and Diabetes • Independent risk factor for development of cardiovascular disease • Predictor of cardiovascular mortality in the diabetic population • Part of the cardiometabolic syndrome

  26. Microalbuminuria and Diabetes • Test for urine protein yearly • If negative, screen for microalbuminurea • Dipstick + microalbuminurea should be confirmed on a separate specimen • A/C ratio: 30mg/gm • Treat with ACE-inhibitor, regardless of BP

  27. Smoking Cessation

  28. Smoking Cessation • Smoking doubles the risk of CVD in patients with diabetes • Attenuates the benefit of gained from modifying other risks • Synergistic with TC, possibly through enhanced oxidation of LDL • MRFIT: independent and ing risk of CVD based on #cigarettes/day

  29. Smoking Cessation: Standards of Care • Assessment of smoking status and history • Counseling on smoking prevention and cessation • Referral to program for delivery of smoking cessation

  30. Aspirin Therapy

  31. Aspirin Therapy in Diabetes “Aspirin - the poor man’s statin” • Reduces risk of MI by ~ 15-60% • Treat all high risk patients with diabetes over the age of 35 • Use 81 – 325mg/day The Lancet

  32. Procoagulant State • Platelets are overly sensitive to platelet aggregating agents • High levels of Thromboxane, a potent vasoconstrictor • Decreased fibrinolytic activity • Increased levels of Plasminogen Activitor Inhibitor-1 • Clot lysis cannot precede normally

  33. Goals for treatment Primary Prevention: • Strongly consider ASA in patients > 30 with diabetes and high risk for CVD • FHx CVD, smoking, HTN, obese, albuminurea, dyslipidemia Secondary Prevention: • ASA for patients with know CVD: MI, stroke, PVD, claudication, angina DOSE: 162mg to 325mg

  34. Conclusion: Aggressive modification of all identified CVD risks factor is essential to reduce the macrovascular complications of diabetes

More Related