INCIDENCE OF MACROVASCULAR COMPLICATIONS IN NEWLY

DIAGNOSED DIABETICS

Dr. Awadhesh Kumar sharma,SRMEDICINE,MLB,MEDICALCOLLEGE

JHANSI

What is Diabetes?What is Diabetes? Normally, blood sugar (glucose) levels are kept Normally, blood sugar (glucose) levels are kept

in the normal range by the release of insulin in the normal range by the release of insulin from the islet cells of the pancreasfrom the islet cells of the pancreas

Insulin helps glucose enter the cells. Insulin helps glucose enter the cells. Diabetes occurs when the body doesn’t Diabetes occurs when the body doesn’t

produce enough produce enough insulininsulin or the body can’t use it or the body can’t use it properly. This results in sugar (glucose) properly. This results in sugar (glucose) building up within the bloodstreambuilding up within the bloodstream

Diagnosed by blood test Diagnosed by blood test Fasting glucose > 125mg/dl Fasting glucose > 125mg/dl Random blood glucose > 200mg/dlRandom blood glucose > 200mg/dl

Pancreas

Cannot Produce Enough Insulin

Body lacks insulin or is Body lacks insulin or is unable to use insulin unable to use insulin

effectivelyeffectively

DiabetesDiabetes

Muscle and Fat Cells

Cannot Use Insulin Effectively

Diagnosis CriteriaDiagnosis Criteria

One test is not enough! The diagnosis must be done by a physician.

Normal Pre diabetes Diabetes

Fasting Blood Glucose Test (FBG)*

Less than100

Between 100 - 125

More than or equal

to 126

Glucose Tolerance Test (GTT) **

Less than 140

Equal to or more than 140 but

less than 200

More than or equal to 200

* FBG blood test is done after fasting 8 hours.

** GTT results are repeated after 2 hours. A person drinks a 75 mg glucose solution before test. 100 mg for Pregnant women.

Epidemiology Diabetes is an ‘iceberg” disease. According to recent estimation the prevalence of diabetes mellitus in adult is 4% worldwide and it means that over 14.3 million persons are affected.

At present the prevalence of DM is estimated to be 0.19% in people < 20 years old and 8.6% in people > 20 years. In individuals > 65 years old the prevalence of DM estimated to be 20.1%. The prevalence is similar in men and women through out most age ranges but its slightly greater in men more than 60 years.

It is projected that disease prevalence will be 5.4% by

year 2025 with global diabetic population reaching 300

million. Of the close to 77% of global burden of disease

is projected to occur in developing countries.

The most recent study, National Urban Diabetes Survey

carried out in six cities found age standardized

prevalence rate of 12% for diabetes and 14% for IGT. At

present total no diabetic patient in India is about 33

million and may increase upto 80 million by 2030.

Risk Factors for the Risk Factors for the Development ofDevelopment of Type 2 Type 2

DiabetesDiabetes Family history of Family history of

diabetesdiabetes ObesityObesity

Especially centralEspecially central HypertensionHypertension High triglyceridesHigh triglycerides Low HDL-CLow HDL-C Elevated glucoseElevated glucose

Ethnicity other than Ethnicity other than CaucasianCaucasian

Vascular diseaseVascular disease History of gestational History of gestational

diabetesdiabetes History of baby History of baby

weighing > 9 lbsweighing > 9 lbs Sedentary lifestyleSedentary lifestyle

Complications of Diabetes

Eye diseaseo Retinopathy (non

proliferative / proliferative)Macular edema

Nephropathy Neuropathy

o Sensory and motor (Mono or polyneuropatyhy)

o Autonomic neuropathy

The deadly triangle of morbidity and mortality in the diabetic population are

• Coronary artery disease

• Cerebrovascular disease

• Peripheral vascular disease

Coronary artery disease is leading cause of mortality followed by cerebrovascular disease.

• Gastrointestinal (Gastro paresis and diarrhea)

• Genitourinary (uropathy/ sexual dysfunction)

• Dermatologic• Infectious • Cataracts • Glaucoma

Vascular Non-Vascular

Microvascular Macrovascular

Retinopathy: 25x

Complications of DiabetesComplications of Diabetes

End-Stage Kidney Disease: 17x

Heart Disease: 2-4x

Foot/Leg Amputations:

5x

Stroke: 2-6x

Macrovascular complication of diabetes

Diabetes mellitus is the most prevalent, chronic non

communicating disorder and risk of complication

increases with function of duration of

hyperglycemia. It involves various organs especially

kidney, heart, blood vessels, eye, brain. Clinical

manifestation of macrovascular disease is

atherosclerosis.

Insulin resistance diabetes Insulin resistance diabetes mellitusmellitus

HypertensionHypertension

ObesityObesity

HyperinsulinemiaHyperinsulinemia

DiabetesDiabetes

DyslipidemiaDyslipidemia

Small, dense LDLSmall, dense LDL

InflammationInflammation

HypercoagulabilityHypercoagulability

InsulinInsulinResistanceResistance

InsulinInsulinResistanceResistance

AtherosclerosisAtherosclerosisAtherosclerosisAtherosclerosis

Aims and objectives

To study the incidence of macrovascular

complications in DM in newly diagnosed

patient (diagnosed within 6 months)

Material & MethodsThe study will include diabetes mellitus patients new

cases which is diagnosed within 6 months.

Sources of cases

1. OPDs in MLB Medical College

2. Patient admitted in wards

3. Patients admitted in ICCU.

Criteria of selection

Any volunteer who fulfils the criteria of diagnosis of DM new cases (diagnosed within 6 months) will be included in study.

Method of study

Name

Age and sex

Residence

History

- H/o present illness

- Past history

- Personal history

- Family history

- H/O risk factors

Anthropometry

- Height

- Weight

- BMI

- Waist circumference

General examinations

- Pulse

i. Radial

ii. Dorsalis pedis

- BP

i. Brachial BP

ii. Ankle BP

iii. Ankle brachial index

Systemic examinations

- Detailed CVS examination

- Detailed CNS examination

- Detailed peripheral vascular systemic examination

INVESTIGATION General investigation

-Hemoglobin

-S. creatinine

-Micral test

-24 hr urinary protein

Lipid profile

-Total cholesterol

-HDL cholesterol

-LDL cholesterol

-VL/DL cholesterol

-HDL/LDL ratio

Specific investigations for macrovascular disorders ECG

o Routine ECG

o With long lead II & V1

o Double speed ECG

o Tread Mill Test (TMT)

X-ray chest PAV

Echo cardiography

Duplex imaging of carotids

o Carotid intimal medial thickness

NCCT

Distribution of cases according to sex

Male87%

Female13%

020406080

100120140160180

No

. o

f ca

ses

20-29 30-39 40-49 50-59 60-69

Age group (in years)

Distribution of cases according to age

0

30

60

90

120

150

No

. o

f ca

ses

40-49 50-59 60-69 70-79 80-89

Weight (in kg)

Distribution of cases according to weight

0

30

60

90

120

150

No

. o

f ca

ses

130-139 140-149 150-159 160-169 170-179

Height (in cm)

Distribution of cases according to Height

Distribution of cases according to risk factors (Hypertension)

27%

73%

Hypertensive Non Hypertensive

0

20

40

60

80

100

No

. o

f ca

ses

Cholesterol LDL Triglyceride HDL

Types of dyslipidemia

Distribution of cases according to type of dyslipidemia

Distribution of cases according to BM I (Obesity)

12%

8%5% 3%

72%

Preobese Class I Obese Class II Obese Class III Obese Others

Distribution of cases according to risk factors (Family H/o diabetes)

15%

85%

Family H/o Diabetes No family H/o diabetes

Distribution of cases according to risk factors (Smoking)

60%

40%

Smoker Non smoker

Distribution of cases according to risk factors (Central obesity)

28%

13%59%

Central Obesity (Male Central Obesity (Female) Others

Macrovascular complications at the time of presentation (Cardiovascular)

8%

33%

59%

MI Angina Others

Macrovascular complications at the time of presentation (Peripheral vascular disease)

3% 5%

92%

Diabetic gangrene Claudication Others

Macrovascular complications at the time of presentation

44%

11%9%

36%

Cardiovascular Cerebrovascular

Peripheral vascular Without complications

Diabetes control starts knowing patient’s A1c levels. Diabetes control starts knowing patient’s A1c levels.

Good diabetes control avoids or delays complications.Good diabetes control avoids or delays complications.

A1c test every 3 months.A1c test every 3 months.

A1c < 7% is the goalA1c < 7% is the goal

Diabetes ControlDiabetes Control

meal plan meal plan (always eating (always eating healthy)healthy)

exercise exercise moderately (eg. moderately (eg. walking 30 walking 30 minutes a day)minutes a day)

Diabetes Diabetes Self-Self-managementmanagementwhat a person with diabetes should do by what a person with diabetes should do by

her/himself to maintain controlher/himself to maintain control

DiabetesDiabetes Self-Self-managementmanagement

monitor glucose monitor glucose levels frequentlylevels frequently

take medications take medications properlyproperly

take care of eyes, take care of eyes, feet, teeth and feet, teeth and skin skin

Remember the values of good Remember the values of good controlcontrol

A1c test < 7 %Blood Pressure

< 130/80

LDL cholesterol

< 100

If a person with diabetes keeps these values between medical check ups, means a good

diabetes control

ConclusionThe following conclusions can be drawn from the present study :-

1. The average age of newly diagnosed type-2 diabetes mellitus

patients was 40-60 years.

2. Incidence of cardiovascular disease in newly diagnosed type-2 DM

found to be 40%.

3. Incidence of cerebrovascular complications were found to be 10%

in newly diagnosed type-2 DM.

4. Incidence of peripheral vascular disease was found to be 8% in

newly diagnosed type-2 DM.

5. Incidence of macrovascular complications were more in those

having risk factors like hypertension, dyslipidemia, obesity,

smoking and family history of diabetes.