Diabetes Macrovascular Complications (half of one lecture)

Question 1

What are 3 microvascular complications of chronic diabetes?

Answer 1

1. Coronary artery disease
2. Cerebrovascular disease (stroke)
3. Peripheral vascular disease

Question 2

How much higher of a risk do diabetics have for CVD than normal individuals?

Answer 2

2-4x, more likely to have asymptomatic disease and worse clinical outcomes

Question 3

Risk factors for CVD with diabetes?

Answer 3

• AGe
• Duration of diab
• Poor gluc control
• hypertens
• Dyslipidemia
• Albuminuria and kidney dis
• Gender (W>M)
• Obesity
• Smioking
• Sedentary lifestyle

Question 4

Risk for macrovascular disease in type 1 vs type 2

Answer 4

Type 1: duration of diabetes is most impt factor, higher risk after 20-25 years with disease

Type 2: >50% have pre-existing CVD at time of diabetes diagnosis. Factors include underlying insulin resistance and presence of multiple CVD risk factors

Question 5

How do we prevent macrovascular dis?

Answer 5

• Glucose, BP and lipid control
• Reduc of microalbuminuria
• Wt loss and exercise
• Smoking cessation
• Aspirin for selected pts

Question 6

Diabetes Control and Complications Trial (DCCT)

Answer 6

Put newly diagnosed T1D patients on either conventional (insulin 2x/day) or intensive (mult daily injections or insulin pump) therapy and followed for 6.5 yrs.

Intensive therapy showed a dec in microvasc complications, but CV complications were not stat signif

Question 7

Epidemiology of Diabetes Interventions and Complications STudy (EDIC)

Answer 7

Followed up the DCCT for about 20 years, but all pts were offered intensive therapy
-discovered metabolic memory (risk reduction in retinopathy and microalbuminuria persisted)

Question 8

UKPDS

Answer 8

• Put newly diagnosed T2D pts on conventional or intensive (Sulfonylurea or metformin) therapy and followed up for about 10 yrs. Found a 25% dec in microvasc dis with intensive therapies but, CV outcomes were not stat signif.
• Also found that blood pressure control reduced retinopathy risk
• Followed up post-trial and found a significant dec in diabetes related death and MI in intensive therapy group, mortality benefit was greater with metformin

Question 9

Newer trials (VADT/ACCORD/ADVANCE)

Answer 9

Tried to control T2D even more aggressively

• No dec in CV outcomes, but more confounding factors tho (like older pts, longer disease etc)
• ACCORD found inc mortality with intensive therapy

-All studies failed to show a dec in macrovascular outcomes with intensive glycemic control

Question 10

Retinopathy screening

Answer 10

• Annual dilated eye examination

- Women who are pregnant need an eye exam, retinopathy risk inc during preg

Question 11

Nephropathy screening

Answer 11

-Annual urine microalbumin and creatinine
Type 1: 5 yrs post diag, Type 2: at diag

• Confirm abnormal test
• Annual serum creatinine

Question 12

Neuropathy screening

Answer 12

• Annual exam (type 1 after 5 yrs, type 2 right away)
• Screen for signs and symptoms of cardiovasc autonomic neuropathy
• Peripheral neuropathy and foot care req inspection, pulses, sensation, vibration tests (like monofilament testing) and self care

Question 13

CV Screening and Prevention

Answer 13

• Check BP
• Fasting lipid panel annually
• Aspirin therapy for some pts

Question 14

Findings of the DCCT/EDIC

Answer 14

Glycemic control in T1D improves micro and macrovascular outcomes

Question 15

Findings of UKPDS

Answer 15

Glycemic control in T2D improves micro and macro outcomes (new onset)

Question 16

Findings of VADT/ACCORD/ADVANCE

Answer 16

Found that near normal glycemic control in pts with long standing T2D and multiple cardiac risk factors does not prevent CV events

Question 17

Risk factor management for macrovascular complications

Answer 17

BP, dyslipidemia, microalbuminuria, wt loss/exercise, smoking cessation, asprin (secondary prevention or high-risk)