cvd workshop sdpi cvd risk reduction project meeting #5 denver, colorado
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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
• Medication: HCTZ 25 mg Q day
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
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
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
Cardiovascular Risk Assessment:
Modifiable Major Risk Factors
• Hypertension• Hypercholesterolemia• Smoking • Microalbuminurea• Hyperglycemia
Contributing Causes• Obesity, fat distribution• Lack of physical
exercise
• Genetic factors• Age• Disease duration
Garber, AJ American Family Practice December 15 2000
AnyAnydiabetes-diabetes-related related
endpointendpoint
Diabetes-Diabetes-related related deathdeath
Micro-Micro-vascularvascular
endpointsendpoints
-12%-12%((PP<.0001)<.0001)
-10%-10%((PP=.34)=.34)
-25%-25%((PP<.01)<.01)
StrokeStroke
-25%-25%((PP<.005)<.005)
-32%-32%((PP=.019)=.019)
-44%-44%((PP=.013)=.013)
-37%-37%((PP=.009)=.009)
Micro-Micro-vascularvascular
endpointsendpoints
AnyAnydiabetes-diabetes-related related
endpointendpoint
Diabetes-Diabetes-related related deathdeath
UK Prospective Diabetes Study Group 38. BMJ. 1998;317:703-713.UK Prospective Diabetes Study Group 33. Lancet. 1998;352:837-853.
Glucose ControlBP Control
(144/82 vs 154/87 mm Hg)
00
-10-10
-50-50
-20-20
-30-30
-40-40
United Kingdom Prospective DiabetesStudy (UKPDS): Results
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.
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.
• End point:– Death from cardiovascular causes– Nonfatal myocardial infarction– Stroke– Coronary or peripheral artery
revascularization– Amputation as a result of ischemia
STENO-2 Study:Multifactorial Intervention and CVD in Patients with Type 2 Diabetes
Gaede P, et al. N Eng J Med. 2003;348:383-393.
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.
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.
Pri
mar
y C
om
po
site
En
dp
oin
t* (
%)
Months of Follow-Up
60
40
20
12 24 36 48 60 72 84 96
Conventional Therapy
Intensive Therapy†
20% Absolute Risk Reduction
N=160; follow-up=7.8 years
Aggressive treatment of†:– Microalbuminuria with ACEIs, ARBs, or combination– Hypertension– Hyperglycemia– Dyslipidemia– Secondary prevention of CVD
Intensive Multiple Risk Factor Management Patients with Type 2 Diabetes and
Macroalbuminuria
CVD Risk
Reduction
Hyperglycemia
Hypertension Control
Lipid Control
Daily AspirinLifestyle ChangesWeight loss, healthy foods,Increased activity
Smoking Cessation
Hypertension
““Failure to titrate or combine medications, Failure to titrate or combine medications, despite knowing the patient is not at goal despite knowing the patient is not at goal BP, represents clinical inertia and must BP, represents clinical inertia and must be overcome.”be overcome.”
Chobanian A, et al. JAMA. 2003;289:2560-2572.
JNC 7
Treatment of Hypertension in DiabetesDiagnosis of Hypertension
BP>130/80 mm Hg
Non-Pharmacologic Therapies
Drug TherapiesACE based regimes preferred
Multi-drug therapy often needed
Target BP<130/85
ACE & ARBSLimits nephropathy and
Lower CVD risk
Thiazide -Blocker* Blocker Ca++CB
Step-wise progression to controlling Blood pressure
Average Number of Antihypertensive Agents Needed Per Patient to Achieve Target BP
UKPDS DBP<85
ABCD DBP<75
VDRD MAP<92
HOT DBP<80
AASK MAP<92
1 2 3 4
Number of Antihypertensive AgentsTrail Target BP mm Hg
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
Hypercholesterol
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
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
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
Microalbuminuria and CVD in Diabetes
Microalbuminuria and Diabetes
• Independent risk factor for development of cardiovascular disease
• Predictor of cardiovascular mortality in the diabetic population
• Part of the cardiometabolic syndrome
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
Smoking Cessation
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
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
Aspirin Therapy
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
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
Goals for treatmentPrimary 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
Conclusion:
Aggressive modification of all identified CVD risks factor is essential to reduce the macrovascular complications of diabetes