Clinical aspects of managing the cardiovascular risk in
diabetes Dr SH Song MD FRCP Consultant Diabetologist Northern
General Hospital Sheffield
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Increased CHD in type 1 diabetes Laing at al Diabetologia 2003;
46: 760-5
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STENO-2 Evidence - Intensive multifactorial intervention are
effective in reducing CVD events in type 2 DM Behaviour
modification (weight, diet, smoking cessation) Pharmacological
intervention aimed at diabetes, hypertension, lipids along with
aspirin and ACE-I 50% reduction in CVD events, nephropathy,
retinopathy and neuropathy Risk reduction 20% higher than
single-factor intervention studies (glycaemia, BP, lipid lowering)
Important to target all risk factors
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JBS2 guidelines 2005 Treatment targets for patients with
diabetes: HbA 1c 6.5% BP 40 years with either Type 1 or 2 diabetes
Joint British Societies Guidelines on Prevention of Cardiovascular
Disease in Clinical Practice 2005
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Glycaemic control
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Glycaemic control and CVD events
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Effect of reducing HbA 1c : UKPDS 1% reduction in HbA 1c
significantly reduced the risk of diabetes-related complications
Stratton et al. BMJ 2000; 321: 405412 Microvascular complications
Any diabetes- related endpoint Myocardial infarction Amputation or
death from PVD Stroke * -37% * -21% * -14% * -43% ** -12% UKPDS,
United Kingdom Prospective Diabetes Study PVD, peripheral vascular
disease Median follow up = 10 years, n = 3642 for relative risk
analysis Primary endpoint; *p
No role for CVD risk calculation table To guide initiation of
lipid-lowering treatment in primary prevention Calculates absolute
risk of developing CHD (over 10 yrs) introduced when statin cost
was expensive (predominantly financial reason) prior to statin
trials in diabetes (HPS, CARDS) not evidence-based Purpose: to
target high risk individuals to maximise cost-effectiveness to
reduce unnecessary treatment in some individuals JBS (1998) and
NICE (2002) recommends risk tables statin Rx when >15% (NICE) or
>30% (JBS) Available risk calculators:Framingham & UKPDS
risk engine
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Framingham equation under-estimate CHD risk in diabetes up to
50% PredictedObserved UKPDSCHD event (%/yr)1.62.7 (Diabetes)
WOSCOPSCHD event (%/yr)1.91.8 (Non-diabetes) (Yeo et al Diabet Med
2001; 18: 341-44) CardiffCHD eventMale8.319 (Diabetes)(% / 4 yrs)
Female7.517 Stevens et al Diabet Med 2005; 22: 228
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UKPDS risk engine is not a better alternative Comparison
between UKPDS risk engine and Framingham equation SH Song et al
Diabetic Med 2004; 21: 238-45 Mean CHD risk (over 10 yrs) in type 2
diabetes malefemale JBS1917.3 UKPDS24.916.5 Conclusion: Overall,
UKPDS risk engine estimated higher CHD risk score. At high risk
(>30%), UKPDS risk engine consistently estimated higher risk
score than Framingham equation. At lower risk levels (~15%) where
clinical decision to start statin occurs (as per NICE), UKPDS risk
engine and Framingham equation equivalent. 15% threshold UKPDS risk
engine better Framingham calculator better
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Why under-estimate risk in diabetes? Model based on largely
non-DM population (Framingham calculator) Traditional risk factors
do not account for excess CHD death in diabetes. Other important
factors not included in risk calculation. (ie small dense LDL,
microalbuminuria, hypercoagulable state, impaired fibrinolysis,
endothelial dysfunction, inflammatory states, insulin resistance
etc) Other limitations: No risk calculation method for type 1
diabetes. Young type 2 diabetes increasing and risk cant be
calculated by current methods.
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Forms the basis for degree of aggressiveness with lipid Rx
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Young T2DM patients
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Facts: high CVD risk (especially with CVD risk factors) no
trial data in this age group (compared to >40yrs HPS/CARDS)
increasing number of young T2DM patients
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SH Song, CA Hardisty. Practical Diabetes International 2007;24:
20-24 Sheffield experience Young type 2 diabetes patients: Similar
CVD risk profile as older type 2 diabetes patients High prevalence
of obesity, hypertension and dyslipidaemia Less likely to be
treated with statin and anti-hypertensive agents
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Sheffield experience Tendency to multiple CVD risk factor
clustering in young type 2 diabetes patients of similar proportion
to older T2DM SH Song, CA Hardisty. Practical Diabetes
International 2007;24: 20-24
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High prevalence of metabolic syndrome in T2DM regardless of age
~70% 40 yrs 70 IDF ATP Average WC ~113 cm or 44 inches (male and
female) 70 SH Song. Presented at EASD Copenhagen 2006 Sheffield
experience (2)
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Recommendation for statin in diabetes: Joint British Societies2
guideline (Dec 2005)
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Effect of intensive lifestyle intervention on CVD risk factors
in T2DM Diabetes Care 2007; 30: 1374-83 T2DM 45-74 yrs Intensive
lifestyle intervention with diet, physical activity, behaviour
modification Aim: to determine effect of intensive lifestyle
intervention on CVD outcome
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Diabetes Care 2007; 30: 1374-83 At 1 yr, Intensive life style
intervention results improvement in: Glycaemic control BP Lipid
profile (HDL, Trig)
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Intensive life style management focusing on dietary and
physical activity with community dietitian and Sheffield Active
group To achieve coordinated and integrated intervention with diet
and exercise T2DM inadequately controlled on oral hypoglycaemic
agents Started May 2007 for 2 years
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Conclusions: Intensive management focusing on glycaemic
control, BP, lipid, lifestyle Oral hypoglycaemic agents with CVD
outcome data metformin, pioglitazone Lowering BP require multiple
agents including ACE-I Statin remains first choice for lipid
lowering. Additional agents may be needed to further lower
cholesterol in some patients Young T2DM have multiple CVD risk
factors as older patients Some evidence of lifestyle intervention
beneficial effect on CVD risk factors