Post on 30-Dec-2015
description
Coronary Heart Disease in Diabetes
Dr Akhil KapurConsultant Interventional Cardiologist
Honorary Senior LecturerLondon Chest Hospital
Barts and the London NHS Trust
An explosion of diabetes
1995
2000
2025
1995
2000
2025
DevelopedCountries
EmergingCountries
Worldwide
350
300
250
200
150
100
50
0
350
300
250
200
150
100
50
0
Number of people with diabetes in the adult populationmillionsmillions
The Burden of Diabetes MellitusThe Burden of Diabetes Mellitus
US diabetes prevalence in 1994
Source: CDC
US diabetes prevalence in 1996
Source: CDC
US diabetes prevalence in 1998
Source: CDC
US diabetes prevalence in 2000
Source: CDC
US diabetes prevalence in 2002
Source: CDC
US diabetes prevalence in 2004
Source: CDC
Epidemic of diabetes - causes
There’s something wrong with this ….
Causes of death in patients with diabetes
0
5
1015
20
25
3035
40
45
Coronaryheart
disease
Otherheart
disease
Diabetesrelated
Cancer Stroke Infection Other
% o
f d
eath
s
Geiss LS et al. In: Diabetes in America 2nd ed. 1995: 233-257
Diabetes and CV mortality
% change in age adjusted mortality rate since 1979
Diabetic patients are different
Hypertension
Clotting Abnormalities
Dyslipidaemia
Endothelial Dysfunction
Hyperglycaemia
AcceleratedCAD
Risk Reduction
Reducing cardiac risk in diabetic patients
• Good Diabetic control
• Treat Blood Pressure
• Treat Cholesterol and lipid abnormalities
• Treat increased risk of clotting
• Lifestyle modifications
What can be done?
School fruit scheme
(over 2 million children in 14,000 schools)
Ban on tobacco advertising
The First Diabetic Coronary Disease Clinic
DCD Clinic rationale
Patients with diabetes
• die from CHD more often
• are more difficult to diagnose often presenting with silent ischaemia or atypical symptoms
• have more diffuse disease on presentation, with more LV dysfunction often first presenting with an ACS
• suffer a more aggressive disease process
• receive evidence based standard CHD treatments less often in both acute and clinic settings
Clinic Aims
• Allow earlier diagnosis of CHD in diabetic patients even when they present atypically
• Commence and optimise evidence based medical therapies
• “Fast-track” high risk patients to angiography and appropriate revascularisation
Clinic Structure
• Consultant Cardiologist led
• DCD Specialist Nurse support
• Referral base• General Practice• Endocrinologists• Cardiologists• General medical teams
Our ResultsApril 2007 to April 2009
• 200 consecutive diabetic patients were followed up for 6 months
• 105/200 had atypical symptoms on presentation
• All patients received exercise, dietary and lifestyle education.
• 99% had changes to initial medical therapy
Modifiable Risk Factors
Overall 10 year UKPDS Risk Score
The Future
• DCD clinic in every NHS trust ???
• Asymptomatic diabetic patients