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Endocrinology > Micro and Macrovascular > Flashcards

Micro and Macrovascular Flashcards

1
Q

Microvascular complication

A

Retinopathy
Nephropathy
Neuropathy

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2
Q

Macrovascular complications

A

Cerebrovascular disease
Ischaemic heart disease
Peripheral vascular disease

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

Prevention of macrovascular disease requires aggressive management of multiple risk factors

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3
Q

Relationship of risk with rising HbA1c

A

Extent of hyperglycaemia (as judged by HbA1c) is strongly associated with the risk of developing microvascular complications

Target HbA1c to reduce risk of microvascular complications
= 53 mmol/mol (<7%)

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4
Q

Hypertension also increases complication risk

A

Clear relationship between rising systolic BP and risk of MI and microvascular complications in people with T1DM and T2DM

Therefore, prevention of complications requires reduction in HbA1c and BP control

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5
Q

Other factors related to the development of microvascular complications

A

Duration of diabetes
Smoking – endothelial dysfunction
Genetic factors – some people develop complications despite reasonable glycaemic control
Hyperlipidaemia
Hyperglycaemic memory – inadequate glucose control early on can result in higher risk of complications LATER, even if HbA1c improved

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6
Q

Mechanism of damage

A

Increased formation of mitochondrial superoxide free radicals in the endothelium
Generation of glycated plasma proteins to form advanced glycation end products (AGEs)
Activation of inflammatory pathways
Damaged endothelium results in
‘Leaky’ capillaries
Ischaemia

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7
Q

Diabetic retinopathy

A

Main cause of
visual loss in people with diabetes
blindness in people of working age
The early stages of retinopathy are all asymptomatic, therefore screening is needed
Aim of screening - to detect retinopathy EARLY when it can be treated before it causes visual disturbance / loss
Annual retinal screening in the UK for all diabetes patients

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8
Q

Retinopathy

A

Background retinopathy
Pre-proliferative retinopathy
Proliferative retinopathy
Maculopathy

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9
Q

Background retinopathy

A 
Hard exudates (cheese colour, lipid)
Microaneurysms (“dots”)
Blot haemorrhages
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10
Q

Pre-proliferative retinopathy

A

Cotton wool spots also called soft exudates

Represent retinal ischaemia

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11
Q

Proliferative retinopathy

A

Visible new vessels

On disc or elsewhere in retina

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12
Q

Maculopathy

A

Hard exudates / oedema near the macula
Same disease as background, but happens to be near macula
This can threaten vision

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13
Q

Treatment of retinopathy & maculopathy

A

Continued annual surveillance

If left alone will progress to new vessel growth
So, early panretinal photocoagulation

Panretinal photocoagulation

Oedema: Anti-VEGF injections directly into the eye (VEGF: vascular endothelial growth factor)
Grid photocoagulation

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14
Q

Why is diabetic nephropathy important?

A

Associated with progression to end-stage renal failure requiring haemodialysis

Healthcare burden

Associated with increased risk of cardiovascular events

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15
Q

Diagnosis of nephropathy

A

Progressive proteinuria (urine albumin:creatinine ratio - ACR)
Increased blood pressure
Deranged renal function (eGFR)
Advanced: peripheral oedema

Microalbuminuria
>2.5 mg/mmol
Proteinuria = ACR > 30mg/mmol
Nephrotic Range > 3000mg/24hr

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16
Q

Mechanism of diabetic nephropathy

A

Hyperglycaemia and hypertension

Lead to glomerular hypertension

Proteinuria
Glomerular and interstitial fibrosis
Glomerular filtration rate decline
Renal failure

17
Q

Renin-Angiotensin System (RAS)

A

Angiotensin II acts via angiotensin receptors
ACE inhibitors (ACEi) are antihypertensives which block ACE
Angiotensin receptor blockers (ARBs) are antihypertensives which block angiotensin receptors

18
Q

Diabetic nephropathy & RAS

A

Blocking RAS with an ACE inhibitor (‘-pril) or angiotensin 2 receptor blocker (ARB, ‘-sartan’) reduces blood pressure & progression of diabetic nephropathy
All diabetes patients with microalbuminuria/proteinuria should have an ACEi/ARB even if normotensive
No benefit to having both ACEi/ARB simultaneously

19
Q

Management of diabetic nephropathy

A

Aim for tighter glycaemic control
ACEi/ARB even if normotensive as soon as patient has microalbuminuria
Reduce BP (aim <130/80 mmHg) usually through ACEi or A2RB
Stop smoking
Start an SGLT-2 inhibitor if T2DM?

20
Q

Diabetic neuropathy

A

Diabetes mellitus is the most common cause of neuropathy and therefore lower limb amputation
Small vessels supplying nerves are called vasa nervorum
Neuropathy results when vasa nervorum get blocked

Risk factors include

- Age
- Duration of diabetes
- Poor glycaemic control
- Height (longer nerves in lower limbs of tall people)
- Smoking
- Presence of diabetic retinopathy

Longest nerves supply feet – so more common in feet
Commonly glove & stocking distribution – peripheral neuropathy
Can be painful
Danger is that patients will not sense an injury to the foot (eg. stepping on a nail)

21
Q

Diabetic foot ulceration

A

All people with diabetes: annual foot check

- Look for foot deformity, ulceration
- Assess sensation (monofilament, ankle jerks) 
- Assess foot pulses (dorsalis pedis and 	posterior tibial)

Risk of foot ulceration in patients with

- reduced sensation to feet (peripheral 	neuropathy)
- poor vascular supply to feet (peripheral 	vascular disease)
22
Q

Management of diabetic foot disease

A 
Peripheral neuropathy
1. Regular inspection of feet by affected individual
2. Good footwear
3. Avoid barefoot walking
Podiatry and chiropody if needed
Peripheral neuropathy with ulceration
Multidisciplinary diabetes foot clinic
Offloading
Revascularisation if concomitant PVD
Antibiotics if infected
Orthotic footwear
Amputation if all else fails
23
Q

Other neuropathies

A 
Mononeuropathy
Usually, sudden motor loss
eg wrist drop, foot drop
Cranial nerve palsy
double vision due to 3rd (oculomotor) nerve palsy
24
Q

Autonomic neuropathy

A

Damage to sympathetic and parasympathetic nerves innervating GI tract, bladder, cardiovascular system

GI tract

  • Delayed gastric emptying: nausea and vomiting (can make prandial short-acting insulin challenging)
  • Constipation / nocturnal diarrhoea

Cardiovascular

  • Postural hypotension: can be disabling - collapsing on standing.
  • Cardiac autonomic supply: sudden cardiac death
25
Q

Risk factors for macrovascular disease

A 
Non-modifiable
Age
Sex
Birth weight
FH/Genes
Modifiable
Dyslipidaemia
Hypertension 
Smoking
Diabetes mellitus
Central obesity
26
Q

Managing cardiovascular risk in diabetes mellitus

A

Smoking status – support to quit
Blood pressure < 140/80 mmHg, < 130/80 mmHg if microvascular complication (NB often needs multiple agents)
Lipid profile – total chol <4, LDL <2
Weight – discuss lifestyle intervention +/- pharmacological treatments
Annual urine microalbuminuria screen – risk factor for cardiovascular disease

Endocrinology (13 decks)

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