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Microvascular and Macrovascular Complication

Diabetes - Microvascular and Macrovascular Complications

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Screening & Management of Cardiovascular Complications

Diabetes is characterised by three to four fold increase in cardiovascular morbidity & mortality.

In addition to traditional cardiovascular risk factors, glucose toxicity, insulin resistance & central adiposity contribute to widespread endothelial dysfunction and accelerated atherosclerosis.

Cardiovascular disease occurs prematurely & relative female gender protection is lost in diabetes.

Cardiovascular disease is 2-3 fold more in prevalent in certain racial groups, particularly those from Asian subcontinent compared to Caucasians.

Diabetes often co-exists with 2-3 modifiable cardiovascular risk factors and often the diagnosis of type 2 diabetes is made at or following an acute cardiovascular event.

Impaired Glucose Tolerance (IGT) also predisposes to higher risk of cardiovascular disease.

Following are some established risk factors

Hypertension

Dyslipidemia

Obesity

Smoking

Minority ethnic groups (Asians & Afro-Caribbeans)

Miscellaneous – family history, gender & age.

 

Relative pre-menopausal protection of women from cardiovascular diseases is lost in diabetes.

 

Principles of Screening Cardiovascular Risk:

Opportunistic / targeted screening of patients at the diagnosis of diabetes & annual diabetes review.

Due to clustering of cardiovascular risk factors in diabetes, if one risk factor is identified then proactively screen for other risk factors.

 

Principles of Management of Cardiovascular Risk:

Regular monitoring for progression of risk and response to therapeutic & life style intervention/s

Multiple interventions are often required for optimal control of single cardiovascular risk

People with diabetes should be empowered to understand their cardiovascular risk & benefit of medical & life style intervention/s

Promote / maintain optimal body weight, healthy life style & cessation of smoking.

Proactive & target orientated management of dyslipidemia, hypertension & hyperglycaemia to achieve optimal control

Primary interventions with ACE - inhibitors in high-risk patients and all patients with type 2 diabetes over the age of over 40 years. The role of aspirin in primary prevention is under review at present.

Periodic monitoring of patients by multi-disciplinary diabetes team in the community & timely referral to specialist/s.

 

Prognosis & outcome of evidence based management of cardiovascular risk factors

Cardiovascular risk intervention/s often confers greater benefit in people with diabetes but needs to be early & more aggressive to reduce cardiovascular morbidity & mortality to the level seen in people without diabetes.

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Cardiovascular Risk - Hypertension

Prevalence & Causes

Hypertension may occur in 80% of patients with diabetes.

Hypertension in diabetes doubles the risk of both micro- & macro-vascular complications.

Minority of cases may have secondary hypertension & should be suspected if results of initial screening are abnormal or hypertension is severe.

Hypertension in type 1 diabetes is often related to nephropathy that requires specialist review.

Diagnosis of Hypertension

In people with diabetes, a sustained blood pressure greater than 130/80 measured under standardised condition constitute hypertension i.e lower level than required to diagnose hypertension in people without diabetes

Category of Hypertension in Diabetes

  Category Systolic BP Diastolic BP
 

 

(mmHg)

(mmHg)
  Mild 130 - 149 80 - 90  
  Moderate 150 - 160 90 - 100  

 

Severe >170 >100  
  Isolated Systolic Hypertension >130 <80  

Management of Hypertension

Confirm sustained hypertension under standardised conditions.

Perform routine tests (Urine dipstick/microscopy, Renal function, ECG) to exclude common causes of secondary hypertension as well as effect of hypertension for end-organ damage.

Introduce life style changes - weight, salt & alcohol reduction., cessation of smoking and regular aerobic exercises

Commence drug therapy if BP > 130/80

Consider cholesterol lowering therapy in all cases.

Most patients will require two-three antihypertensives to achieve optimal blood pressure target. Beware of postural hypotension on high dose vasodilators/diuretics.

Consider referral to specialist opinion in patients with severe hypertension or those with suspicion of secondary hypertension or evidence of end organ damage.

Treatment Target: Systolic <130 & diastolic <80mmHg in uncomplicated diabetes & lower BP is recommended (<120/80) in people with microvascular complications as well those with end-organ damage.

 
Management of Hypertension
All patients with diabetes should have their BP measured every six months

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Lipids & Diabetes

Most people with diabetes have at least one or more lipid abnormalities irrespective of age, sex or ethnicity.

Small number of patients with diabetes may have various types of familial hyperlidaemia.

The commonest & most typical dyslipidaemia in diabetes & metabolic syndrome is characterised by “the lipid triad” :

low plasma levels of high-density lipoprotein cholesterol (HDL-C),

elevated triglycerides and an

increase in small, dense low-density lipoprotein (LDL-C) particles

LDL-C reduction, remains a focus of therapeutic intervention in people with diabetes because of significant reduction of cardiovascular risk.

The residual absolute cardiovascular risk, however, remains higher in people with diabetes than in individual without diabetes and metabolic syndrome.

The management of dyslipidemia in diabetes, therefore, often demands management of all lipid abnormalities.

Management of Dyslipidaemia:

Measure fasting lipid profile at diagnosis & assess overall cardiovascular risk. Risk engines are not recommended in diabetes.

Institute effective non-pharmacological & pharmacological interventions Advise healthier life style & dietary modification (30% less intake of total (specifically saturated) fat. Check TSH.

Optimal management of hyperglycaemia significantly improves dyslipidemia, particularly elevated levels of serum triglycerides. Glitazones also improve HDL-C (5-10 %).

Weight loss promotes rise in HDL-C and can be safely recommended to majority of patients with diabetes

Monitor every three months intervals & progressively titrate interventions till target / optimum lipid profile is achieved

Follow up annual measurement of lipid profile. This can be non-fasting unless there are concerns about triglycerides).

Choice of specific initial pharmacological lipid intervention should be determined by predominant lipid abnormality (see flow chart below).

Statins are effective as an initial pharmacological intervention for control of elevated total cholesterol and LDL-C but has modest effect on levels of HDL-C (<10%) & triglycerides (<20).

 JPC Guidance on the Choice of Statins 2013

Fibrates (peroxisome proliferative-activated receptor agonists) and Nicotinic Acid are particularly effective in increasing HDL-C and lowering of triglycerides but modest effect in lowering total cholesterol & LDL-C.

Other agents such as Ezetimibe or Omega 3 fatty acids specifically lower triglycerides but former is generally used as dual therapy.

Dual pharmacological intervention for treatment of dyslipidaemia is increasingly recognised.

Flow Cart: Management of Dyslipidaemia

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Useful External Links & Resources

View

JPC Website

View

NICE Guidance The Management of Type 2 Diabetes 2015

PDF File

Management of Hypertension Algorithm

PDF File

Management of Dyslipidaemia Algorithm

PDF File

Guidance on the Choice of Statins 2013

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