blood sugar- how much low is safe in coronary artery disease- copy
DESCRIPTION
HOW MUCH BLOOD SUGAR LEVEL IS SAFE.TRANSCRIPT
![Page 1: Blood sugar- how much low is safe in coronary artery disease- copy](https://reader033.vdocuments.mx/reader033/viewer/2022060200/5597e1dc1a28ab52758b465b/html5/thumbnails/1.jpg)
Diabetes &CAD: Blood Sugar, How much low is safe.
Dr Ramachandra Barik,MD,DNB.
Assistant Professor,NIMS.
![Page 2: Blood sugar- how much low is safe in coronary artery disease- copy](https://reader033.vdocuments.mx/reader033/viewer/2022060200/5597e1dc1a28ab52758b465b/html5/thumbnails/2.jpg)
Define DM-II
Diabetes mellitus is a state of premature cardiovascular death associated with chronic hyperglycemia and may also be associated with blindness and renal failure. – Miles Fisher.
ADA-2012
![Page 3: Blood sugar- how much low is safe in coronary artery disease- copy](https://reader033.vdocuments.mx/reader033/viewer/2022060200/5597e1dc1a28ab52758b465b/html5/thumbnails/3.jpg)
95% of DM patients are Type 2
![Page 4: Blood sugar- how much low is safe in coronary artery disease- copy](https://reader033.vdocuments.mx/reader033/viewer/2022060200/5597e1dc1a28ab52758b465b/html5/thumbnails/4.jpg)
INDIAAsian Indian Phenotype” - 40-60% of global CVD burden within the next 10-15 years. India, Pakistan and Bangladesh- 3 of the top ten countries in world and together, the highest number of DM -related deaths. India - 50.8 million DM , the biggest. Delhi Diabetes Community (DEDICOM) and DiabCare Asia Sub-optimal Rx-50 % (HbA1c >8%) Aspirin-20% ,Lipid and BP targets- 50%, Severe late-stage complications -55%.
World DM II -21.9 % now and 26.3% by 2030 of total death
x2-4 ↑ risk of CVD.
AusDiab –
DM II-(HR 2.6,95%CI:1.4–4.7) IOGTT - (HR 2.5, 95% CI: 1.2–5.1).
CVD - 65-75% of deaths in DM II
DM Type II
![Page 5: Blood sugar- how much low is safe in coronary artery disease- copy](https://reader033.vdocuments.mx/reader033/viewer/2022060200/5597e1dc1a28ab52758b465b/html5/thumbnails/5.jpg)
![Page 6: Blood sugar- how much low is safe in coronary artery disease- copy](https://reader033.vdocuments.mx/reader033/viewer/2022060200/5597e1dc1a28ab52758b465b/html5/thumbnails/6.jpg)
The PathoPhysiology.Hyperglycemia and its 2ndary effect.
Worsening of atherogenic dyslipidaemia (small LDL, reduced HDL & ↑TG, SNS dysfunction,CKD. Endothelial dysfunction, vasoconstrictive, proinflammatoryand prothrombotic processes that contribute to plaque development and rupture.
protein kinase C, and the formation of polyols,hexosamine and advanced glycation endproducts.
NKF-B & ↑ reactive O2 species- pivotal accelerated CVD .
HTN
![Page 7: Blood sugar- how much low is safe in coronary artery disease- copy](https://reader033.vdocuments.mx/reader033/viewer/2022060200/5597e1dc1a28ab52758b465b/html5/thumbnails/7.jpg)
![Page 8: Blood sugar- how much low is safe in coronary artery disease- copy](https://reader033.vdocuments.mx/reader033/viewer/2022060200/5597e1dc1a28ab52758b465b/html5/thumbnails/8.jpg)
![Page 9: Blood sugar- how much low is safe in coronary artery disease- copy](https://reader033.vdocuments.mx/reader033/viewer/2022060200/5597e1dc1a28ab52758b465b/html5/thumbnails/9.jpg)
![Page 10: Blood sugar- how much low is safe in coronary artery disease- copy](https://reader033.vdocuments.mx/reader033/viewer/2022060200/5597e1dc1a28ab52758b465b/html5/thumbnails/10.jpg)
DM II Update surrounding the relationship between glucose control and the risk of CVD.
![Page 11: Blood sugar- how much low is safe in coronary artery disease- copy](https://reader033.vdocuments.mx/reader033/viewer/2022060200/5597e1dc1a28ab52758b465b/html5/thumbnails/11.jpg)
![Page 12: Blood sugar- how much low is safe in coronary artery disease- copy](https://reader033.vdocuments.mx/reader033/viewer/2022060200/5597e1dc1a28ab52758b465b/html5/thumbnails/12.jpg)
Screen clipping taken: 28-Nov-12, 3:36 PM
![Page 13: Blood sugar- how much low is safe in coronary artery disease- copy](https://reader033.vdocuments.mx/reader033/viewer/2022060200/5597e1dc1a28ab52758b465b/html5/thumbnails/13.jpg)
![Page 14: Blood sugar- how much low is safe in coronary artery disease- copy](https://reader033.vdocuments.mx/reader033/viewer/2022060200/5597e1dc1a28ab52758b465b/html5/thumbnails/14.jpg)
![Page 15: Blood sugar- how much low is safe in coronary artery disease- copy](https://reader033.vdocuments.mx/reader033/viewer/2022060200/5597e1dc1a28ab52758b465b/html5/thumbnails/15.jpg)
Observational Studies1.Relation between glucose & CVD related death Linear ,continuous,“J-shaped” or U shape.
2. In AusDiab Study N=10,000 without DM , reported a continuous ↑ risk for CV mortality with ↑ 2hrs glucose levels after OGTT & increasing HbA1c levels.
3. No association between HbA1c levels < 5.0% and fatal and non-fatal CHD.
4.↑ HbA1c levels were associated with an ↑ HR for CHD events of 1.38 (95% CI:1.22–1.56) when compared with a reference range HbA1c 5.0–5.5%.
![Page 16: Blood sugar- how much low is safe in coronary artery disease- copy](https://reader033.vdocuments.mx/reader033/viewer/2022060200/5597e1dc1a28ab52758b465b/html5/thumbnails/16.jpg)
5. United Kingdom Prospective Diabetes Study (UKPDS)- a study of subjects with newly DM II shows 1% ↓ HbA1c → 14%(95% CI: 8–21%) decrease in the relative risk MI .
6. UK General Practice Research Database (elderly- 28,000) - “U-shaped” association between HbA1c levels and CV events and lowest at an HbA1c level of approximately 7.5% .
These theoretical relationships between glycaemia and CV outcomes have been
recently tested in interventional trials of intensive glucose control that have been published over the last two years.
![Page 17: Blood sugar- how much low is safe in coronary artery disease- copy](https://reader033.vdocuments.mx/reader033/viewer/2022060200/5597e1dc1a28ab52758b465b/html5/thumbnails/17.jpg)
N=13867 newly DM II randomised to an intensive glucose control using of SU or insulin and a conventional lifestyle management. Intensively Rx - mean HbA1c of 7.0% compared with conventionally Rx - 7.9%.
1% ↓ HbA1c and a 16% (RR 0.84, 95% CI: 0.71–1.0) ↓ MI compared to conventional Rx which just failed (p = 0.052). No effects of intensive glucose control on any other CVD outcomes.
Intensive glucose control reduced the risk of microvascular complications by 25% (95% CI: 7–14, p = 0.01).
Non-significant (6%) relative reduction in all-cause mortality associated with intensive glucose control.
metformin (N=343) Vs conventional Rx (n = 411) , no significant gap in HbA1c between metformin or placebo , metformins associated with a 39% relative ↓ MI (p = 0.01) and a 36% relative ↓ in all-cause mortality (p = 0.01) without any effect on microvascular complications metformin ↓ CV events that are to some extent independent of glucose control.
The United Kingdom Prospective Diabetes Study (UKPDS) Glucose Interventional Study-10Yrs F/u.
![Page 18: Blood sugar- how much low is safe in coronary artery disease- copy](https://reader033.vdocuments.mx/reader033/viewer/2022060200/5597e1dc1a28ab52758b465b/html5/thumbnails/18.jpg)
![Page 19: Blood sugar- how much low is safe in coronary artery disease- copy](https://reader033.vdocuments.mx/reader033/viewer/2022060200/5597e1dc1a28ab52758b465b/html5/thumbnails/19.jpg)
As most patients without DM II have an HbA1c level < 6.5%, the question remained after the completion of the UKPDS in 1997 as to whether targeting HbA1c levels close to the non-diabetic range might still result in a significant reduction in CV events.
intensive glucose control could reduce the risk of CV outcomes in DM II three large interventional trials published in mid 2008 .
Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial , the Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified Release Controlled Evaluation (ADVANCE) and the Veterans Administration Diabetes Trial (VADT) .
Recent Intensive Glucose Control Trials
![Page 20: Blood sugar- how much low is safe in coronary artery disease- copy](https://reader033.vdocuments.mx/reader033/viewer/2022060200/5597e1dc1a28ab52758b465b/html5/thumbnails/20.jpg)
![Page 21: Blood sugar- how much low is safe in coronary artery disease- copy](https://reader033.vdocuments.mx/reader033/viewer/2022060200/5597e1dc1a28ab52758b465b/html5/thumbnails/21.jpg)
![Page 22: Blood sugar- how much low is safe in coronary artery disease- copy](https://reader033.vdocuments.mx/reader033/viewer/2022060200/5597e1dc1a28ab52758b465b/html5/thumbnails/22.jpg)
![Page 23: Blood sugar- how much low is safe in coronary artery disease- copy](https://reader033.vdocuments.mx/reader033/viewer/2022060200/5597e1dc1a28ab52758b465b/html5/thumbnails/23.jpg)
![Page 24: Blood sugar- how much low is safe in coronary artery disease- copy](https://reader033.vdocuments.mx/reader033/viewer/2022060200/5597e1dc1a28ab52758b465b/html5/thumbnails/24.jpg)
![Page 25: Blood sugar- how much low is safe in coronary artery disease- copy](https://reader033.vdocuments.mx/reader033/viewer/2022060200/5597e1dc1a28ab52758b465b/html5/thumbnails/25.jpg)
![Page 26: Blood sugar- how much low is safe in coronary artery disease- copy](https://reader033.vdocuments.mx/reader033/viewer/2022060200/5597e1dc1a28ab52758b465b/html5/thumbnails/26.jpg)
![Page 27: Blood sugar- how much low is safe in coronary artery disease- copy](https://reader033.vdocuments.mx/reader033/viewer/2022060200/5597e1dc1a28ab52758b465b/html5/thumbnails/27.jpg)
Metaanalysis :Intensive glucose level lowering.1.Only glycemic not enough.2.Significant ↓ in MI rates with no increase in CV or all-cause mortality despite increased rates of severe hypoglycaemia.
3.↓ microvascular outcomes and that in the setting of newly diagnosed type 2 diabetes→ benefit on CV outcomes.
4.Early strict glycaemic control protects in long run. 5. ADVANCE and VADT :if the correct strategy is used, glucose levels can be safely reduced toHbA1c levels between 6.5% and 7.0%.
6. ACCORD warns detail scanning ,before intensive GLU control for established DM II and at high CV risk, using a combination of multiple-insulin injections and oral agents to rapidly target an HbA1c of <6.5% should be avoided.7.Younger age and early onset of DM II do tolerate agressive glycemic controls.8.Metformain has over other hyglycemic agents to ↓ CVD till today in young obese till incretin analogs and DPP-4 inhibitors takes over.
![Page 28: Blood sugar- how much low is safe in coronary artery disease- copy](https://reader033.vdocuments.mx/reader033/viewer/2022060200/5597e1dc1a28ab52758b465b/html5/thumbnails/28.jpg)
Define DM-II
Diabetes mellitus is a state of premature cardiovascular death associated with chronic hyperglycemia and may also be associated with blindness and renal failure. – Miles Fisher.
ADA-2012
![Page 29: Blood sugar- how much low is safe in coronary artery disease- copy](https://reader033.vdocuments.mx/reader033/viewer/2022060200/5597e1dc1a28ab52758b465b/html5/thumbnails/29.jpg)
HbA1c levels of <7.0% still remains gold standard 1.In general good GLU control.2.New Dx DM3.Young without significant co-morbidities to ↓ microvascular and macrovascular complications.
TOO TIGHT FOR AGED AND LONG STANDING DM II IS HARMFUL. Australian Diabetes Society published a position statement on individualisation of HbA1c targets for DM II as below.
ARROWING THE TARGET
![Page 30: Blood sugar- how much low is safe in coronary artery disease- copy](https://reader033.vdocuments.mx/reader033/viewer/2022060200/5597e1dc1a28ab52758b465b/html5/thumbnails/30.jpg)
![Page 31: Blood sugar- how much low is safe in coronary artery disease- copy](https://reader033.vdocuments.mx/reader033/viewer/2022060200/5597e1dc1a28ab52758b465b/html5/thumbnails/31.jpg)
![Page 32: Blood sugar- how much low is safe in coronary artery disease- copy](https://reader033.vdocuments.mx/reader033/viewer/2022060200/5597e1dc1a28ab52758b465b/html5/thumbnails/32.jpg)
Life’s Simple 7 Tips to CV Health.
![Page 33: Blood sugar- how much low is safe in coronary artery disease- copy](https://reader033.vdocuments.mx/reader033/viewer/2022060200/5597e1dc1a28ab52758b465b/html5/thumbnails/33.jpg)
![Page 34: Blood sugar- how much low is safe in coronary artery disease- copy](https://reader033.vdocuments.mx/reader033/viewer/2022060200/5597e1dc1a28ab52758b465b/html5/thumbnails/34.jpg)
I FEEL YOU LOVED LAST PAGE