Macrovascular complications

Question 1

What is macrovascular disease?

Answer 1

A systemic disease of multiple arterial beds.
Early widespread atherosclerosis.
Ischaemic heart disease.
Cerebrovascular disease (stroke).
Peripheral vascular disease.
Renal artery stenosis.

Question 2

What are the sequences in the progression of atherosclerosis?

Answer 2

Initial lesion: histologically ‘normal’, macrophage infiltration, isolated foam cells.
Fatty streak: mainly intracellular lipid accumulation.
Intermediate lesion: intracellular lipid accumulation, small extracellular lipid pools.
Atheroma: intracellular lipid accumulation, core of extracellular lipid.
Fibroatheroma: single or multiple lipid cores, fibrotic/calcific layers.
Complicated lesion: surface defect, haematoma haemorrhage, thrombosis.

Question 3

What is metabolic syndrome?

Answer 3

Accumulation of risk factors.
Fasting glucose: >6.0mmol/L.
Waist circumference: men >102, women >88.
Insulin resistance, inflammation, elevated CRP, adipocytokines, urine microalbumin.
Hypertension: BP>135/80.
Low HDL: men <1.0, women <1.3.

Question 4

How is macrovascular disease associated with the metabolic syndrome?

Answer 4

Initial lesion, fatty streak and intermediate stage of atherosclerosis: growth with insulin resistance, lipid accumulation, BP damaging arteries.
Smooth muscle hypertrophy, associated with insulin resistance, is a feature of atheroma.
Complicated: thrombosis/haematoma more likely in insulin resistant subject.

Question 5

What is the major cause of morbidity and mortality in diabetes mellitus?

Answer 5

Ischaemic heart disease.

Question 6

What are the non-modifiable risk factors for macrovascular disease?

Answer 6

Age.
Sex.
Birth weight.
Family history/genes.

Question 7

What are the modifiable risk factors for macrovascular disease?

Answer 7

Dyslipidaemia.
Hypertension.
Smoking.
Diabetes.

Question 8

Should statins be given to diabetic patients?

Answer 8

Yes, practically all diabetic patients over 50 should be given statin (HMG-CoA reductase inhibitor) to tackle lipids- enormous risk reduction for MI and stroke.

Question 9

What should the treatment strategy be in T2DM to reduce the risk of macrovascular complications and mortality?

Answer 9

Multifactorial intervention: treat hypertension, lipid profile, lifestyle etc.
Treat all aspects of the disease, not just sugar control. Management of glucose alone does not address vascular risk. Aggressive management of all modifiable risk factors is required.

Question 10

What is canakinumab and what may it be used for?

Answer 10

Reduces inflammation, without affecting lipid concentration.
Monoclonal antibody targets interkeukin-1B.
HbA1c lower.
Lower risk recurrent cardiovascular events.
Higher risk infection.
Novel treatment.