smoking, lipids and lifestyle dr shirley copland associate specialist
TRANSCRIPT
Diabetes and cardiovascular risk
• Adults with diabetes have a reduced life expectancy of some 5-10 years
• Most deaths are due to circulatory diseases • Heart attacks rates are 3 -5 fold increased• Stroke risk is increased 2-3 fold• After 15 years duration of type 2 diabetes more
than 20% of patients have had a heart attack ( UK prospective diabetes study)
DIABETES AND CARDIVASCULAR DISEASE
AGE DIABETES
45-54 24.8
55-64 37.9
65-74 40.5
Incidence of MI per 1000 women
NO DIABETES
4.3
12.6
22.6
Why the excess risk in Diabetes ?
• Thought that raised blood glucose levels are toxic to the lining of blood vessels
• Vessels are then more susceptible to damage from all the other risk factors e.g. high blood pressure, smoking
• Low density lipoprotein (LDL) is more densely packed with triglyceride which is more readily taken up into the vessel walls causing atheroma plaques
Coronary Risk Factors
• Modifiable
• Smoking• High blood pressure• Cholesterol levels• Excess weight• Lack of exercise• High glucose levels
• Unmodifiable
• Being male *• Family history• Age• Diabetes mellitus• Proteinuria
Risk Factors - Smoking
• Widely recognised to accelerate coronary artery disease and to increase risks of certain cancers
• Smoking >20 per day more than doubles the risk of coronary disease
• Scottish Diabetes Survey 2004 showed 18% patients with diabetes in Grampian remain smokers
Risk Factors - Smoking
• Simple advice to stop smoking has a small but significant effect
• Nicotine replacement therapy can double quitting success rates
• Zyban also helps more people to be successful but can increase the BP
• No definite evidence for benefit of acupuncture • Many people need several attempts to stop –encourage to
keep trying!• Monitor for relapse !
Risk Factor - Lifestyle
• A 10 kg weight loss in obese patients with diabetes has been shown to reduce mortality by 25%
• Exercise helps control weight, blood pressure and lowers blood sugar
• In the UK 60-70% of the adult population is considered to be physically inactive
• Moderate exercise works - taking a brisk walk most days reduces coronary risk by up to 50%
Risk Factors - Cholesterol
• Cholesterol is essential in the body• Component of all cell membranes, needed for
manufacture of steroid hormones, used to make bile salts which are necessary for digestion
• Excess dietary saturated fat increases blood lipids
• Liver is involved in cholesterol manufacture
Risk Factors - Cholesterol
• Cholesterol is carried in the blood in particles called lipoproteins.
• Lab tests report the total cholesterol (TC) and the amounts of the component particles:
• HDL ‘the good’• LDL ‘the bad’• TC to HDL ratio ‘the ugly’ • In type 2 diabetes the ratio is often raised due to low
HDL
How to reduce Cholesterol
• We all know the healthy eating messages - reduced saturated fats, more fruit and veg and oily fish - emphasis is on a balanced diet.
• Fish oil supplements shown to be cardio-protective in the short term in high risk patients. No long term overall benefits.
• Benecol and Flora pro-active margarines do lower the LDL cholesterol - probably beneficial but no long term studies to date.
How to reduce Cholesterol
• Weight loss• Exercise• Good blood sugar control• Exclude secondary causes e.g. hypothyroidism
• However despite best efforts the cholesterol levels often remain relatively too high
Heart Protection Study 2002/3
• Major recent trial studying >20,000 subjects aged over 40 with vascular disease, hypertension or diabetes
• Patients had ‘normal’ cholesterols at entry• In diabetes patients taking simvastatin:• 27% reduction in major coronary events• 25% reduction in strokes • Note - need to treat 100 people for 5 years to
prevent 7 events but benefits would accrue
CARDS 2004
• Almost 3000 patients with type 2 DM
• Patients had no known vascular disease but had either retinopathy, microalbuminuria, hypertension or were smokers
• LDL < 4.14 on entry
• Showed atorvastatin prevented 37 vascular events per 1000 people treated for 4 years
Statin drug therapy
• Most effective lipid lowering medications• Many large studies have now shown consistent
reductions in cardiovascular risks• Do more than just reduce the cholesterol - protect
the circulation• Low incidence of side effects in clinical trials
Potential benefits of ‘statins’
• Reduce major coronary events
• Reduce stroke risk
• Reduce mortality from heart disease
• Reduce need for coronary procedures (angioplasty, coronary artery bypass grafts)
• Reduce total mortality
‘STATINS’
• Simvastatin, pravastatin, atorvastatin, fluvastatin and most recently rosuvastatin
• Act on the liver enzyme (HMG Co A reductase) involved in cholesterol synthesis hence lowering blood levels
• Not used in active liver disease• Few drug interactions (but avoid combination with
clarithromycin /erythromycin, ketoconazole, antivirals, ciclosporin)
• Grapefruit juice avoidance with simvastatin
‘STATINS’
• Few side effects
• Most common are GI effects or headache
• Rare side effects include muscle or liver inflammation (< 1 in 10,000 patient years)
• Liver tests checked before starting treatment and periodically thereafter and patients are advised to report any new muscle pain
• Contra -indicated in pregnancy
Guidelines - shifting the goalpost
• Grampian Diabetes Guidelines - Feb 2004
• GP contract targets - April 2004
• Joint British Societies 2 - November 2005
Joint British Societies Guidelines (JBS 2)
• All patients with diabetes should receive lifestyle advice and lipids monitored
• All patients with known vascular disease should be offered statin therapy
• For primary prevention if patients with diabetes meet the following criteria then statin therapy should be offered
• Treat to a target of TC 4 and LDL 2
Joint British Societies Guidelines (JBS 2)
• All patients with diabetes aged 40 years
• Patients with diabetes aged 18-39 years who have at least one of: -retinopathy (severe, prolif. or maculopathy) -nephropathy (incl. microalbuminuira) -poor glycaemic control (HBA1c >9%) -hypertension -TC 6 or features of metabolic syndrome -FH of premature IHD
Joint British Societies Guidelines (JBS 2)
• Low dose aspirin :
• All people with type 2 DM aged 50 years
• Younger patients with diabetes with either -more than 10 years duration -treatment for hypertension or -evidence of complications e.g. retinopathy or nephropathy
Mr JD 69 years
• Type 2 DM onset 2005• Ex smoker 1989 BMI 27 HBA1c 6.9%• BP 158/78 • Left calf claudication• No retinopathy MA screen normal• TC 5.2 LDL 2.9• Rx Metformin •
Mr JD 69 years
• Encourage activity increase within limits
• Update on foot self care and refer to podiatry
• Aspirin
• Statin - simvastatin 40 mgs
• Ace inhibitor as first line anti-hypertensive
Mrs SD 38 years
• Type 2 DM onset 2001
• Smoker BMI 33 HBA1c 7.2%
• BP 140/86
• Check out assistant
• No retinopathy MA screen normal
• TC 4.2 LDL 2.3 TRIGs 1.2
• Rx Metformin
Mrs SD 38 years
• Smoking cessation support
• Reinforce dietary advice
• Consider Xenical
• ?Exercise class
Mr J S 38 years
• Type 2 DM onset 2000
• Ex smoker BMI 35 HBA1c 8.5%
• On anti-hypertensive Rx BP 148/78
• Erectile dysfunction 2003
• No retinopathy MA screen normal
• TC 4.8 LDL 2.6
• Rx Insulin, metformin, ramipril, sildenafil
Mr J S 38 years
• Review advice on weight reduction and activity level
• Insulin and metformin
• Ace inhibitor and other agent to lower BP
• Sildenafil
• Statin
• Aspirin
Mr AF 49 years
• Type 1 DM since 1994
• Non smoker BMI 27 HBA1c 8.5%
• BP 128/76
• Fit joiner
• No retinopathy MA screen normal
• TC 4.3 LDL 2.5
• Rx Basal bolus insulin regime
Mr AF 49 years
• Basal bolus insulin regime
• Review education
• Simvastatin 20 mgs
• Aspirin (nearly 50 years)
Miss C D 34 years
• Type 1 DM since 1980
• Smoker BMI 27 HBA1c 7.5%
• BP 135/78
• Moderate retinopathy
• Microalbuminuria present
• TC 4.8 LDL 2.7