Smoking, lipids and lifestyle

Dr Shirley Copland

Associate Specialist

Normal heart and coronary artery

Diseased coronary artery

Diabetes and cardiovascular risk

• Adults with diabetes have a reduced life expectancy of some 5-10 years

• Most deaths are due to circulatory diseases • Heart attacks rates are 3 -5 fold increased• Stroke risk is increased 2-3 fold• After 15 years duration of type 2 diabetes more

than 20% of patients have had a heart attack ( UK prospective diabetes study)

DIABETES AND CARDIVASCULAR DISEASE

AGE DIABETES

45-54 24.8

55-64 37.9

65-74 40.5

Incidence of MI per 1000 women

NO DIABETES

4.3

12.6

22.6

Why the excess risk in Diabetes ?

• Thought that raised blood glucose levels are toxic to the lining of blood vessels

• Vessels are then more susceptible to damage from all the other risk factors e.g. high blood pressure, smoking

• Low density lipoprotein (LDL) is more densely packed with triglyceride which is more readily taken up into the vessel walls causing atheroma plaques

Coronary Risk Factors

• Modifiable

• Smoking• High blood pressure• Cholesterol levels• Excess weight• Lack of exercise• High glucose levels

• Unmodifiable

• Being male *• Family history• Age• Diabetes mellitus• Proteinuria

Risk Factors - Smoking

• Widely recognised to accelerate coronary artery disease and to increase risks of certain cancers

• Smoking >20 per day more than doubles the risk of coronary disease

• Scottish Diabetes Survey 2004 showed 18% patients with diabetes in Grampian remain smokers

Risk Factors - Smoking

• Simple advice to stop smoking has a small but significant effect

• Nicotine replacement therapy can double quitting success rates

• Zyban also helps more people to be successful but can increase the BP

• No definite evidence for benefit of acupuncture • Many people need several attempts to stop –encourage to

keep trying!• Monitor for relapse !

Risk Factor - Lifestyle

• A 10 kg weight loss in obese patients with diabetes has been shown to reduce mortality by 25%

• Exercise helps control weight, blood pressure and lowers blood sugar

• In the UK 60-70% of the adult population is considered to be physically inactive

• Moderate exercise works - taking a brisk walk most days reduces coronary risk by up to 50%

Risk Factors - Cholesterol

• Cholesterol is essential in the body• Component of all cell membranes, needed for

manufacture of steroid hormones, used to make bile salts which are necessary for digestion

• Excess dietary saturated fat increases blood lipids

• Liver is involved in cholesterol manufacture

Risk Factors - Cholesterol

• Cholesterol is carried in the blood in particles called lipoproteins.

• Lab tests report the total cholesterol (TC) and the amounts of the component particles:

• HDL ‘the good’• LDL ‘the bad’• TC to HDL ratio ‘the ugly’ • In type 2 diabetes the ratio is often raised due to low

HDL

How to reduce Cholesterol

• We all know the healthy eating messages - reduced saturated fats, more fruit and veg and oily fish - emphasis is on a balanced diet.

• Fish oil supplements shown to be cardio-protective in the short term in high risk patients. No long term overall benefits.

• Benecol and Flora pro-active margarines do lower the LDL cholesterol - probably beneficial but no long term studies to date.

How to reduce Cholesterol

• Weight loss• Exercise• Good blood sugar control• Exclude secondary causes e.g. hypothyroidism

• However despite best efforts the cholesterol levels often remain relatively too high

Heart Protection Study 2002/3

• Major recent trial studying >20,000 subjects aged over 40 with vascular disease, hypertension or diabetes

• Patients had ‘normal’ cholesterols at entry• In diabetes patients taking simvastatin:• 27% reduction in major coronary events• 25% reduction in strokes • Note - need to treat 100 people for 5 years to

prevent 7 events but benefits would accrue

CARDS 2004

• Almost 3000 patients with type 2 DM

• Patients had no known vascular disease but had either retinopathy, microalbuminuria, hypertension or were smokers

• LDL < 4.14 on entry

• Showed atorvastatin prevented 37 vascular events per 1000 people treated for 4 years

Statin drug therapy

• Most effective lipid lowering medications• Many large studies have now shown consistent

reductions in cardiovascular risks• Do more than just reduce the cholesterol - protect

the circulation• Low incidence of side effects in clinical trials

Potential benefits of ‘statins’

• Reduce major coronary events

• Reduce stroke risk

• Reduce mortality from heart disease

• Reduce need for coronary procedures (angioplasty, coronary artery bypass grafts)

• Reduce total mortality

‘STATINS’

• Simvastatin, pravastatin, atorvastatin, fluvastatin and most recently rosuvastatin

• Act on the liver enzyme (HMG Co A reductase) involved in cholesterol synthesis hence lowering blood levels

• Not used in active liver disease• Few drug interactions (but avoid combination with

clarithromycin /erythromycin, ketoconazole, antivirals, ciclosporin)

• Grapefruit juice avoidance with simvastatin

‘STATINS’

• Few side effects

• Most common are GI effects or headache

• Rare side effects include muscle or liver inflammation (< 1 in 10,000 patient years)

• Liver tests checked before starting treatment and periodically thereafter and patients are advised to report any new muscle pain

• Contra -indicated in pregnancy

Guidelines - shifting the goalpost

• Grampian Diabetes Guidelines - Feb 2004

• GP contract targets - April 2004

• Joint British Societies 2 - November 2005

Joint British Societies Guidelines (JBS 2)

• All patients with diabetes should receive lifestyle advice and lipids monitored

• All patients with known vascular disease should be offered statin therapy

• For primary prevention if patients with diabetes meet the following criteria then statin therapy should be offered

• Treat to a target of TC 4 and LDL 2

Joint British Societies Guidelines (JBS 2)

• All patients with diabetes aged 40 years

• Patients with diabetes aged 18-39 years who have at least one of: -retinopathy (severe, prolif. or maculopathy) -nephropathy (incl. microalbuminuira) -poor glycaemic control (HBA1c >9%) -hypertension -TC 6 or features of metabolic syndrome -FH of premature IHD

Joint British Societies Guidelines (JBS 2)

• Low dose aspirin :

• All people with type 2 DM aged 50 years

• Younger patients with diabetes with either -more than 10 years duration -treatment for hypertension or -evidence of complications e.g. retinopathy or nephropathy

Mr JD 69 years

• Type 2 DM onset 2005• Ex smoker 1989 BMI 27 HBA1c 6.9%• BP 158/78 • Left calf claudication• No retinopathy MA screen normal• TC 5.2 LDL 2.9• Rx Metformin •

Mr JD 69 years

• Encourage activity increase within limits

• Update on foot self care and refer to podiatry

• Aspirin

• Statin - simvastatin 40 mgs

• Ace inhibitor as first line anti-hypertensive

Mrs SD 38 years

• Type 2 DM onset 2001

• Smoker BMI 33 HBA1c 7.2%

• BP 140/86

• Check out assistant

• No retinopathy MA screen normal

• TC 4.2 LDL 2.3 TRIGs 1.2

• Rx Metformin

Mrs SD 38 years

• Smoking cessation support

• Reinforce dietary advice

• Consider Xenical

• ?Exercise class

Mr J S 38 years

• Type 2 DM onset 2000

• Ex smoker BMI 35 HBA1c 8.5%

• On anti-hypertensive Rx BP 148/78

• Erectile dysfunction 2003

• No retinopathy MA screen normal

• TC 4.8 LDL 2.6

• Rx Insulin, metformin, ramipril, sildenafil

Mr J S 38 years

• Review advice on weight reduction and activity level

• Insulin and metformin

• Ace inhibitor and other agent to lower BP

• Sildenafil

• Statin

• Aspirin

Mr AF 49 years

• Type 1 DM since 1994

• Non smoker BMI 27 HBA1c 8.5%

• BP 128/76

• Fit joiner

• No retinopathy MA screen normal

• TC 4.3 LDL 2.5

• Rx Basal bolus insulin regime

Mr AF 49 years

• Basal bolus insulin regime

• Review education

• Simvastatin 20 mgs

• Aspirin (nearly 50 years)

Miss C D 34 years

• Type 1 DM since 1980

• Smoker BMI 27 HBA1c 7.5%

• BP 135/78

• Moderate retinopathy

• Microalbuminuria present

• TC 4.8 LDL 2.7

Miss C D 34 years

• Basal bolus regime of insulin

• Support re smoking cessation

• Ace inhibitor

• Statin

• Aspirin

• Contraception!