Macrovascular Complications of Diabetes Flashcards
What are the microvascular diseases in diabetes?
- Early widespread atherosclerosis
- Ischaemic heart disease
- Cerebrovascular disease
- Peripheral vascular disease
What are the fasting glucose measures for CAD risk factor?
> 6.0mmol/l
What are the waist circumference measures for CAD risk factor?
Men>102
Women>88
What are the HDL measurements for CAD risk factor?
Men<1.0
Women<1.3
What are the hypertension measurements for CAD risk factor?
BP>135/80
What are some metabolic complications?
- DKA
* Hyperosmolar
What are some macrovascular complications?
•Ischaemic heart disease •Cerebrovascular •Renal artery stenosis •Peripheral vascular disease -More atheroma and contributes to cardiovascular morbidity
What is the pathogenesis of atheroma?
- Initial lesion
- Fatty streak (third decade)
- Intermediate lesion: intracellular lipid and small extracellular lipid pools
- Atheroma: intracellular lipid accumulation and core of extracellular lipid
- Fibroatheroma: single or multiple lipid cures and fibrotic layer
- Complicated. lesion: surface defect, thrombosis, and haematoma-haemorrhage
What is the initial lesion?
Mechanism: macrophage
Age: 10
Growth with: lipid
Clinical: silent
What is the fatty streak?
Mechanism: intracellular lipid
Age: 20
Growth with: lipid
Clinical: silent
What is the intermediate?
Mechanism: +extraceullar lipid
Age: 30
Growth with: lipid
Clinical: silent
What is the atheroma?
Mechanism: + core of extracellular lipid
Age: 30
Growth with: smoothmuslce
Clinical: overt
What is the fibroatheroma?
Mechanism: + fibrotic/calficifc layers
Age: 40
Growth with: +collagen
Clinical: overt
What is the complicated lesion?
Mechanism: +surface defect, thrombosis
Age: 50
Growth with: thrombosis/haematoma
Clinical: overt
What is the initial lesion related to?
Diabetic dyslipideiama, increase LDL cholesterol a and lower HDL cholesterol
What are other markers for coronary artery disease?
- Insulin resistance
- Inflammation CRP
- Adipocytokines
- Urine microalbumin
When can insulin resistance be implicated?
In non-diabetic microvascular disease
What is hyperglycaemia associated with?
- Significantly reduced life expectancy
- Diabetes in young people especially more lost years
What do macrovascular diseases cause compared to microvascular?
Microvascular disease causes morbidity;
macrovascular disease causes morbidity and mortality - if diabetes one heart attack more likely to have another then in non diabetic
What else effects coronary heart disease risk in diabetes?
Ethnicity
What is macrovascular disease?
a systemic disease and is commonly present in multiple arterial beds
What is ischaemic heart disease?
- The major cause of morbidity and mortality in diabetes. (earlier)
- The mechanisms are similar with and without diabetes
What is cerebrovascular disease?
•Earlier than without diabetes
•More widespread
-e.g. stoke
What does peripheral vascular disease contribute to?
Contributes to diabetic foot problems with neuropathy - ischameia due narrowing arteries
What can renal artery stenosis contribute to?
May contribute to hypertension and renal failure
Does treatment targeted to hyperglycaemia alone affect increased risk of cardiac disease?
has minor effect on increased risk of cardiovascular disease
What are the non-modifiable risk factors for macrovascular disease?
- Age
- Sex
- Birth weight
- FH/Genes
How do you prevent macrovascular disease?
- Prevention of macrovascular disease requires aggressive management of multiple risk factors
- Insulin resistance before hyperglycaemia itself contributes very important
What are the modifiable risk factors for macrovascular disease?
- Dyslipidaemia (very helpful in preventing macrovascular disease in diabetes)
- High blood pressure
- Smoking
- Diabetes
What is important to manage?
- Blood pressure
- Blood lipid
What are the complication fo diabetes predisposing to foot disease?
- Neuropathy; sensory, motor and autonomic
2. Peripheral vascular disease
What is the epidemiology of foot disease?
- Prevalence of diabetes in England and Wales = 2-3 %
- Prevalence of current or past foot ulceration in diabetes: 5 - 7 % (about 50,000 in England and Wales)
- Risk of amputation up to 60× in diabetes. Poor subsequent prognosis.
- 10 % of NHS bed occupancy due to diabetes related problems (50% foot disease)
What is the pathway to foot ulceration?
- Sensory neuropathy (10g microfilimaent thing)
- Motor neuropathy
- Limited joint mobility
- Autonomic neuropathy (grease and sweat)
- Peripheral Vascular disease
- Trauma – repeated minor/discrete episode
- Reduced resistance to infection
- Other diabetic complications
- e.g. retinopathy
What is the neuropathic foot?
- numb
- warm
- dry
- palpable foot pulses
- ulcers at points of high pressure loading
What is the ischaemic foot?
- cold
- pulseless
- ulcers at the foot margins
What is the neuroischaemic foot?
- numb
- cold
- dry
- pulseless
- ulcers at points of high pressure loading and at foot margins
How do you assess the foot of a diabetic patient?
- Appearance - ? Deformity? Callus
- Feel - ? Hot/cold ? Dry
- Foot pulses- dorsalis pedis / posterior tibial pulse
- Neuropathy - vibration sensation, temperature, ankle jerk reflex, fine touch sensation
What is the preventative management of a diabetic foot?
1.Control diabetes Glycaemia/lipids/BP
2.Inspect feet daily
3.Have feet measured when buying shoes
4.Buy shoes with laces and square toe box
5.Inspect inside of shoes for foreign objects
attend chiropodist
6.Cut nails straight across
7.Care with heat
8.Never walk barefoot
What is the MDT for diabetes foot?
- Diabetologist
- Diabetes nurse
- Chiropodist
- Orthopeadic surgeon
- Limb fitting centre
- Orthotist
- Vascular surgeon
How do you manage a foot ulceration?
1. Relief of pressure -bed rest (risk of DVT, heel ulceration) -redistribution of pressure/total contact cast 2. Antibiotics, possibly long term 3. Debridement 4. Revascularization -angioplasty -arterial bypass surgery 5, Amputation
What does help for microvascular?
- Lots of medicines combatting all aspects - but hard on patient
- Aggressive early management of all risk factors
What is microvascular complications related to?
- Hyperglycaemia
- Dyslipideamia
- Hypertension
- Central fat
- Mutlifactorial
How do hands and toes act in motor neuropathy in the foot?
- Glycosilation of tendons in hand, hand does not bend properly, increasing abnormal pressure loading
- Biggest risk of ulceration on greta toe metatarsal head, toes clawed/flexed
What is osteomyelitis?
- Hot red foot with ulcer
1. Forefoot: MTP’s IP’s
2. Hindfoot: calcaenus
3. Xray: normal first weeks
4. MRI: marrow edema in forefoot and hind foot near ulcer
What is active charcot?
- Hot red foot - no ulcer
1. Midfoot, subarticular
2. Xray: normal first weeks
3. MRI: marrow edema in midfoot subchondral
What is charcots foot and osteomyelitis?
- Can happen from diabetes and if foot ulceration left can lead to
- Charcots: from prolonged neuropathy (not acute!) gradual
- Osteomyelitis: can result from infection in foot or from inside body without clear foot infection
