Endo 19: Macrovascular complications of diabetes

Question 1

Differentate MACROVASCULAR DISEASE in diabetic vs nondiabetic patients

Answer 1

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.

Question 2

T/f controlling glucose alone will have a dramatic effect on vascular risk in diabetics

Answer 2

F… you need to address all risks (BP, lipids)

Question 3

Outline what macrovascular disease entails

Answer 3

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

Question 4

Outine the progression of atherosclerosis

Answer 4

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

Question 5

When does growth of atheroma change from lipid to smooth muscle?

When is growth associated with collagen, and when is it associated with thrombosis

Answer 5

Up to Atheroma it is lipid

At atheroma it is VSMC

At fibroatheroma it is collagen

At compllicated stage it is thrombosis

Question 6

When does growth of atheroma change from lipid to smooth muscle?

When is growth associated with collagen, and when is it associated with thrombosis

Answer 6

Up to Atheroma it is lipid

At atheroma it is VSMC

At fibroatheroma it is collagen

At compllicated stage it is thrombosis

Question 7

What is metabolic syndrome

Answer 7

Elevated glucose,
Low HDL,
Increased BP,
Waist circumference increases (omental obesity)
Insulin resistance, inflammation (CRP), adipocytokines and urine microalbulin (for endothelial damage)

Question 8

How does diabetes lead to the atheroma formation

Answer 8

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

Question 9

T/F High sugar associated w reduced life expectancy

Answer 9

T

Question 10

T/f the later you are diagnosed with fiabetes, the lower the life expectancy

Answer 10

F…. having diabetes and high sugar for a greater number of years (i.e. diagnosed from young) is more damagiung to life expectancy)

Question 11

When is a someone like to live longer with regard to sugar control

Answer 11

If insulin is low (i.e. patient is insulin sensitive)

Question 12

T/F diabetes is progressive and always gets worse with time

Answer 12

T

Question 13

Differentiate risk of microvascular and macrovascular complications in patients with and without diabetes

Answer 13

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

Question 14

Outline the effects of micro and macrovascular disease

Answer 14

Microvascular disease assocatiated with morbidity,

macrovascular disease associated with morbidiy and mortality

Question 15

What is the prevalence of macrovascular events in diabetics

Answer 15

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.

Question 16

Why are diabetics less likely to get malignancy

Answer 16

malignancy is reduced – but this is because patients aren’t living long enough to develop cancer

Question 17

What is the adjusted mortality for type 2 diabetes

Answer 17

Overall 3X age ajusted mortality

Question 18

Outline the disease mortality overtime for diabetic and non-diabetic patients who have and have not had revous MI

Answer 18

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

Question 19

Outline the effectiveness of the framingham risk for coronary heart disease

Answer 19

Was quite correct in white caucasians but underestimated risk in UK south asians

Question 20

Where is macrovascular disease found

Answer 20

Macrovascular Disease is a systemic disease and is commonly present in multiple arterial beds

Question 21

What is the major cause of morbidity and mortality in diabetes

Answer 21

Ischaemic heart disease (similar mechanism)

Question 22

How does cerebrovascular disease differ with and without diabetes

Answer 22

Earlier than without diabetes

More widespread

Question 23

Why is peripheral vascular disease bad in diabetics

Answer 23

Contributes to diabetic foot problems with neuropathy

• Neuropathy alone can cause diabetic foot problems, but peripheral vascular disease worsens this

Question 24

Consequences of renal artery stenosis

Answer 24

May contribute to high blood pressure (hypertension) and renal failure

• It can permanently damage renal function

macrovascular disease is affecting BIG arteries

Question 25

What is the effect of treatment to control hyperglycaemia on CVS disease risk

Answer 25

Treatment targeted to hyperglycaemia alone has minor effect on increased risk of cardiovascular disease

Question 26

What are risk factors of macrovascular disease

important

Answer 26

Non-modifiable
Age 
Sex (men have heart attack earlier)
Birth weight
FH/Genes

Modifiable
Dyslipidaemia
High blood pressure
Smoking
Diabetes

Question 27

T/f the effect of statins is greater on diabetics than normal popuation

Answer 27

T

Question 28

What is a better way to reduced CVS risk than sugar control

Answer 28

Treating lipids significantly reduces risk (however sugar MUST be controlled too)

Question 29

Outline the effect of increasing blood pressure on micro and macrovacular disease

Answer 29

BP increases both steadily

But there isn’t the rapid increase in microvascular disease risk with increasing BP as there is with sugar

Question 30

How should diabetics be treated in TIIDM

Answer 30

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

Question 31

How does canakinumab work

Answer 31

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)