Download - Coronary Heart Disease in Diabetes

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


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