dm and cardio

8/14/2019 Dm and Cardio

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Diabetes management in

cardiovascular diseases

Anwar C Varghese

Prof D Rajasekarans unit


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Magnitude of theproblem

Management of diabetesmellitus in ACS

Management of diabetesin CAD patients

Diabetes and cardiac


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Magnitude of the problem Diabetes confers as much CV risk as

a previous MI

Men have 2 times the risk; womenupto 4.

Account for majority of the disease inyounger men and premenopausalwomen.

Worse prognosis after an acutecoronary syndrome

80% of deaths among diabeticpatients are from CHD

Management of Diabetes with Acute Myocardial InfarctionAMI


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Early mortality from acuteMI


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Hyperglycemia as prognosticindicator

Hyperglycemia on admission

for acute MI indicatedincreased mortality.

FPG is a strong predictor ofmortality


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Mortality and CHF after MI

Wahab NN, Cowden EA, Pearce NJ, on behalf of the ICONs Investigators: Is blood glucose anindependent predictor of mortality in acute myocardial infarction in the thrombolytic era? J Am Coll

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FP


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FP an ay morta ty a teracute MI

Suleiman M, Hammerman H, Boulos M, et al: Fasting glucose is an important independent

risk factor for 30-day mortality in patients with acute myocardial infarction: A prospectivestudy. Circulation 111:754-760, 2005


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Reasons for the poorprognosis

Reluctance to apply clinicalmeasures like beta blockers.

Clustering of other risk factors

The lipid rich atherosclerotic plaques more vulnerable to rupture

overexpression of receptor foradvanced glycation end products(RAGE) more metalloproteinaseactivity which destabilize plaques.


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Reasons for the poorprognosis

Increased levels of plasminogenactivator inhibitor type 1 (PAI-1) inplasma and atheromas which rduce

fibrinolysis, increase thrombusformation, and accelerate plaqueformation

Increased endothelin activity andreduced prostacyclin and nitric oxideactivity, lead to abnormal control of

blood flow


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Management of ACS in

diabetes mellitusAspirin resistance

failure to reduce adhesiveness of

platelets related to poor metabolic control

aspirin, 150 mg, 1 week reduced

platelet adhesiveness in 69 % of thenondiabetic patients but in only 29 %of the patients with type 2 diabetes(p = 0.0006)

Braunwalds heart disease


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Beta blockers

Under prescribed due fear ofhypoglycemia, worsening of metabolicstatus

New studies confirm the greater benefitderived by diabetics

Noncardioselective beta blocker carvedilolassociated with better metabolic control.

Beta blockers restore sympathovagalbalance in autonomic neuropathy

Decrease fatty acid utilization within the

myocardium, reducing oxygen demand


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Glycemic control

What is the drug to be used? Insulin

How to give insulin?

Intravenous infusion

How long to give iv insulin?

At least 24 hours What is the target?

Tight glycemic control (4-7 mmol/dl)


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Stop oral hypoglycaemic agents.

Infuse 10% Dextrose iv at 15 mls / hourfor at least 24 hours.

Commence iv insulin infusion at 1u / hour.

Check BG hourly .

Aim for BG of 4 7 mmol/l by adjusting the

insulin infusion rate. Institute all normal post-infarct procedures

and drug interventions using standardcriteria (ACE inhibitor, oral beta blockers,statins, aspirin, etc).

The serum potassium should be monitoredclosely. Potassium supplements can be

given either orally or iv. The serum


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How to treat after the

acute phase?

If prior OHA or Insulin regime

seemed adequate, then continuethe same.

If prior OHA regime was givingpoor control, consider insulin

If prior insulin regime was giving

poor control, consider


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Hypoglycemia and mortality


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Hypoglycemia

Detrimental to the recoveringmyocardium by causing beta

adrenergic stimulation and lackof metabolic substrate.

Hypoglycaemia during admission

may increase re-infarction rates. Predisposes to fatal arrhythmias.


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Glucose-insulin-potassium(GIK) solution

regaining favor as a method toinfluence myocardial metabolismpositively during treatment of MI

polarizing agent maintainingelectrical stability

attenuate the rise in free fattyacids (FFAs) during MI, shiftsmyocardial oxidative metabolismfrom FFAs to glucose oxidation.

Has antiinflammator and


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Treatment of diabetes inCAD

Sulfonylureas Associated with fear of loss of

ischemic preconditioning

Blockage of K+-ATP channels in

myocardium UKPDS findings strongly disprove

this theory


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Thiazolidinediones

not recommended for use in

patients with NYHA Class III orIV CHF

causes fluid retentionUsed in diabeticcardiomyopathy


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Metformin Contraindicated inpatients requiring

pharmacological treatmentof CHF

Cardiac failure increase

lactic acidosis due to


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CABG vs. Coronary stenting

Higher restenosis rates and

worse long-term outcomesafter PTCA

CABG may provide betteroutcomes than standard

PTCA, especially in patients


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Diabetes and cardiac failure

Diabetics 2.5 times more likely todevelop cardiac failure

Increased mortality in cardiac failure

patients; especially in ischemiccardiomyopathy

diabetes and ischemic heart diseaseinteract to accelerate the progression of

myocardial dysfunction1 % increase in average HbA1C was

associated with a 16 percent increase inCHF


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Diabetes-specific factorsrelated to CHF

Advanced glycation end products(AGES) Accumulation of AGE-modifiedextracellular matrix results in loss of

elasticity of the vessel wall and interferewith myocardial function.

Myocardial calcium handling slowsCa removal from the cytoplasm in diastole

increasing diastolic stiffness.

Myocardial metabolism the diabeticheart have exaggerated impairment of

ATP generation during ischemia.


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Diabetes-specific factorsrelated to CHF

Coronary microcirculation

Endothelial dysfunction

(reduced synthesis of thevasodilator nitric oxide),

abnormal angiogenic

responseFailure of ischemicpreconditioning


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Diabetic cardiomyopathy

Diabetic cardiomyopathy affects themyocardium in diabetic patientseventually leading to LVH and

diastolic and systolic dysfunction. The concept is based upon the idea

that diabetes is the factor which

leads to changes at the cellular level,leading to structural abnormalities

DCM may overlap with CAD and

hypertension


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