18. Macrovascular complications

Question 1

what is the difference between macrovascular disease in people with diabetes and in people without?

Answer 1

• the extent to which it occurs in all vascular beds

- how much earlier it occurs

Question 2

give some examples of macrovascular disease

Answer 2

• early widespread atherosclerosis
• ischaemic heart disease (MI)
• cerebrovascular disease (e.g. stroke)
• renal artery stenosis
• peripheral vascular disease

Question 3

what things are associated with artery damage?

Answer 3

• elevated glucose affects atheroma production
• low levels of HDL affect atheroma production
• hypertension
• large waist circumference is associated with ischaemic heart disease

Question 4

how does macrovascular disease develop?

Answer 4

the initial arterial lesions and fatty streaks are a result of insulin resistance, lipid accumulation and BP damaging arteries. these develop collagen and can go on to thrombose on top of the lesion and block the vessel.

Question 5

why is diabetes called a progressive disorder?

Answer 5

it gets worse over time

Question 6

how is the risk for micro and macrovascular disease different in patients with T2DM?

Answer 6

• as glucose enters a diabetic range microvascular disease risk shoots up
• the risk of macrovascular disease is more proportional to the increase in glucose

Question 7

describe ischaemic heart disease

Answer 7

• major cause of morbidity and mortality in diabetes

- occurs earlier on with diabetes

Question 8

describe cerebrovascular disease

Answer 8

• occurs earlier on with diabetes (younger individuals)

- more widespread

Question 9

describe peripheral vascular disease

Answer 9

• worsens diabetic foot problems with neuropathy

Question 10

describe renal artery stenosis

Answer 10

• may contribute to high BP and renal failure

- can permanently damage renal function

Question 11

what is the problem with targeting hyperglycaemia alone in treatment of diabetes?

Answer 11

treatment has little effect on increased risk of CVD

Question 12

what factors need to be modified to reduce the risk of macrovascular disease?

Answer 12

• dyslipidaemia
• high BP
• smoking
• diabetes

Question 13

what is the recommended treatment for diabetes to reduce macrovascular disease risk?

Answer 13

statins - giving a statin early on in diabetes has a very significant reduction in the risk of a heart attack or stroke

Question 14

what is canakinumab?

Answer 14

• a new drug which reduces inflammation without affecting lipids
• monoclonal antibody that targets IL1-b
• treatments result in reduced HBA1C and lower risk of recurrent cardiovascular events

Question 15

what % of NHS bed occupancy is due to diabetes? what % of cases are foot disease?

Answer 15

• 10%

- 50% are cases of foot disease

Question 16

what is the pathway to foot ulceration?

Answer 16

1. sensory neuropathy
2. motor neuropathy
3. limited joint mobility
4. autonomic neuropathy
5. peripheral vascular disease
6. trauma - repeated minor/discrete episode
7. reduced resistance to infection (athlete’s foot)
8. other diabetic complications (e.g. retinopathy = patients stubbing their foot as they walk)

Question 17

what is angiopathy?

Answer 17

extensive atheroma blocking arteries and preventing blood from reaching the feet properly

Question 18

describe the neuropathic foot

Answer 18

numb, warm, dry, palpable foot pulses, ulcers at points of high pressure loading

Question 19

describe the ischaemic foot

Answer 19

cold, pulseless, ulcers at foot margins

Question 20

describe the neuro-ischaemic foot

Answer 20

numb, cold, dry, pulseless, ulcers at points of high pressure loading and at foot margins

Question 21

how is the foot of a diabetic person assessed?

Answer 21

APPEARANCE - deformity or callus?

FEEL - temperature? dry?

FOOT PULSES - dosalis pedis pulse? posterial tibial pulse?

NEUROPATHY - vibration sensation? temperature? ankle jerk reflex? fine touch sensation?

Question 22

what is the preventative management for diabetic foot?

Answer 22

1. control diabetes
2. inspect feet daily
3. have feet measured when buying shoes
4. buy shoes with laces and square toe box
5. inspect side of shoes for foreign objects
6. cut nails straight across
7. care with heat
8. never walk barefoot

Question 23

how is foot ulceration managed?

Answer 23

• relief of pressure: bed rest, redistribution of pressure/total contact cast
• antibiotics (possibly long term)
• debridement (remove dead tissue and callous tissue)
• revascularisation: angioplasty, arterial bypass surgery
• amputation

Question 24

what is charcot and how can it be investigated?

Answer 24

inflammation in particular bones

can be investigated with MRI because ulceration and infection can be seen