Cardiovascular evaluation of a Diabetic patient

1. Dr A P Naveen Kumar
Chief Specialist
VSGH

2. 38 male
Recently detected T2DM
BP 140/94
Lipids 206 / 174 /32 /123
Smoker , no exercise

3.  52 female Obese
 Newly detected T2DM
 Family h/o premature CAD
 Known HTN on treatment
 Lipids 212 / 376 / 32 / 96

4. 56 female T2DM 15 yrs.
Obese and HTN
BP 130/82
Lipids 168/178/36/94
FBS 96 PPBS 156 Sr. Crea. 0.9
ECG - LVH
Retinopathy ,neuropathy +
H/O TIA
On OHA ,ACEI ,Aspirin ,Statin

5.  A majority of patients with T2DM either die from
or acquire serious manifestations of CV disease.
 The risk of a patient with T2DM suffering a major
adverse cardioarvascular event (MACE) of either
myocardial infarction (MI), stroke, or heart failure
(HF) and subsequent CV death is more than double
that of a person without T2DM

6. Beneficial effect of blood glucose lowering on macrovascular
events (ie, MACE) is very limited
UKPDS - followed for up to 20 years, a significant effect on
CV mortality emerged
ACCORD, ADVANCE, and VADT trials failed to show sig.
benefits on lowering the incidence of macrovascular events.
Lifestyle changes (diet, exercise, not smoking) and controlling
dyslipidemia and high blood pressure, with the use of
statins and antihypertensive medications respectively, are
thought to be proportionately more important than glycemic
control in reducing MACE events in patients with T2DM

7. Cardiovascular risk rises from 2-4 % to as high as 55%
Mortality-twice in men and 4-5 times in women
DM is CHD risk factor equivalent
DM patient more likely to die after MI than non DM patient
Coronary atherosclerosis DM – 49% Non DM - 33%
High prevalence of sub clinical Atherosclerosis in DM
Higher prevalence of Left Main disease and reduced coronary
collateral artery recruitment
Mortality ACS to 30 days
STEMI DM - 8.5% Non DM - 5.4%
NSTEMI DM - 2.1% Non DM - 1.1%

11.  CVD is increased two- to threefold in patients with DM
 In a meta-analysis involving 447,064 patients, the rate of
fatal coronary heart disease in patients with DM was
reported to be 5.4% versus 1.6% in nondiabetic subjects.
 Diabetic females had a significantly higher relative fatal
cardiovascular risk than males
 The factors responsible for DM being a CVD risk factor are
insulin resistance, HTN, lipid abnormalities, endothelial
dysfunction, inflammation, and procoagulant factors.

12. Screening and diagnosis
 Blood pressure should be measured at every routine
visit B
 Patients found to have elevated blood pressure
should have blood pressure confirmed on a separate
day B
ADA. 8. Cardiovascular Disease and Risk Management. Diabetes Care 2016;38(suppl 1):S49

13. Goals
 People with diabetes and hypertension should be treated to a
systolic blood pressure goal of <140 mmHg A
 Lower systolic targets, such as <130 mmHg, may be
appropriate for certain individuals, such as younger patients,
if it can be achieved without undue treatment burden C
 Patients with diabetes should be treated to a diastolic blood
pressure <90 mmHg A
 Lower diastolic targets, such as <80 mmHg, may be
appropriate for certain individuals, such as younger patients,
if it can be achieved without undue treatment burden B
ADA. 8. Cardiovascular Disease and Risk Management. Diabetes Care 2016;38(suppl 1):S49

14. Treatment (2)
 Lifestyle therapy for elevated blood pressure B
 Weight loss if overweight
 DASH-style dietary pattern including reducing
sodium, increasing potassium intake
 Moderation of alcohol intake
 Increased physical activity
ADA. 8. Cardiovascular Disease and Risk Management. Diabetes Care 2016;38(suppl 1):S49

15. Action to Control Cardiovascular Risk in Diabetes
(ACCORD):
Does SBP <120 provide better cardiovascular
protection than SBP 130-140? No.
ADVANCE-BP: Significant risk reduction
American Diabetes Association Standards of Medical Care in Diabetes. Cardiovascular
disease and risk management. Diabetes Care 2016; 39 (Suppl. 1): S60-S71

16. Treatment (3)
 Pharmacological therapy for patients with diabetes and
hypertension comprise a regimen that includes
either an ACE inhibitor or angiotensin II receptor blocker B
if one class is not tolerated, substitute the other C
 Multiple drug therapy (two or more agents
at maximal doses) generally required to
achieve blood pressure targets B
ADA. 8. Cardiovascular Disease and Risk Management. Diabetes Care 2016;38(suppl 1):S50

17. Treatment (4)
 If ACE inhibitors, ARBs, or diuretics are
used, serum creatinine/eGFR and potassium
levels should be monitored E
 In pregnant patients with diabetes and
chronic hypertension, blood pressure
target goals of 110–129/65–79 mmHg are
suggested in interest of long-term maternal
health and minimizing impaired fetal
growth;
 ACE inhibitors, ARBs, contraindicated
during pregnancy E
ADA. 8. Cardiovascular Disease and Risk Management. Diabetes Care 2016;38(suppl 1):S50

18. Screening
 In adults, a screening lipid profile is reasonable E
 At first diagnosis
 At the initial medical evaluation
 And/or at age 40 years and periodically (e.g., every 1-2 years)
thereafter
ADA. 8. Cardiovascular Disease and Risk Management. Diabetes Care 2016;38(suppl 1):S51

19. Treatment recommendations and goals
To improve lipid profile in patients with diabetes,
recommend lifestyle modification A, focusing on
Reduction of saturated fat, trans fat, cholesterol intake
Increase of n-3 fatty acids, viscous fiber,plant stanols/sterols
Weight loss (if indicated)
Increased physical activity
ADA. 8. Cardiovascular Disease and Risk Management. Diabetes Care 2016;38(suppl 1):S51

20. Treatment recommendations and goals
Intensify lifestyle therapy and optimize glycemic control for patients
with C
Triglyceride levels >150 mg/Dl (1.7 mmol/L) and/or HDL cholesterol
<40 mg/dL (1.0 mmol/L) in men and <50 mg/dL (1.3 mmol/L) in
women
For patients with fasting triglyceride levels > 500 mg/dL (5.7 mmol/L),
evaluate for secondary causes and consider medical therapy to
reduce the risk of pancreatitis C
ADA. 8. Cardiovascular Disease and Risk Management. Diabetes Care 2016;38(suppl 1):S52

21. Treatment recommendations and goals
 In clinical practice, providers may need to adjust intensity of
statin therapy based on individual patient response to
medication (e.g. side effects, tolerability, LDL cholesterol
levels.) E
 Cholesterol laboratory testing may be helpful in monitoring
adherence to therapy but may not be needed once the patient
is stable on therapy E
ADA. 8. Cardiovascular Disease and Risk Management. Diabetes Care 2016;38(suppl 1):S52

22. Treatment recommendations and goals
 Combination therapy has been shown not to provide
additional cardiovascular benefit above statin therapy
alone and is not generally recommended A
 Statin therapy is contraindicated in pregnancy B
ADA. 8. Cardiovascular Disease and Risk Management. Diabetes Care 2016;38(suppl 1):S52

23.  Consider aspirin therapy (75–162 mg/day) C
 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
ADA. 8. Cardiovascular Disease and Risk Management. Diabetes Care 2016;38(suppl 1):S54

24.  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 C
 Low risk: 10-year CVD risk <5%, such as in men <50 years,
women <60 years with no major additional CVD risk factors
• In patients in these age groups with multiple other risk
factors (10-year risk 5–10%), clinical judgment is
required E
ADA. 8. Cardiovascular Disease and Risk Management. Diabetes Care 2016;38(suppl 1):S54

25.  Use aspirin therapy (75–162 mg/day)
 Secondary prevention strategy in those with
diabetes with a history of CVD A
 For patients with CVD and documented
aspirin allergy
 Clopidogrel (75 mg/day) should be used B
 Dual antiplatelet therapy is reasonable
for up to a year after an acute coronary
syndrome B
ADA. 8. Cardiovascular Disease and Risk Management. Diabetes Care 2016;38(suppl 1):S54

26. Screening
 In asymptomatic patients, routine screening for
CAD is not recommended because it does not
improve outcomes as long as CVD risk factors are
treated A
ADA. 8. Cardiovascular Disease and Risk Management. Diabetes Care 2016;38(suppl 1):S55

27. Treatment :
To reduce risk of cardiovascular events in
patients with known CVD, consider
ACE inhibitor C
Aspirin* A
Statin therapy* A
In patients with a prior MI
β-blockers should be continued for at least
2 years after the event B
*If not contraindicated.
ADA. 8. Cardiovascular Disease and Risk Management. Diabetes Care 2016;38(suppl 1):S55

28. Treatment
In patients with symptomatic heart failure,
thiazolidinedione treatment should not be
used A
In patients with stable CHF, metformin B
May be used if renal function is normal
Should be avoided in unstable or hospitalized
patients with CHF
ADA. 8. Cardiovascular Disease and Risk Management. Diabetes Care 2016;38(suppl 1):S55

29.  : The 2014, ACC/AHA guidelines strongly
advocate use of statins for primary and
secondary prevention in all patients with
diabetes.
 The expert panel observed that there was no
strong evidence to set any LDL and non-HDL
goals for such patients.
 The patients should not be evaluated for
cardiovascular risk and diabetes alone is
sufficient justification for use of moderate to
high intensity statins.

30.  These guidelines are more patient specific and
focused than ACC/AHA guidelines and suggest the
following:
 • For patients with diabetes aged < 40 years with
additional CV risk factors, consider using moderate
or high intensity statin with lifestyle therapy.

31.  • For patients with diabetes aged 40–75 without
CV risk factor consider moderate intensity statin
with lifestyle therapy.
CARDS trial showed CV event reduction by 38%
 • For patients with diabetes aged 40–75 with
additional CV risk factor consider high intensity
statin with lifestyle therapy.

32.  •
 For patients with diabetes > 75 years of age without
CV risk factor consider mod. intensity statin with
lifestyle therapy.
 • For patients with diabetes > 75 years of age with
additional CV risk factor consider moderate or high
intensity statin with lifestyle therapy.
 • Combination therapy of statin+ fibrates or statin +
niacin has not been shown to have any additional
cardiovascular benefits over and above statins alone
and generally not recommended.

33. Age Risk factors
Recommended
statin dose*
Monitoring with
lipid panel
<40 years
None None Annually or as
needed to
monitor for
adherence
CVD risk
factor(s)**
Moderate or
high
Overt CVD***
High
40–75 years
None Moderate As needed to
monitor
adherence
CVD risk factors High
Overt CVD High
>75 years
None Moderate
As needed to
monitor
adherence
CVD risk factors
Moderate or
high
Overt CVD High
* In addition to lifestyle therapy.
** CVD risk factors include LDL cholesterol ≥100 mg/dL (2.6 mmol/L), high blood pressure, smoking, and
overweight and obesity.
*** Overt CVD includes those with previous cardiovascular events or acute coronary syndromes.
ADA. 8. Cardiovascular Disease and Risk Management. Diabetes Care 2016;38(suppl 1):S52, Table 8.1

34. HIGH-INTENSITY STATIN
THERAPY LOWERS LDL > 50%

 Atorvastatin 40–80 mg
Rosuvastatin 20–40 mg
MODERATE-INTENSITY STATIN
THERAPY LOWERS LDL BY 30-50%
 Atorvastatin 10–20 mg
Rosuvastatin 5–10 mg
Simvastatin 20–40 mg
Pravastatin 40–80 mg
Lovastatin 40 mg
Fluvastatin XL 80 mg
Pitavastatin 2–4 mg

35.  The non–HDL-C level is the number of circulating
atherogenic particles (chylomicrons ,LDL,Lp –a,IDL,VLDL
and their remnants)
 It is a more precise therapeutic target than LDL-C when the
triglyceride level is above 200 mg/Dl.
 Reaching ideal goals for non–HDL-C, especially in persons
with diabetes, is one of the most significant means of
reducing cardiovascular events.
 LDL goal is achieved with optimal statin therapy, non-
statin agent may be considered for uncontrolled non-HDL
cholesterol level
Non HDL

36. RISK CATEGORY LDL Goal (mg/dL) Non-HDL Goal
(mg/dL)
CHD and CHD Risk Equivalent
(10-year risk for CHD >20%)
<70 <100
Multiple (2+) Risk Factors and
10-year risk ≤20%
<100 <130
0-1 Risk Factor
<130 <160
Available at: http://www.nhlbi.nih.gov/guidelines/cholesterol/atglance.pdf. Last accessed 07 October 2013.

37.  In conclusion, among statin-treated patients, levels
of LDL-C, and non–HDL-C, was strongly associated
with the risk of major cardiovascular events
 Non–HDL-C was more strongly associated than
LDL-C.
 Non–HDL-C may be a more appropriate target for
statin therapy than LDL-C.


39. Krolewski AS, et al. Evolving natural history of coronary disease in diabetes mellitus. Am J Med 1991;90(Supp 2A):56S-61S.
Diabetes
No Diabetes
60 Men
0-3
Duration of Follow-up (Years)
50
40
30
20
10
0
Women
4-7 8-11 12-1516-1920-23
60
0-3
Duration of Follow-up (Years)
50
40
30
20
10
0
4-7 8-11 12-1516-1920-23
MortalityRatePer1000
MortalityRatePer1000
2x
4-5x

40. Age-adjusted
Biennial Rate Age-adjusted
Per 1000 Risk Ratio
Cardiovascular Event Men Women Men Women
Coronary Disease 39 21 1.5** 2.2***
Stroke 15 6 2.9*** 2.6***
Peripheral Artery Dis. 18 18 3.4*** 6.4***
Cardiac Failure 23 21 4.4*** 7.8***
All CVD Events 76 65 2.2*** 3.7***
Subjects 35-64 36-year Follow-up **P<.001,***P<.0001
________________________________________________________________
_
________________________________________________________________
_

41. 40% greater risk for
women

42. Inherent biological risk [ hormonal]
CV risk factors like obesity, visceral adiposity,
hypertension, prediabetes , dyslipidemia
GDM
Varied clinical presentation

44.  Aggressive screening for prediabetes
among women
 Awareness of excess CV risk even
among IFG or IGT category among
women, with need for aggressive
monitoring and control - ? Impact on
CV risk

45. 45
 38% of women experiencing a heart attack
will die within one year compared to 25%
of men.
 35% of women heart attack survivors will
have another heart attack compared to 18%
of men.
 Women are almost twice as likely as men to
die after bypass surgery.

46.  Consider aspirin therapy (75–162 mg/day)
 As a primary prevention strategy in
those with type 1 or type 2 diabetes at
increased cardiovascular risk (10-year
risk >10%)
 women >60 years of age who have at
least one additional major risk factor
 Family history of CVD
 Hypertension
 Smoking
 Dyslipidemia
 Albuminuria
 For patients with CVD and documented
aspirin allergy
 Clopidogrel (75 mg/day) should be used
ADA. VI. Prevention, Management of Complications. Diabetes Care 2014;37(suppl 1):S40

47. Women with diabetes ARE at high risk of CVD and stroke
Age, menopausal status not protective
Screen all women with diabetes for CV risk factors and
treat aggressively
Use internationally accepted targets
A1C <7.0%*
Blood pressure <140/80 mmHg†
Lipids: LDL
cholesterol
<100 mg/dL (<2.6 mmol/L)‡
Statin therapy for those with
history of MI or age >40+ or
other risk factors

48. Women with diabetes are at very high for CVD and Cer.VD
Aggressive search for risk factors and risk stratification is
necessary
Targets are the same as for men
Presenting symptoms may be different
Avoid medications that can increase CHF/ Ischemia/ weight/
hypoglycemia
Depression, dental health, obstructive sleep apnea linked to
CVD

49.  Advise all patients not to smoke or use
tobacco products
 Include smoking cessation counseling and
other forms of treatment as a routine
component of diabetes care
ADA. VI. Prevention, Management of Complications. Diabetes Care 2014;37(suppl 1):S41

50. STENO-2

51. STENO-2
 The Steno-2 study was designed in 1990
 There was no evidence base for the treatment of type 2 diabetes
 Some diabetes educators were suffering from therapeutic
nihilism
 Intervention studies including the UKPDS were ongoing

52. STENO-2
 An attempt to validate the efficacy of
 daily clinical practice, i.e. the
 multifactorial treatment of type 2
 diabetes

 High risk type 2 diabetes patients

 A single center study
 An organisation which allowed for
 intensive intervention
 Longterm intervention

53. STENO-2
 To investigate the impact on
microvascular and cardiovascular disorders
of a target driven behaviour modification
and polypharmacy
 as compared
 to a conventional multifactorial treatment of
high-risk type 2 diabetic patients with the
metabolic syndrome including
microalbuminuria

54. STENO-2
160 patients stratified according to urinary
albumin excretion rate and then randomly
assigned to treatment groups
80 patients received
conventional therapy
80 patients received
intensive therapy
15 died
7 of CVD
5 of cancer
3 of other causes
12 died
7 of CVD
2 of cancer
3 of other causes
2 withdrew2 withdrew 1 withdrew
63 patients completed
the study after 7.8 yrs
67 patients completed
the study after 7.8 yrs

55. STENO-2
Conventional
n=80
Intensive
n=80
Gender (M/F) 56/24 63/17
Age (yrs) 55 55
Known DM (yrs) 6 6
Body mass index (kg/m2
) 30 30
Haemoglobin A1c (%) 8.8 8.4
Fasting s- -cholesterol (mmol/l) 5.8 5.4
Blood pressure (mm Hg) 149/86 146/85
Albumin excretion rate (mg/24 h) 69 78

56. STENO-2
Conventional * Intensive
Haemoglobin A1c (%) <7.5 <6.5
F-s-cholesterol (mmol/l) <6.5 <4.5
F-s-triglycerides (mmol/l) <2.2 <1.7
Systolic BP (mm Hg) <160 <130
Diastolic BP (mm Hg) <95 <80
ACEi irrespective of BP No Yes
Aspirin, primary prevention No Yes
* Guidelines from the Danish Medical Association

57. STENO-2
Patients and spouses were
motivated to join smoking
cessation courses
Nicotine substitutes were
given for free

58. STENO-2
Have some kind of seafood every
day
Cut down on animal fat

59. STENO-2
5-6 servings of vegetables and fruits/day

60. STENO-2
Enjoy physical performance
more than 150 min/week

61. STENO-2
ACE inhibitor/Angiotensin II antagonist
Diuretics
Calcium antagonist
ß-blocker
Other
Severity of
hypertension
Stepwise approachStepwise approach
to the treatment ofto the treatment of
hypertensionhypertension

62. STENO-2
 Primary: Cardiovascular diseasePrimary: Cardiovascular disease
• Cardiovascular mortality
• Non-fatal myocardial infarction
• Coronary artery bypass graft
• Non-fatal stroke
• Revascularization
• Amputation

 Secondary: Microvascular diseaseSecondary: Microvascular disease
• Progression to nephropathy
• Development of/progression in retinopathy
• Development of/progression in neuropathy

63. STENO-2
PCI or
CABG
Vascular
surgery AmputationStrokeCVD death
Myocardial
infarction
Number of eventsNumber of events
Intensive Conventional

64. STENO-2
0.50 2.52.01.51.0
Nephropathy
(NNT 4)
Retinopathy
(NNT 5)
Auto. neuropathy
(NNT 3)
Periph. neuropathy
Relative risk
0.39
0.42
0.37
1.09
In favor of intensive In favor of conventional

65. STENO-2
Conventional
n=63
Intensive n=67
p-value
NS4239At least one minor episode
NS49Major episode during insulin
treatment
0.07512At least one major episode
Data are number of patients

66.  Our study was not designed to identify which elements of
intensive diabetes therapy contributed most to the
reduction in cardiovascular risk.
 However, using a risk calculator based on epidemiologic
and interventional data from patients with type 2 diabetes
in the United Kingdom Prospective Diabetes Study
 we concluded that the use of statins and
antihypertensive drugs might have had the largest effect
in reducing cardiovascular risk during the 7.8 years of
intervention
 with hypoglycemic agents and aspirin the next
most important interventions.24

67. STENO-2
Compared with a conventional multifactorialCompared with a conventional multifactorial
treatment an intensive and target driventreatment an intensive and target driven
behaviour modelling and polypharmacy for 7.8 yrsbehaviour modelling and polypharmacy for 7.8 yrs
induced an absolute risk reduction ofinduced an absolute risk reduction of 20%20% (RRR(RRR
0.53; NNT 4) in CVD in patients with type 2 DM and0.53; NNT 4) in CVD in patients with type 2 DM and
the metabolic syndrome incl. microalbuminuriathe metabolic syndrome incl. microalbuminuria
The RRR’s found for microvascularThe RRR’s found for microvascular
events after 4 years were main-events after 4 years were main-
tained at a similar level after 7.8tained at a similar level after 7.8
years of intervention: nephropathyyears of intervention: nephropathy
61%, retinopathy 58% and autono-61%, retinopathy 58% and autono-
mic neuropathy 63%mic neuropathy 63%

68.  Do we screen asymptomatic people
(men or women) for CVD
 ADA – NO
 ACC – coronary artery calcium score
can be used

69. Consider investigations for coronary artery disease in
the presence of any of the following:
1. Atypical cardiac symptoms (e.g., unexplained
dyspnea, chest discomfort)
2. Signs or symptoms of associated vascular disease
including carotid bruits, transient ischemic attack,
stroke, claudication, or peripheral arterial disease
3. Electrocardiogram abnormalities (e.g., Q waves).

70. 1. Resting ECG
2. Exercise stress testing with ECHO cardiography
3. Those who cannot exercise we van use pharmacological
stress echo
4. For those with baseline ECG abnormalities we can use
pharmacological stress echo or nuclear imaging
5. Coronary artery Calcium score can also be considered in
women > 40

71. Complex lesions - CABG
Lower disease complexity - PCI
Left main - CABG
SYNTAX score < 22 - PCI
Secondary risk reduction with guideline directed
therapies for HTN,Cholesterol ,Smoking and
HbA1c

72. 38 male
Recently detected T2DM
BP 130/90
Lipids 206 / 174 /32 /123
Smoker , no exercise

73.  52 female Obese
 Newly detected T2DM
 Family h/o premature CAD
 Known HTN on treatment
 Lipids 212 / 376 / 32 / 96

74. 56 female T2DM 15 yrs.
Obese and HTN
BP 130/82
Lipids 168/178/36/94
FBS 96 PPBS 156 Sr. Crea. 0.9
ECG - LVH
Retinopathy ,neuropathy +
H/O TIA
On OHA ,ACEI ,Aspirin ,Statin

75.  Lifestyle changes (diet, exercise, not smoking)
and controlling dyslipidemia and high blood
pressure, with the use of statins and
antihypertensive medications respectively are
important than glycemic control in reducing
MACE events in patients with T2DM
 Treat women as aggresively as men if not more
 High dose statins in certain patients
 Anti-platelets according to guidelines

76. THANK YOU