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The Science: CHD and Diabetes as Co-morbidities

The Science: CHD and Diabetes as Co-morbidities. Kathy Reims, MD Center for Strategic Innovation 8/27/07. Objectives:. What is the rationale to think about diabetes and coronary heart disease (CHD) together? Patient perspective Pathophysiology Treatment

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The Science: CHD and Diabetes as Co-morbidities

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  1. The Science: CHD and Diabetes as Co-morbidities Kathy Reims, MD Center for Strategic Innovation 8/27/07

  2. Objectives: • What is the rationale to think about diabetes and coronary heart disease (CHD) together? • Patient perspective • Pathophysiology • Treatment • How can you leverage the systems that you already have in place to include CHD? • What measures might you consider?

  3. Patient-centric, not Disease-centric

  4. Gender Age Race Smoking BP control Lipid management Physical activity Weight Diabetes Renal Insufficiency What are the CHD risk Factors?

  5. Much overlap in what causes the complications in diabetes and Cardiovascular Disease (CVD) We know the correlations, not always the scientific basis

  6. Incidence of Myocardial Infarction in Type 2 Diabetes 50 40 30 20 10 0 No diabetes (n=1373) Type 2 Diabetes (n=1059) 7-year Incidence (%) No Prior MI Prior MI Haffner SM et al. N Engl J Med 1998;339:229-234.

  7. Disconnected! • 68% of diabetes patients do not consider CVD to be a serious diabetes-related complication, and they are much more aware of complications such as blindness (65%) or amputation (36%) than heart disease (17%), heart attack (14%), or stroke (5%). • 88% of providers had discussed diabetes related CVD risk

  8. What is it about diabetes that increases CVD risk? • Metabolic milieu? • Inflammation? • Pro-thrombotic state? • Insulin resistance?

  9. C-Reactive Protein • C-reactive protein (CRP) - one of the acute phase proteins that increase during systemic inflammation • High levels of CRP consistently predict new coronary events. Newer high sensitivity (hs-CRP) now used to better predict CVD risk. • Higher CRP levels also are associated with lower survival rate • Higher levels of CRP may increase the risk that an artery will re-close after it’s been opened by balloon angioplasty.  • High levels of CRP predict prognosis and recurrent events in patients with stroke and peripheral arterial disease.

  10. What about Metabolic Syndrome?

  11. Newer findings with nonfasting triglyceride values • Women's Health Study demonstrated that nonfasting triglycerides were better independent predictors of cardiovascular events over 11 years than were fasting triglycerides. • Same finding recent study of about 14,000 men and women in Copenhagen, Denmark • Fat-load (or fat-tolerance) tests have been found to be abnormal, with higher postprandial triglyceride levels, in people with CVD when compared with control subjects. • Best predictor of high nonfasting TG levels is the fasting level.

  12. Prothrombotic state • Associated with insulin resistance • Increased fibrinogen levels, • Increased plasminogen activator inhibitor-1, • Various platelet abnormalities

  13. What does all this mean? • Much overlap between what is going on metabolically with diabetics and with those with CHD. • Interventions that mitigate CHD risk are of paramount importance in diabetics • Due to the pathophysiological overlap, interventions are similar.

  14. AHA/ACC Secondary Prevention Guidelines 2006: Smoking • Smoking status each visit • Advise tobacco users to quit • Use behavioral and pharmacological strategy to support cessation • Avoid exposure to second hand smoke Smith SC, et.al. AHA/ACC guidelines for secondary prevention for patients with coronary and other atherosclerotic vascular disease:2006 update. Circulation. 2006; 113:2363-2372

  15. Control Blood Pressure • Diabetics, CVD, Framingham risk score >10% or kidney disease – 130/80 • Otherwise 140/90 • Lifestyle • ACE/ARB + thiazides as needed

  16. UKPDS: Blood Pressure Control Study in Type 2 DiabetesEffect of Intensive BP Lowering on Micro- and Macrovascular Complications Risk Any Diabetes-relatedEnd Point Diabetes-relatedDeath MyocardialInfarction Vision Deterioration RenalFailure HeartFailure Retinopathy Stroke 0 -10 -20 -21 -30 -24 Risk Reduction (%) -32 -34 -40 -42 -44 -50 -47 -56 -60 Benefits of 144/82 vs 154/87 -70 UKPDS Group. UKPDS 38. BMJ. 1998;317:703–713.

  17. Manage Lipids • LDL-C goal <100 • “reasonable” to treat to <70 • Statins

  18. HPS: Conclusions for people with diabetes • Lowering LDL cholesterol by 1 mmol/L (40 mg/dL) reduces the risk of major vascular events by about one-quarter during 5 years of treatment • Similar proportional reductions in risk among people with or without diabetes ― irrespective of age, sex, vascular disease or lipid levels • Continued statin treatment prevents not only first but also subsequent major vascular events

  19. Exercise Prescription • 30 minutes, 7 days/week moderate intensity activity • Supplement with increased lifestyle activities – gardening, housework • Medically supervised programs prn

  20. Weight Management • BMI 18.5 to 24.9 kg/m2 • Waist circumference: • Men <40 inches • Women <35 inches • 10% decrease from baseline

  21. Diabetes Management • HbA1c < 7.0% • Manage other risk factors aggressively

  22. Antiplatelet Agents/Anticoagulants • 81 mg • Additional clopidgrel guidelines for ACS and s/p stent • Warfarin guidelines for a. fib. and LV thrombus

  23. ACE/ARB • LV function < 40%, hypertension, diabetes, CKD • Consider for all other patients • ARBs for those intolerant of ACE • ARBs + ACE systolic-dysfunction heart failure

  24. ß-blockers • S/P MI • ACS • LV dysfunction with or without symptoms of heart failure

  25. Statins for Primaryor Secondary Prevention:Heart Protection Study (HPS) Entry Criteria • Increased risk of CV death due to prior disease (MI, CHD, occlusive disease of noncoronary arteries, or RX’ed HTN) • Age 40-80 y • TC >135 mg/dL • Statins not clearly indicated or contraindicated Placebo (n=10,267) Simvastatin 40 mg (n=10,269) Primary end point: All-cause and CV mortality Lancet 2002, 360:7

  26. Steno-2 Study: Multi-risk-factor Intervention Approach • 160 patients with type 2 diabetes randomized to conventional or intensive treatment • Intensive treatment: stepwise implementation of behavior modification and pharmacologic therapy targeting hyperglycemia, hypertension, dyslipidemia and microalbuminuria • Secondary prevention of cardiovascular disease with aspirin

  27. 160 Type 2 DM Subjects With Microalbuminuria 80 Intensive Rx 70 Conventional Rx 60 50 Percent 40 30 20 10 0 HbA1C<6.5% TC<175 mg/dL TG <150 mg/dL SBP <130 mm Hg DBP <80 mm Hg Steno-2 Study * * * * *= stat.signif. Gaede P et al. N Engl J Med.2003;348:383-393.

  28. -48 -50 -52 -54 -56 -58 -60 -62 -64 CV Disease Nephropathy Retinopathy Autonomic Dysfunction Steno-2 Study: Reduction in CV and Microvascular Disease Reductions After 7.8 Years of Intensive vs Conventional Rx Gaede P et al. N Engl J Med.2003;348:383-393.

  29. Steno-2 Study Conclusions • Multifactorial intervention, including patient • education and motivation in diabetes management, • may reduce risks of both cardiovascular and • microvascular events by up to 50%.

  30. How do you leverage current systems? • Use baseline data • Pick those areas you think most important to change; PDSAs • Encourage all members of the care team to participate to improve outcomes • Re-enforce the message and the importance of lifestyle issues – self-management • Measure over time

  31. Selected measures: • AQA http://www.aqaalliance.org/ • NQF http://www.qualityforum.org/ • NCQA (HEDIS) http://web.ncqa.org/ • HDC http://www.healthdisparities.net • PQRI http://www.cms.hhs.gov/apps/ama/license.asp?file=/PQRI/downloads/Measure_Specifications_061807.pdf

  32. Time for Dialogue

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