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DIABETIC HEART DISEASE

WHO Definition of Diabetes


Mellitus
Diabetes mellitus is a state of chronic
hyperglycaemia which may result from
many environmental and genetic factors,
often acting jointly
WHO Expert Committee on Diabetes
Mellitus 1980

Re-definition of Diabetes
Diabetes is a state of premature
cardiovascular death which is associated
with chronic hyperglycaemia and may also
be associated with blindness and renal
failure
Miles Fisher, Dublin 1996

Diagnostic Criteria
Normoglycemia

Pre-Diabetes Diabetes

Fasting Plasma
Glucose (FPG)

<100 mg/dl

100-125 mg/dl
(Impaired Fasting
Glucose)

FPG > 126 mg/dl

2-hour Plasma
Glucose

<140 mg/dl

140-200 mg/dl
(Impaired Glucose
Tolerance)

> 200 mg/dl

Casual plasma
glucose

(Previously <110
mg/dl)

> 200 mg/dl with


symptoms

A diagnosis of diabetes must be confirmed on a subsequent day by any of the above tests in the absence of unequivocal hyperglycemia. FPG is preferred
because of ease of administration, convenience, acceptability to patients, and lower cost. Fasting is defined as at least 8 hours of no caloric intake. 2-hour
testing involves an equivalent of 75 g anhydrous glucose dissolved in water.

Diabetes Classification
Type 1 DM
Patient profile
Most diagnosed < 30 y/o; 20% diagnosed after age
30.
Caucasian race or population with substantial white
genetic admixture (including African Americans)
Significant weight loss despite polyphagia (severe
catabolic state)
Thin body habitus
Presence of other autoimmune diseases
Ketoacidosis prone

Type 2 Diabetes90-95% of cases

Combination of insulin resistance and inadequate


compensatory insulin secretion.
Insulin resistance

Obesity (particularly abdominal/visceral)


Habitual inactivity
Ketoacidosis less common but can occur with severe stressors or
new onset DM.

Insulin secretory defect

Beta-cells incapable of compensating for insulin resistance.


Progressive loss of beta-cell function with time.

Strong genetic predisposition


Nearly 100% concordance among monozygotic twins
(compared to 50% in autoimmune type 1 DM)
Genetics are more complex (polygenic)

PREVALENCE OF TYPE 1
DIABETES IN THE US
1 million people
Caucasians constitute the majority of

type 1 diabetics
Most prominent during childhood

PREVALENCE OF TYPE 2
DIABETES IN THE US
Most common type of diabetes among

all ethnic groups


17 million patients with known diabetes
45% of children and teens with new

diagnoses

Diabetes in the World


79.4
India

21.3
Indonesia

Year
2010

42.3
China

30.3
USA

8.9

millions

Japan

Reference: Wild S, Roglic G, Green A, Sicree R, King H. Global prevalence of diabetes. Diabetes Care. 2004; 27(5): 1047-1053 .

Cardiovascular Disease and


Diabetes

20

15

10

Pathophysiology
of Type 2 Diabetes
and
Insulin Resistance

Natural History of Type 2


Diabetes

Development of Type 2
Diabetes

Hyperglycemia in Type 2
Diabetes Results From Three
Major Metabolic Defects

Insulin Resistance: Associated


Conditions

Complications of Diabetes
Cardiovascular
complications

Renal
failure

Blindness

Diabetes
Amputation

Nerve
damage

Cardiovascular Complications
Heart Attack

Stroke

Coronary artery
disease

Peripheral
vascular
disease

Diabetes and Cardiovascular


Disease
Macrovascular disease including CAD and other
vascular events (CVA, PVD) is responsible for
nearly 80% of all diabetes mortality
75% of all hospitalizations in diabetes patients is
due to cardiovascular events
A third of individuals have CVD by the time they
are diagnosed with diabetes

Beaser R, et al.

Diabetes and heart


abnormalities
Coronary heart disease
Specific heart disease of diabetes
Diabetic autonomic neuropathy

Heart Disease Risk


Age: men over 45 and women over 55
Family history of heart disease
Little or no daily exercise
Dyslipidemia
elevated LDL (smaller, denser)
reduced HDL
elevated triglycerides
Hypertension
Smoking
Pre-diabetes
Hyperglycemia /Diabetes
Metabolic syndrome

Hypertension and diabetes


Hypertension worsens diabetes by promoting
insulin resistance
Diabetes and hypertension doubles CVD risk
Aggressive hypertension management reducer
CVD RISK

Risk of CVD and Hyperglycemia


Hyperglycemia promotes vascular dysfuction,
dyslipidemia and hypercoagulability
Meta- anaysis faund relation between increased
CVD risk and plasma glucose level
Increase risk began to appear ay HbA1c of 0,2
% but ability to decrease risk with tight control
has been harder to prove

Metabolic Syndrome
(insulin resistance syndrome)
Any two of the following
Blood pressure: >130/85 mm Hg
FBG >100 mg/dL; two-hour >140 mg/dL
HDL <50 mg/dL (F); <40 mg/dL (M)
Triglycerides >150 mg/dL

Myocardial infarction
Mortality twice the
non-diabetic
Increased silent or
painless infarction
Delay in receiving
treatment
Increased congestive
cardiac failure,
cardiogenic shock,
rupture, re-infarction

Coronary artery disease


Most commom vascular complication of diabetes
Age adjusted prevalence of CAD in white
Americans with type 2 DM is 2 4 times that of
non diabetic
Angina, MI and sudden death are at 2 6 times
as common in patients with type 2 diabetes

Mortality Data
Relative risk of age specific death from MI
among diabetic patients during the first year of
dyalysis ia 89 times higher than that of the
general population
CAD accounts for 40% of all death in renal
transplant patients

Post myocardial infarction


First month after MI, mortality 14-26 % higher in
diabetic men and 21-39% higher in diabetic
women
In first 28 days, diabetes in diseases mortality by
58 % in men and by 160 % in women
5 year mortality may be as high as 50 % more
than twice that non diabetic

10 year mortality may be 60 % in males with


diabetes and as high as 80% in women with
diabetes
Increase in mortality and major morbidity,
including congestive heart failure and
reinfarction

Diabetic cardiomyopathy
CHF development is 2.4-5.1 times higher in diabetics
than controls
Even in pt with DM2 without significant coronary arterial
disease
myocardial histopathological changes are noted (Regan et al.)
there are abn in LV myocardial contractility

Thus the diabetic milieu appears to result in abn in


myocardial structure and function
Result is diabetic cardiomyopathy

Rubler 1972
Described postmortem findings in 4 diabetic adults
with CHF
no coronary artery disease
no valvular cardiac disease
no hypertensive cardiac disease
no alcoholic cardiac disease
Postulated to represent either a result of
diabetic microangiopathy or a direct consequence of
the abnormal myocardial
metabolism in DM

Interstitial Fibrosis
Regan et al.
autopsy of 11 diabetic patients, with no discernable
CAD.
Suggested that filamentous PAS positive
glycoprotiens accumulated early in DM (?
coinciding with abnormalities in LVDD even at this
stage.)
Later accumulation of collagen as a consistent
background
Similar to changes in diabetic glomeruli

Small Vessel disease


Blumenthal et al.
Series of 116 diabetic compared to 105 controls
Endothelial proliferation and PAS (periodic acid schiff)
material in 50% of diabetics compared to 21% of non
diabetics

Regan et al
12 diabetics underwent angiograms and studies of myocardial
fn.
During atrial pacing induced tachycardia no lactate production
in coronary sinus vv bld sampling
Small vessel disease prominence in cardiomyopathy
questioned.

Metabolic Syndrome
(insulin resistance syndrome)
Any two of the following
Blood pressure: >130/85 mm Hg
FBG >100 mg/dL; two-hour >140 mg/dL
HDL <50 mg/dL (F); <40 mg/dL (M)
Triglycerides >150 mg/dL

Treatment Recommendations
A1c <7% (AACE 6.5%)
LDL <100 mg/dL vs <70 mg/dL
BP <130/80 mm Hg
ASA daily
ACE-l or ARB (albuminuria)
Beta-blockers (DM + CAD)

Lifestyle Considerations
Physical activity
Weight reduction and maintain healthy weight
Meal plan designed to lower blood glucose and
alter lipids
Risk reduction (smoking cessation)
Stress management
Alcohol in moderation
Take medication (if prescribed)

Treatment Recommendations
A1c <7% (AACE 6.5%)
LDL <100 mg/dL vs <70 mg/dL
BP <130/80 mm Hg
ASA daily
ACE-l or ARB (albuminuria)
Beta-blockers (DM + CAD)

How should we protect the


diabetic heart?
Treat the diabetes (primary prevention)
Treat the cardiovascular risk factors
Other preventative measures
Treat the heart disease
Miles Fisher Dublin 1996