Cardiology Rds Talk

Cardiology Rds Talk - Diabetes mellitus Diabetes...

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Cardiovascular Disease Cardiovascular Disease Cardiology Grand Rounds May 11, 2004 Dr. William Harper Assistant Professor of Medicine, McMaster University. Endocrinologist, Hamilton General Hospital www.drharper.ca
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1. Understanding cardiovascular risk in patients with diabetes 2. 3. Glycemic control & CVD: best practice
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Macrovascular Microvascular Stroke Heart disease and hypertension 2-4 X increased risk Foot problems Diabetic eye disease (retinopathy and cataracts) Renal disease Peripheral Neuropathy Peripheral vascular disease Diabetes: Complications Diabetes: Complications Meltzer et al. CMAJ 1998;20(Suppl 8):S1-S29. Complications Erectile Dysfunction
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Fatal and Non-Fatal Myocardial Infarction Fatal and Non-Fatal Myocardial Infarction 14% decrease per 1% decrement in HbA1c p<0.0001 0.5 1 5 0 5 6 7 8 9 10 11 Updated mean HbA 1c Hazard ratio UKPDS 35. BMJ 2000; 321: 405-12
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Disease Burden of Diabetes Mellitus Disease Burden of Diabetes Mellitus Leading cause of blindness (12.5% of cases) Leading cause of ESRD (42% of cases) 50% of all non-traumatic amputations 2.5x increase risk of stroke 2-4x increase in cardiovascular mortality DM responsible for 25% of cardiac surgeries Mortality in DM: 70% due to Cardiovascular disease
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How is CAD Different in Diabetes ? How is CAD Different in Diabetes ? > CAD extent Multi-vessel disease Distal disease – more difficult to revascularize Silent ischemia/MI Younger Women Worse outcomes despite revascularization Increased re-stenosis after PCI even with stents ACB: worse periop & long-term outcomes
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Haffner et al, NEJM, 339(4):229-34, 1998. Haffner et al, NEJM, 339(4):229-34, 1998.
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Was Haffner right? Was Haffner right? Conclusions based on no difference found between 2 groups: No DM, prior MI N= 69 DM, no prior MI N = 890 Underpowered!
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Evans et al. Evans et al. BMJ 324: 939-942 April 2002 Cross-sectional study DM 1155 patients MI 1347 patients Cohort study DM 3477 patients MI 7414 patients
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0.00 0.05 0.10 0.15 0.20 0.25 OASIS Study:  Total Mortality OASIS Study:  Total Mortality Event Rate Months 6 9 15 3 18 21 12 RR=2.88 (2.37–3.49) RR=2.88 (2.37–3.49) Malmberg K et al.  Circulation  2000;102:1014-1019. 24 RR=1.99 (1.52–2.60) RR=1.99 (1.52–2.60) RR=1.71 (1.44–2.04) RR=1.71 (1.44–2.04) RR=1.00 RR=1.00 Diabetes/CVD (n = 1148) Diabetes/CVD (n = 1148) No Diabetes/CVD (n = 3503) No Diabetes/CVD (n = 3503) Diabetes/No CVD (n = 569) Diabetes/No CVD (n = 569) No Diabetes/No CVD (n = 2796) No Diabetes/No CVD (n = 2796)
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Canadian Lipid Working Group: Canadian Lipid Working Group: Target Levels in Diabetes = established CVD Target Levels in Diabetes = established CVD Canadian recommendations place patients with diabetes in “very high” risk group for CAD (1999): LDL TC/HDL ratio TG < 2.5 mmol/L < 4 < 2.0 mmol/L
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Cardiology Rds Talk - Diabetes mellitus Diabetes...

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