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Y2 - ENDO > Macrovascular Complications of Diabetes > Flashcards

Macrovascular Complications of Diabetes Flashcards

1
Q

5 potential types of macrovascular disease that might be complications arising from diabetes?

A
  1. Early widespread atherosclerosis
  2. Ischaemic heart disease (e.g. MI)
  3. Cerebrovascular disease (e.g. stroke)
  4. Renal artery stenosis
  5. Peripheral vascular disease
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2
Q

What are the stages of development of atheroma and possible subsequent embolisation?

A
  1. Initial lesion formation - with macrophage infiltration and foam cells
  2. Fatty streak formation - intracellular lipid accumulation
  3. Intermediate lesion - intracellular lipid accumulation and some small extracellular lipid accumulation pools
  4. Atheroma - more intracellular lipid accumulation and development of a core of extracellular lipid accumulation
  5. Fibroatheroma - fibrotic / calcific layers formation
  6. Complicated lesion - surface defects - and associated thrombosis and haematoma
  7. Emboli can form coming off the complicated lesions
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3
Q

5 association sort of axis for macrovascular complications that occur with diabetes?

A
  1. Fasting glucose >6 mmol/L - i.e hyperglycaemia
  2. HDL: Men - < 1.0, Women < 1.3
  3. HTN 135 > 80
  4. High waist circumference
  5. Insulin resistance type things - inflammation, adipocytokines, urine microalbumin
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4
Q

Briefly list the order of atheroma formation by name and then mention the pathophysiology in terms of how it is actually related to diabetes or otherwise

A
  1. Initial lesion - insulin resistance, metabolic dyslipidaemia and HTN damage the walls of the vessel
  2. Fatty streak - insulin resistance, metabolic dyslipidaemia and HTN - allow development of lipid accumulations (continues for next few steps)
  3. Intermediate lesion - insulin resistance, metabolic dyslipidaemia and HTN
  4. Atheroma - mitogenic smooth muscle hypertrophy, insulin resistance
  5. Fibroatheroma - collagen
  6. Complicated lesion - thrombosis / haematoma
  7. Embolisation
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5
Q

Why and how can non-diabetics also get macrovascular complications and not microvascular complications?

A
  • Insulin resistance may still be associated with macrovascular complications in non-diabetics
  • Microvascular complications, however, occur due to continuous poor glycaemic control in DM
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6
Q

How does diabetes, hyperglycaemia and insulin resistance relate to life expectancy?

A
  • Diabetes, hyperglycaemia and high insulin (indicative of high insulin resistance) are related to a lower life expectancy, potentiated by earlier onset
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7
Q

How does ethnicity come into play in coronary heart disease and in relation to what data - what investigation?

A
  • Framingham heart survey data estimated risk faily well in caucasians but underestimated risk of CHD in UK south asians (based on other factors) - indicating a role of ethnicity
  • Ethnicity has a role in CHD
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8
Q

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

A

Ischaemic heart disease

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9
Q

What can peripheral vascular disease contribute to and what is its partner in crime?

A
  • Diabetic foot problems
  • Diabetic neuropathy (a microvascular complication)
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10
Q

What 2 other morbidities can renal artery stenosis contribute to?

A
  1. HTN
  2. Renal failure
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11
Q

List the risk factors for macrovascular disease:

1) Non-modifiable
2) Modifiable

A

1)

  • Age
  • Sex
  • Birth weight (low birth weight predicts lower macrovascular disease)
  • FH
  • Genetic makeup

2)

  • Dyslipidaemia
  • High BP
  • Smoking
  • Diabetes
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12
Q

Apart from controlling the modifiable risk factors for macrovascular disease, how can you medically

A
  • Give statins to control dyslipidaemia
  • Anti-hypertensive medication to lower BP
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13
Q

1) What drug do you give to reduce the risk of macrovascular complications in diabetics?
2) How does it work?
3) What does it do to HbA1C?
4) What risks might it cause?

A

1)

  • Canakinumab

2)

  • Monoclonal antibody
  • Targets IL-1
  • Reduces inflammation without lowering [lipids]

3)

  • Lowers

4)

  • Risk of infection due to interference with antibodies
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14
Q

What 2 diabetic complications contribute to the risk of development of foot disease in the diabetic foot?

A
  1. Peripheral vascular disease
  2. Diabetic neuropathy
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15
Q

8 things that cause foot ulceration / the diabetic foot?

A
  1. Sensory neuropathy - can’t detect pain so can’t adjust
  2. Motor neuropathy - imbalance between short and long extensors and flexors are required for weight balance
  3. Limited joint mobility
  4. Autonomic neuropathy
  5. Peripheral vascular disease
  6. Trauma - repeated minor / major episode
  7. Reduced resistance to infection (athlete’s foot)
  8. Other diabetic complications e.g. retinopathy - poor vision so you stub your foot lots for example
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16
Q

What causes the foot to ‘claw’ in the diabetic foot?

A
  • Motor neuropathy (microvascular diabetic complication)
  • Imbalance between short and long flexors and extensors are required for balance of toes
17
Q

What vessel related (non-neuropathic) macrovascular complications can lead to the diabetic foot?

A
  • Angiopathy due to extensive atheroma blocking arteries and preventing blood reaching the feet
  • Peripheral vascular disease
18
Q

What are the 3 types of diabetic foot and what are the signs?

A
  1. The neuropathic foot - numb, warm (ok blood supply), dry (due to autonomic neuropathy) , palpable foot pulses, ulcers at point of high pressure loading
  2. The ischaemic foot - cold, pulseless, ulcers at foot margins
  3. The neuro-ischaemic foot - numb, cold, dry, pulseless, ulcers at points of high pressure loading and at foot margins - (so the same as the neuropathic foot except poor circulation)
19
Q

How to assess the foot of a diabetic patient?

A
  • APPEARANCE - look for deformity and callus / ulcers
  • FEEL - temp and dryness
  • FOOT PULSES - dorsalis pedis pulse, posterior tibial pulse
  • NEUROPATHY - vibration sensation, temp, ankle jerk reflex, fine touch sensation
20
Q

How to test fine touch sensation in the foot of a diabetic?

A
  • Microfilament test - microfilament with set pressures placed at points along the diabetic foot and ask the patient at what point they stop feeling the pressure (adjustable pressures)
21
Q

How to manage the diabetes in general (apart from medication)?

A
  • Hyperglycaemia control - if glucose is high, infection risk is high
  • HTN control - stop further damage to blood vessels
  • Dyslipidaemia control
  • Stop smoking
  • Education
22
Q

Methods of preventative management of the diabetic foot?

A
  • Control diabetes
  • Inspect feet regularly
  • Have feet measured when buying shoes
  • Buy shoes with laces and square toe box
  • Inspect inside of shoes for foreign objects (e.g. pebbles)
  • Cut nails straight across
  • Care with exposure to heat
  • Never walk barefoot
23
Q

How to manage foot ulceration in the diabetic foot?

A
  • Pressure reliefe by bed rest, pressure redistribution, total contact cast
  • Antiobiotics - possibly long term e.g. for osteomyelitis
  • Debridement (dead tissue and callous has to go)
  • Revascularisation (angioplasty, arterial bypass surgery)
  • Amputation
24
Q

What 2 things look similar on an MRI in the diabetic foot and how to differentiate?

A
  • Osteomyelitis vs Charcot’s

Osteomyelitis

  • ​Hot red foot with ulcer
  • MRI - marrow oedema in forefoot and hindfoot with ulcer

Active Charcot

  • Hot red foot, no ulcer
  • MRI - marrow oedema in midfoot subchondrial

Y2 - ENDO (18 decks)

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