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An update for Northern diabetes educators Cardiovascular disease: the long-term complication with Diabetes Mellitus November 20 th, 2014 Brian Butkus, PA-C,. MS. AACC Physician assistant, St. Lukes Hospital Depart: Cardiology/Electrophysiology bbutkus@slhduluth.com

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Presenters Disclosures

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Heart Disease: Atherosclerosis Slow progressive disease which begins in childhood. Plaque in the artery wall forms as a response to injury to the endothelium. Artery narrows and symptoms begin when >50% blocked.

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Diabetes mellitus: A state of premature cardiovascular death which is associated with chronic hyperglycemia. Fisher BM. Diabetes Mellitus and myocardial infarction: a time to act or a time to wait? Diabetes Medicine. 1998, 15: 275

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The State of Risk 2 out of 3 Americans are overweight or obese More than 70 million (nearly 1 in 4) Americans have varying degrees of insulin resistance There are an estimated 54 million (more than 1 in 6) Americans with prediabetes Nearly 1 in 4 U.S. adults has high cholesterol 1 in 3 American adults has high blood pressure 2 out of 3 Americans are overweight or obese More than 70 million (nearly 1 in 4) Americans have varying degrees of insulin resistance There are an estimated 54 million (more than 1 in 6) Americans with prediabetes Nearly 1 in 4 U.S. adults has high cholesterol 1 in 3 American adults has high blood pressure

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Direct and Indirect Cost of CVD and Diabetes $296 billion$152 billion $116 billion$58 billion $412 billion$210 billion *Note: these figures may not account for potential overlap. Sources: 2008 statistics from the American Diabetes Association and American Heart Association. Cardiovascular Disease Diabetes TOTAL Estimated Direct Medical Costs Estimated Indirect Costs (disability, work loss, premature mortality)

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Heart disease strikes people with DM twice as often than those without. Diabetics are 2-4x more likely to suffer strokes after having had a stroke. By far the greatest cause of death in people with diabetes is CVD. Deaths from heart disease in men with diabetes have decreased by only 13% compared to a 36% decreased in number without diabetes. Why the diff? In people with Diabetes:

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DM and all CV-events according to the Framingham study

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Can a Hba1c Predict a MI in Type 2 Diabetes??

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UKPDS 35--Study

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So does this mean we should treat everyone to the lowest attainable hemoglobin A1c Goal?

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Despite clear epidemiology, controversy continues regarding the role of glucose lowering to prevent coronary events This is the position statement by the ADA on glycemia and CVD--2010

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--11,140 patients randomized. --Followed 5.9 years. --There was no evidence that intensive glucose (Hga1

Cholesterol Management For patients >20 years of age, cholesterol should be checked every 5 years Ordering a fasting lipid panel is preferred to gauge the patients total cholesterol, LDL-C, HDL-C and triglycerides New guidelines based on ASCVD risk score vs ATPIII guidelines based on treating to targets. For patients >20 years of age, cholesterol should be checked every 5 years Ordering a fasting lipid panel is preferred to gauge the patients total cholesterol, LDL-C, HDL-C and triglycerides New guidelines based on ASCVD risk score vs ATPIII guidelines based on treating to targets.

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New Recommendations for Diabetics and statins (LDL:70-189). --Age 40-75(no CAD): Mod-intens statin. --Age 40-75(CAD): High-intens statin. 2013 ACC/AHA LIPID GUIDELINES

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Statins???

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Do statins cause diabetes ? It is clear that statins can prevent future major cardiovascular events!!!!!!!! Trials do show that Statins can modestly raise blood sugars. In 1 study, diabetes mellitus was diagnosed in 27% more patients receiving a statin (rosuvastatin) compared with patients receiving placebo (an identical appearing pill that does not contain medication), but patients receiving the statin had a significant 54% lower risk of heart attack, 48% lower risk of stroke, and 20% lower risk of death from any cause.

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of Min LDL cholesterol) from a meta-analysis of 14 clinical trials risk of experiencing a cardiac event or death by diabetes status (for a near 40 mg/dL reduction in LDL cholesterol) from a meta-analysis of 14 clinical trials of statin therapy. Shah R V, and Goldfine A B Circulation. 2012;126:e282- e284 Copyright American Heart Association, Inc. All rights reserved.

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So how much does a statin increase your glucose? Non- diabetics Fasting sugars are increased by 3mg/dl Diabetics Increased hemoglobin A1c by 0.3% Simsek S, Schalkwijk C, Wolffenbuttel B. Effects of rosuvastatin and atorvastatin on glycemic control in type 2 diabetes: the Corall Study. Diabet Med. 2012;29:628 631.

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Diabetes and heart failure: Numerous trials (HOPE,SOLVD) have found DM as a major risk factor for the development of heart failure. DM: can cause heart failure independent of CAD or HTN, via the development of diabetic cardiomyopathy.

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Relation of glucose tolerance to LV Left ventricular size increases with worsening glucose tolerance especially in women. Multiple mechanisms have been implicated in this cause of CHF. Henry RMA et al. Diabetes care. 2004; 27:522 -529.

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--AF is the most common arrhythmia in the world. --AF is likely multifactorial and the mechanism is elusive. --Population based studies suggest DM is an independent risk factor for AF. --Most importantly is the fact that DM and AF are predictors for stroke!!!!!!!! Link between DM and Atrial fibrillation cause or correlation?

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Age (years) Prevalence % PREVALENCE OF AF 0.5 1.8 4.8 8.8 0 2 4 6 8 10 50-5960-6970-7980-89

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Priorities in the Management of A FIB The Patient Care Pathway Rhythm Control Prevention of Thromboembolism Rate Control

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C CHF = 1 H Hypertension = 1Hypertension A Age >75 years = 1 D Diabetes = 1Diabetes S Prior Stroke or TIA = 2StrokeTIA Gage et al. Validation of Clinical Classification Schemes for Predicting Stroke. JAMA 2001: 285: 22 (2864-2870).

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Antithrombotic Therapy ACC/AHA/ESC Guidelines 2006 Risk Factor Recommended Therapy No risk factors CHADS 2 = 0 Aspirin, 81-325 mg qd One moderate risk factor CHADS 2 = 1 Aspirin, 81-325 mg/d or Warfarin (INR 2.0-3.0, target 2.5) Any high risk factor or >1 moderate risk factor CHADS 2 >2 or Mitral stenosis Warfarin (INR 2.0-3.0, target 2.5) Prosthetic valve Warfarin (INR 2.5-3.5, target 3.0)

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Case - Mr. Martin Ms. Anderson 57-year-old female, hasnt seen doctor in years Works as a driver, eats mostly fast food Smokes 1 pack per day At health fair found to have BP = 146/86, total cholesterol = 210 Weight = 200 lbs; Family history of HTN and diabetes Ms. Anderson 57-year-old female, hasnt seen doctor in years Works as a driver, eats mostly fast food Smokes 1 pack per day At health fair found to have BP = 146/86, total cholesterol = 210 Weight = 200 lbs; Family history of HTN and diabetes

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Chief Complaint: -SOB -Jaw discomfort when walking out in the cold -Fatigue

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46 yo female transferred to SLH by Life Flight with Chest Discomfort. -Admits to being diabetic but is on no medications. -HTN -Smokes 1-pack cigarrettes -unknown lipid status --under initial circumstances, difficult to obtain medical hx. Ms. Johnson

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Ms Johnson Her Hemoglobin A1c 8.4%

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Risk factors(modifiable) for the prevention and management of cardiovascular disease: 1. Hypertension 2. Dyslipidemia 3. Smoking cessation 4. Hyperglycemia

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Patients with blood pressure >120/80 mmHg should be advised on lifestyle changes to reduce blood pressure. Patients with confirmed blood pressure higher than 140/80 mmHg should, in addition to lifestyle therapy, have prompt initiation and timely subsequent titration of pharmacological therapy to achieve blood pressure goals. Recommendations: Hypertension/Blood Pressure Control ADA. VI. Prevention, Management of Complications. Diabetes Care 2014;37(suppl 1):S36

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Recommendations: Hypertension/Blood Pressure Control Lifestyle therapy for elevated blood pressure Weight loss if overweight DASH-style dietary pattern including reducing sodium, increasing potassium intake Moderation of alcohol intake Increased physical activity

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Antiplatelet and Diabetics Consider aspirin therapy (75162 mg/day) As a primary prevention strategy in those with type 1 or type 2 diabetes at increased cardiovascular risk (10- year risk >10%) Includes most men >50 years of age or women >60 years of age who have at least one additional major risk factor Family history of CVD Hypertension Smoking Dyslipidemia Albuminuria 2010, a position statement of the ADA, the American Heart Association (AHA), and the American College of Cardiology Foundation (ACCF)

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Aspirin continued Aspirin should not be recommended for CVD prevention for adults with diabetes at low CVD risk, since potential adverse effects from bleeding likely offset potential benefits --Low risk: 10-year CVD risk