عوارض قلبی دیابت

مظاهری شهرام دکترتهرانیعروق و قلب تخصصی بورد

ATHEROSCLEROSIS

Pations with diabetes have two to eight-fold higher rates of future cardiovascular events as compared with age and ethinicity-matched nondiabetic individuals

patients with diabetes have worse CVD outcomes after ACS events.Worse prognosis with higher glucose level

SILENT MI

In addition to CHD, diabetes increases the risks of stroke and peripheral arterial disease. The diagnosis of diabetes portends a twofold increased stroke risk compared with nondiabetic individuals

Abnormalities in lipid metabolism also contribute to the increased atherosclerotic risk associated with diabetes

Diabetic dyslipidemia is characterized by high triglyceride levels, low HDL concentration, and increased atherogenic small dense LDL particles, each of which is likely to contribute to the accelerated development and progression of atherosclerosis

METABOLIC SYNDROME

At least 3 of following 5 critria

1-waist circumference larger than 102 cm in men and 88 cm in women2-TG at least 150 mg/dl3-HDL less than 40 mg/dl in men and less than 50 mg/dl in women4-BP of at least 130/855- FBS at least 110 mg/dl

Therapeutic lifestyle interventions remain the cornerstone of prevention of the atherosclerotic complications associated with diabetes

include smoking abstinence, at least 150 minutes of moderate-intensity aerobic activity weekly, and medical nutrition therapy recommendations for weight control and dietary composition

Beyond lifestyle, a number of pharmacologic strategies have proven effective for CVD risk reduction in diabetes and are recommended for routine prescription for patients with diabetes

Such interventions include intensive blood pressure and lipid management, consideration for angiotensin-converting enzyme (ACE) inhibitors independent of blood pressure, and daily antiplatelet therapy for patients with prevalent CVD or increased primary risk

Aspirin Therapy

The ADA and AHA presently recommend daily aspirin (75 to 162 mg/day) for all patients with diabetes who have prevalent CVD or for primary prevention in all patients older than 40 years with additional CVD risk factors or younger in the presence of prevalent CVD risk

LIPID CONTROL

considering diabetes as a coronary disease risk equivalent, an optional target for LDL cholesterol of <70 mg/dL should be considered for patients with diabetes Contemporary guidelines for the management of diabetic dyslipidemia focus on the use of statin medications

Once LDL cholesterol targets have been achieved through lifestyle modification and statin therapy, the principal secondary therapeutic lipid target for patients with diabetes who have persistent fasting triglyceride elevation >200 mg/dL

The preferred method to achieve the secondary target is by intensification of statin monotherapy as tolerated, with the secondary option to add another lipid-modifying agent such as niacin, ezetimibe, bile acid binders, or fibric acid derivatives

HYPERTENSION

Hypertension affects approximately 70% of diabetic patients

Given the potent benefits for both macrovascular and microvascular disease complications, blood pressure management is of principal importance in this high-risk population

Blood pressure targets for patients with diabetes are more aggressive than for the overall population, with a goal of <130/80 mm Hg most patients requiring a combination of multiple blood pressure medications to achieve such targets

ACE inhibitors and angiotensin II receptor blockers (ARBs) have become keystones of therapy for hypertension in diabetes because of their broadly demonstrated favorable effects on diabetic nephropathy and CVD outcomes, as well as their modest favorable effects on measures of glucose metabolism

ACE inhibitors are the first-line treatment for hypertension in the setting of diabetes and should be considered for all diabetic patients with prevalent CVD or a clustering of CVD risk factors

ARBs should be considered second-line therapy, and their use reserved for those patients who cannot tolerate ACE inhibitors because of cough, angioedema, or rash

Calcium Channel Blockers

Dihydropyridine calcium channel blockers, such as nifedipine, nitrendipine, nisoldipine, and amlodipine, are well tolerated and effective at lowering blood pressure

BETA BLOCKERS

beta blockers are another key component of effective CVD risk reduction in diabetes.

Early in the course of clinical use, beta blockers were considered relatively contraindicated in the setting of diabetes because of concerns about masking hypoglycemia symptoms and adverse effects on glucose and lipid metabolism. These concerns have been mitigated by the results of CVD outcomes trials supporting the benefit of beta blockers for patients with diabetes

Thiazide Diuretics

Concern about the adverse glycometabolic effects of the thiazide diuretic class of medication has resulted in some degree of hesitancy to use these medications in the setting of diabetes or in patients at increased risk for development of diabetes

However, randomized trials of thiazide diuretics that included substantial numbers of patients with diabetes have consistently demonstrated CVD benefits despite their adverse metabolic effects

Heart Failure in the Patient with Diabetes

diabetes associates independently with a twofold to fivefold increased risk of heart failure compared with those without diabetes, comprising both systolic and diastolic heart failure

once HF is present, diabetes portends especially adverse prognosis for subsequent morbidity and mortality

In general, drug therapies for HF evaluated in the overall population of patients with risk and disease generally have similar if not better efficacy in patients with diabetes compared with those without diabetes

ACE inhibitors should be first-line therapy for the prevention and treatment of HF in patients with diabetes