diabetes & heart attack - saha.ac.in fellows/diabetes... · diabetes: diagnostic criteria any...
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Diabetes & Heart Attack The two headed monster of the
21st. Century
Dr. Arnab SenguptaProfessor of PhysiologyRG Kar Medical College
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Diabetes Mellitus
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Diabetes Mellitus
A group of metabolic disorders sharing the common underlying feature of hyperglycemia.
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Diabetes Mellitus
Diabetes mellitus is a syndrome of impaired carbohydrate, fat, and protein metabolism caused by either lack of insulin secretion or decreased sensitivity of the tissues to insulin or both.
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Epidemiology
Worldwide, more than 140 million people suffer
from diabetes, making this one of the most common noncommunicable diseases.
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THE CURRENT COST OF DIABETES IN THE UK
1030% reduction in life expectancy Most common cause of blindness in age
group 2065 years 1000 patients per annum reach endstage
renal failure
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THE CURRENT COST OF DIABETES IN THE UK
Lower limb amputation rate increased 25fold.
Use of hospital beds increased six fold.57% of total National Health Service
budget.
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Epidemiology
The number of affected individuals with diabetes is expected to double by 2025. The countries with the largest number of diabetics are,India, China, United States.
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Incidence of adult diabetes
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Incidence of adult T2DM
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Diabetes Mellitus
How & Why ?
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PancreasExocrineEndocrine Islets of Langerhans
InsulinGlucagon etc. etc.
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PancreasExocrineEndocrine Islets of Langerhans
InsulinGlucagon etc. etc.
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Insulin
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Insulin action on target cell
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Metabolic action of Insulin
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Diabetes Mellitus
Deficiency of Insulin
AbsoluteRelative
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Metabolic derangements in Diabetes
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Effect of Insulin deficiency
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FeaturesClassical symptoms
Polyurea – increased urination
Polyphagia – increased appetite
Polydipsia – increased thirst
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FeaturesWeight lossWeight gainIncreased incidence of infectionsNeuropathyNephropathyComa
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Diabetes: diagnostic criteriaany one of three criteria
A random glucose > 200 mg/dL, with classical signs and symptoms.
A fasting glucose > 126 mg/dL on more than one occasion.
An abnormal oral glucose tolerance test (OGTT), in which the glucose is > 200 mg/dL 2 hours after a standard carbohydrate load.
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Blood Sugar estimation
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Diabetes: diagnostic blood test
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PreDiabetes: diagnostic criteriaIntermediate states between normal glucose
tolerance and DM type 2.
Impaired fasting glucose (IFG)Impaired glucose tolerance (IGT)
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PreDiabetes: diagnostic criteria
IFG is defined by fasting plasma glucose of 100 mg/dL to 125 mg/dL.
IGT is defined by a 2hour oral glucose tolerance test plasma glucose from 140 mg/dL to 199 mg/dL.
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PreDiabetes State
Crucial risk factor
Lifestyle modification
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Diabetes: classification
Type 1Type 2
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Diabetes: classificationType 1 diabetes 10%
an absolute deficiency of insulin caused by pancreatic cell βdestruction.
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Diabetes: classification
Type 2 diabetes 80% to 90% a combination of peripheral resistance to insulin action and an inadequate secretary response by the pancreatic cells ("relative insulin βdeficiency").
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CAUSES OF DEATH IN PEOPLE WITH DIABETES
Cardiovascular disease 70%
Renal failure10%
Cancer 10%Infections
6%Diabetic ketoacidosis
1%Other 3%
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Diabetes Mellitus – vicious cycle
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COMPLICATIONS OF DIABETES
Micro vascularMacro vascular
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COMPLICATIONS OF DIABETES
Microvascular/neuropathic• Retinopathy, cataract
Impaired vision • Nephropathy
Renal failure • Peripheral neuropathy
Sensory loss Motor weakness
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COMPLICATIONS OF DIABETES
Microvascular/neuropathic• Autonomic neuropathy
Postural hypotension Gastrointestinal problems
• Foot disease Ulceration Arthropathy
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COMPLICATIONS OF DIABETES
Macrovascular• Coronary circulation
Myocardial ischemia/infarction • Cerebral circulation
Transient ischaemic attack Stroke
• Peripheral circulation Claudication Ischaemia
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Diabetes – Complications
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Diabetic Retinopathy
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Diabetic Retinopathy
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Diabetic Retinopathy
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Diabetic Retinopathy
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Diabetic Iridis
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Diabetic Foot
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Diabetic Foot ulcer
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Diabetic Gangrene
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Diabetes & CAD
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Diabetes & CV disease
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Incidence of Cardiovascular deaths
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PRIMARY PREVENTION OF DIABETES
From a public health standpoint the only costeffective way of dealing with diabetes is to prevent it.
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Type 2 diabetes is associated with an affluent lifestyle
Likely to arise in genetically predisposed individuals who eat too much and exercise too little
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PREVENTION OF T2DM
Effective health education.
Screening for diabetes.
Vigorous and early treatment.
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Anti diabetic drugs
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Injection Insulin
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Injection Insulin – sites
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Diabetes management kits
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Treatment strategy
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Dietary modification
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DIET FOR PEOPLE WITH DIABETES
Carbohydrate 4560%
Fat (total)< 35%
Protein1015%
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DIET FOR PEOPLE WITH DIABETES
Carbohydrate 4560%Sucrose Up to 10%
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DIET FOR PEOPLE WITH DIABETES
Fat (total)< 35%n6 Polyunsaturated< 10%n3 Polyunsaturated Eat oily fish once or
twice weeklyMonounsaturated1020%Saturated< 10%
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DIET FOR PEOPLE WITH DIABETES
Protein1015% (do not exceed 1 g/kg body weight)
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Exercise Improves,
insulin sensitivity,
reduces fasting and postprandial blood glucose, and
offers numerous metabolic, cardiovascular, and psychological benefits in diabetic patients.
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Assessment of glycemic control
Selfmonitoring of capillary blood glucose (SMBG)
HbA1c
Ketonuria
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Heart Attack Biology & Prevention
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Heart Attack – Biology & Prevention
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CAD Epidemic in India : A
cause of concern & a cry for action
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CAD Epidemic in India
Cardiovascular Diseases are becoming major health burden in developing
countries
In 2000 : 16.7 Million died worldwide on Cardiovascular Diseases(30.3% of all death).
>50% of these death are in Developing Countries.
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CAD Epidemic In India
Prevalence
• In 1960: 4%(Every 25th Individual)
• In 2001: 11%(Every 9th Individual)
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Factors causing rise of CAD in IndiaGenetic Determination.Life style Changes.Rapid Urbanization.Insulin Resistance.Central Obesity.Cultural Changes.
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CAD India – A cause of Concern• A Quarter of World’s Population.• Increased Susceptibility.• Unrecognized Target.• Restricted access to high cost tertiary
cardiovascular care.• Does not feature prominently in the Health
Care Agenda of the Country.
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CAD A group of closely related
syndromes caused by imbalance between Cardiac Oxygen Demand &
the blood supply
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CAD – EtiologyCAUSATION
Coronary artery obstruction OR
Narrowing of the Lumina of Coronary arteries
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CAD Member Diseases‘� Angina Pectoris‘� Acute Myocardial Infarction‘� Sudden Cardiac Death‘� Heart Failure
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CAD Underlying Factors
In 90% CasesAtherosclerosis
In 10% Cases Vasospasm Stenosis of the
coronary ostia. Arteritis Embolisms Thrombotic disorders. Trauma Aneurysms Compression
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Atherosclerosis the commonest & most dangerous cause
of CAD
•Athero - Porridge / Gruel, accumulation of lipid materials.
•Sclerosis - Hardening.
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Anatomic Consideration
Coronary Artery• Arise from Aortic Sinus of Aorta• Chief supplier of Myocardium
Number • Two Right & Left.
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Coronary Circulation
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Coronary Circulation
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Genesis of Atherosclerosis
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Normal Coronary Artery
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Coronary Artery – Luminal narrowing
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Coronary Artery – Luminal narrowing
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Coronary Artery – Luminal narrowing
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Coronary Artery – Recent thrombosis
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Coronary Artery – visualization
Coronary angiogram
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Spatial OrientationSpatial Orientation
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Common Location of The Infarct
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Common Location of the Infarct
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Sequence of changes in MI
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Plaque Rupture : Thrombus & Healing
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Plaque Rupture
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A Model of Myocardial Infarction
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A Model of Myocardial Infarction
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A Model of Myocardial Infarction
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A Model of Myocardial Infarction
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A Model of Myocardial Infarction
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A Model of Myocardial Infarction
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A Model of Myocardial Infarction
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A Model of Myocardial Infarction
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A Model of Myocardial Infarction
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A Model of Myocardial Infarction
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A Model of Myocardial Infarction
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A Model of Myocardial Infarction
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A Model of Myocardial Infarction
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A Model of Myocardial Infarction
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A Model of Myocardial Infarction
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MI ComplicationsIn 25% of Cases• Immediate
Mortality (Sudden Cardiac Death)
In 80–90% of Cases 1 or > major
• Cardiac Arrhythmias• Congestive heart Failure• Cardiogenic Shock• Mural Thrombosis /
Thromboembolism• Rupture of free wall
septum / Papillary Muscles• Cardiac Aneurysm• Pericarditis• Post Infarction Syndrome
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ECG
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ECHO
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Prophylaxis - Prevention of Coronary Artery Disease
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Prophylaxis of Coronary artery disease
Management of Risk Factor
Modifiable
Non modifiable
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Modifiable Risk FactorsBy life style
SmokingObesityPhysical inactivity
By pharmacotherapy & life styleLipid disorderHypertensionInsulin resistance
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Non modifiable Risk Factors
AgeMale genderGenetic predisposition
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Prevention of CADPrimary
Secondary
With non-modifiable risk factors, intense management of Modifiable risk factors are necessary.
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Risk assessment
Position or Status of the Patient with respect to Risk factors.
Absolute risk = Parameter of Risk Assessment. = Probability of developing CAD
over a time period (10 Years ).
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Risk assessmentA male smoker aged 52yrs.having a
total cholesterol 220mg/dl, HDL 45mg/dl, BP 160/90, Blood Sugar 130mg/dl.
Total Framingham Risk Point = 11His absolute 10 Years Risk = 25%
Risk Category for MI (Fatal & Nonfatal) =
high
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Smoking
Nothing less than complete cessation.
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Obesity
Body mass index : Kg/M2
> 30 Obesity 25 29.9 Overweight< 25 Acceptable
Abdominal / Intra abdominal Fat depot
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Lipid disorder, Hypertension &
Diabetes
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Risk Factor managementHypertension A Major
Risk factor
Antihypertensives
Diabetes Mellitus & Insulin Resistance
Antidiabetics & Lipid lowering Drugs
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Risk Factor managementLife style modificationDiet
QuantitativeQualitative- Saturated Fat,
Cholesterol, Na
ExerciseSmokingAlcoholObesityStress & anxiety
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Patient & Public education
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Role of the Government
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Thank you