Macrovascular Complications

Question 1

What does macrovascular disease include?

Answer 1

o Early widespread atherosclerosis i.e. renal artery stenosis

o IHD (ischaemic)

o Cerebrovascular disease

o Peripheral vascular disease

Question 2

How are insulin resisitance and atheromas linked?

Answer 2

IR contributed to the first 4 stages of atheroma formation

1. Inital lesion
2. Fatty streak
3. Intermediate
4. Atheroma
5. Fibroatheroma
6. Complicated lesion

Question 3

First Key Concept?

Answer 3

Hyperglycaemia is associated w. significant reduced life expectancy

Question 4

Explain the First Key Concept

Answer 4

o If present with diabetes earlier in life - have a SHORTER life expectancy

o Women lose their protection of their gender when they have diabetes in atheroma formation

• suffer more than men
• hence why relative risk in women is HIGHER

o metabolic syndrome had been associated with hyperglycaemia

o risk of MICROvascular disease is very much related to sugar
- so if do NOT have diabetes, virtually NO risk

o risk associated w. HbA1C and MACROvascular more linear

• the higher HbA1C, the greater the risk
• even people WITHOUT diabetes have a high risk!

Question 5

Second Key Concept?

Answer 5

Microvascular disease causes morbidity

Macrovasular disease causes morbidity AND mortality

Question 6

Explain the Second Key Concept

Answer 6

o IHD is a big cause of mortality in diabetics

• diabetics that have NOT had a HA have same mortality has people without diabetes that HAVE had a HA
• diabetics that appear well likely have IHD

o Malignancy tends to be reduced as a cause of death
- this is many diabetics die before cancer has had chance to manifest

o South Asians have a worse mortality for CHD than white caucasians

Question 7

How can the Second Key Concept be measured?

Answer 7

Farmingham Risk Score

Gender-specific algorithm to estimate 10-year CV event risk

Question 8

Third Key Concept?

Answer 8

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

Question 9

Explain the Third Key Concept

Answer 9

1. IHD
   o major cause of morbidity & mortality in diabetics (2nd KC)
   o mechanism similar with or without diabetes
2. Cerebrovascular disease
   o earlier than without diabetes
   o more widespread
   o uncommon in people <60 years
3. Peripheral Vascular disease
   o contributed to diabetic foot problems w. neuropathy
4. Renal artery stenosis
   o may contribute to hypertension in some

Question 10

Fourth Key Concept?

Answer 10

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

Question 11

Explain the Fourth Key Concept

Answer 11

Intensive glucose control does improve CHD risk
BUT
it does NOT change mortality much

Management of glucose alone does NOT address vascular risk

Question 12

Fifth Key Concept?

Answer 12

Prevention of macrovascular disease required aggressive management of multiple risk factors

(IR before hyperglycaemia itself contributes)

Question 13

Risk Factors for macrovascular diease?

Answer 13

Non-modifiable
 o age
 o sex
 o birth weight
 o FH/genes

Modifiable
 o dyslipidaemia
 o High BP
 o Smoking
 o Diabetes

Question 14

Explain the Fifth Key Concept

Answer 14

BP & cholesterol also need to managed in T2DM to prevent complications

Takin statins has a significant effect in reducing macrovascular disease risk

Question 15

What are the treatment goals?

Answer 15

1. Blood-glucose lowering therapy
   via. metaformin, sulphonylurea, insulin etc.
2. BP measurement
   - if damage to kidneys, eyes or cerebrovascular damage lower considerably (<130/80mmHg)
   - other targets lower less (<140/80mmHg)
   - constant monitoring
3. Management of blood lipids
   - review CV risk annually