Endo 19: Macrovascular complications of diabetes Flashcards
Differentate MACROVASCULAR DISEASE in diabetic vs nondiabetic patients
Macrovascular disease in diabetes and people without diabetes is the same. The difference is the extent to which it occurs in all-vascular beds, and how much earlier it occurs.
T/f controlling glucose alone will have a dramatic effect on vascular risk in diabetics
F… you need to address all risks (BP, lipids)
Outline what macrovascular disease entails
Early widespread atherosclerosis
- Ischaemic heart disease (e.g. myocardial infarction)
- Cerebrovascular disease (e.g. stroke)
- Renal artery stenosis (causes hypertension and renal failure)
- Peripheral vascular disease
Outine the progression of atherosclerosis
Initial lesion, fatty streaks (most have this), intermediate lesion (intracellular lipid accumulation in macrophae), atehroma (core of extracellular lipid) –> fibroatheroma (fibrotic layers, increased VSMC growth ) and compllicated lesioon with haematoma
When does growth of atheroma change from lipid to smooth muscle?
When is growth associated with collagen, and when is it associated with thrombosis
Up to Atheroma it is lipid
At atheroma it is VSMC
At fibroatheroma it is collagen
At compllicated stage it is thrombosis
When does growth of atheroma change from lipid to smooth muscle?
When is growth associated with collagen, and when is it associated with thrombosis
Up to Atheroma it is lipid
At atheroma it is VSMC
At fibroatheroma it is collagen
At compllicated stage it is thrombosis
What is metabolic syndrome
Elevated glucose,
Low HDL,
Increased BP,
Waist circumference increases (omental obesity)
Insulin resistance, inflammation (CRP), adipocytokines and urine microalbulin (for endothelial damage)
How does diabetes lead to the atheroma formation
IR associated with dyslipidaemia (elevated LDL) and HTN, important to the grwoth in the early stages of atheroma
Mitogenic effects of insulin causign VSMC hypertrophy
Mitogenic effects of insulin causes changes in thrombotic pathway
But high sugar not necessary for the progression of this
T/F High sugar associated w reduced life expectancy
T
T/f the later you are diagnosed with fiabetes, the lower the life expectancy
F…. having diabetes and high sugar for a greater number of years (i.e. diagnosed from young) is more damagiung to life expectancy)
When is a someone like to live longer with regard to sugar control
If insulin is low (i.e. patient is insulin sensitive)
T/F diabetes is progressive and always gets worse with time
T
Differentiate risk of microvascular and macrovascular complications in patients with and without diabetes
MICRO:
without diabetes, risk of microvascular disease basically 0, then it shoots up when one becomes diabetic
MACROVASCULAR:
The risk of macrovascular diseases increases steadily as sugar increases. The risk is never that low because 30% of non-diabetics die from heart attacks anyway. But risk gradually increases
Outline the effects of micro and macrovascular disease
Microvascular disease assocatiated with morbidity,
macrovascular disease associated with morbidiy and mortality
What is the prevalence of macrovascular events in diabetics
In diabetes, 60% of patients will die from myocardial infarction. 25% of patients have stroke, but they are having strokes younger than patients in the general population.
Why are diabetics less likely to get malignancy
malignancy is reduced – but this is because patients aren’t living long enough to develop cancer
What is the adjusted mortality for type 2 diabetes
Overall 3X age ajusted mortality
Outline the disease mortality overtime for diabetic and non-diabetic patients who have and have not had revous MI
Obvious,
apart from that diabetic subjects without prior MI have similar mortality to non-diabetics who have had an MI, suggesting the diabetic without an MI did actually already have iscahemic heart disease and it just hadn’t been diagnosed
Outline the effectiveness of the framingham risk for coronary heart disease
Was quite correct in white caucasians but underestimated risk in UK south asians
Where is macrovascular disease found
Macrovascular Disease is a systemic disease and is commonly present in multiple arterial beds
What is the major cause of morbidity and mortality in diabetes
Ischaemic heart disease (similar mechanism)
How does cerebrovascular disease differ with and without diabetes
Earlier than without diabetes
More widespread
Why is peripheral vascular disease bad in diabetics
Contributes to diabetic foot problems with neuropathy
- Neuropathy alone can cause diabetic foot problems, but peripheral vascular disease worsens this
Consequences of renal artery stenosis
May contribute to high blood pressure (hypertension) and renal failure
- It can permanently damage renal function
macrovascular disease is affecting BIG arteries
What is the effect of treatment to control hyperglycaemia on CVS disease risk
Treatment targeted to hyperglycaemia alone has minor effect on increased risk of cardiovascular disease
What are risk factors of macrovascular disease
important
Non-modifiable Age Sex (men have heart attack earlier) Birth weight FH/Genes
Modifiable Dyslipidaemia High blood pressure Smoking Diabetes
T/f the effect of statins is greater on diabetics than normal popuation
T
What is a better way to reduced CVS risk than sugar control
Treating lipids significantly reduces risk (however sugar MUST be controlled too)
Outline the effect of increasing blood pressure on micro and macrovacular disease
BP increases both steadily
But there isn’t the rapid increase in microvascular disease risk with increasing BP as there is with sugar
How should diabetics be treated in TIIDM
n diabetes, we need to consider multi-factorial risk reduction
- Subjects can be intensively treated (in terms of weight, exercise, BP, lipids and glucose)
Use of algorithms… metformin introduced early, BP treated aggressively, as is dyslipidaemia
How does canakinumab work
Canakinumab reduces inflammation, without affecting lipids
- It is a monoclonal antibody that targets interleukin-1-beta
- Treatments results in reduced HbA1c, and lower risk of recurrent cardiovascular events
- However, this agent causes a risk of infection (interference with antibodies)
