DIABETES AND CARDIAC DISEASES

Summary
Diabetes Mellitus (DM)with cardiovascular diseases (CVD) These are clinical conditions that are closely related to each other. DM, coronary artery disease (CAH)as considered and examined as equivalent, CAH Most of the patients followed up with the diagnosis of DM or its precursor have clinical pictures. Therefore, the secret of success in the treatment of this group of patients is the collaboration of diabetologists and cardiologists.

in diabetic patients CVD 2-3observed more frequently, and the most common cause of death in these patients is CVD is . In recent years CVD Although there is a significant decrease in the mortality of diabetes, it is a fact that this decrease is still not sufficient in diabetic patients. Therefore, prevention of these diseases with such high mortality and morbidity gains importance. As a result of studies carried out in recent years, the control of postprandial hyperglycemia can reduce mortality, CVDand Type 2 DM Its value in reducing other complications associated with the disease is better understood. It is recommended to understand the importance of postprandial 2 hour glucose, which is often neglected by clinicians, and to screen in high-risk patients in this regard.

DIABETES MELLITUS AND CARDIVASCULAR DISEASES
Summary 
Diabetes Mellitus (DM)and cardiovascular diseases (CVD)are so closely related clinical entities. DMis generally accepted and treated as a coronary artery disease (CHAD)and also the majority of patients with CHADhave DM, or preclinical syndromes associated with DM . Therefore, diabetologists and cardiologists should work together to be successful in the management of patients with DM and CVD. CVDis 2-3 times more common in diabetic patients and the most common cause of death in these patients is also CVD . In modern era, there is a significant reduction in the mortality of CVDhowever the reduction in mortality of the patients with DM and CVD together is still is not enough. Thus, prevention of these diseases that have high mortality and morbidity rates, becomes more crucial. The importance of managing postprandial hyperglycemia to reduce mortality, CVD , and other complications associated with type 2 DM, has been better understood in recent studies. Clinicians should be aware of the clinical importance of postprandial hyperglycemia which is often neglected. Oral glucose tolerance tests are recommended for screening of high-risk patients.

 
Impaired Fasting Glucose and Impaired Glucose Tolerance

By definition, DM; It is a carbohydrate metabolism disorder with chronic hyperglycemia resulting from a defect in the secretion and/or action of insulin. In some of the patients Type 2 DMimpaired fasting glucose, some of which are thought to be prediabetic metabolic disorders. (BOND)and impaired glucose tolerance (BGT) is seen. Treated as intermediate disorders of carbohydrate metabolism in various guidelines BONDand IGT ; metabolic syndrome, Type 2 DMand independent risk for the development of cardiovascular disease factorsare accepted as ADA (American Diabetes Association) according to the criteria; Diagnostic criteria for DM, IFG and IGT are given in Table 1. BONDand IGT clinical DM has not yet emerged in his patients; most of them are euglycemic in their daily life. Although HbA1c values ​​are usually at normal levels, there is an increased cardiovascular risk independent of HbA1c.

Plasma fasting blood glucose OGTT 2 hour plasma glucose
Normal <100 mg/dl <140 mg/dl

Impaired Fasting Glucose (BAG) 100-125 mg/dl

Impaired Glucose Tolerance (IGT) 140-199 mg/dl

Type 2 Diabetes Mellitus (DM) ≥126 mg/dl ≥200 mg/dl

OGTT: Oral glucose tolerance test

In various studies BONDrather than IGTof CVD was found to be a more important risk factor for In the Chicago Heart Study, which examined approximately 12,000 men without a history of diabetes; asymptomatic hyperglycemia ( 1 hour glucose ≥ 200mg/dl)compared to those who were absent CVD emphasized that the risk is higher. fasting plasma glucose (APG)and post-loading plasma glucose values CVD Its relationship with risk has been studied in several studies. Shaw et al. isolated fasting hyperglycemia. (≥126mg/dl)and post-loading hyperglycemia (2nd hour, ≥ 200mg/dl) reported a significantly higher mortality in patients with Patients with isolated post-loading hyperglycemia CVD mortality has been shown to be twice as high as non-diabetic people. The most convincing evidence for the relationship between glucose intolerance and CAD; This is the DECODE study, in which data from 10 prospective European cohort studies were reviewed and over 22,000 patients were evaluated. As a result of this study; in patients diagnosed with post-loading DM (2nd hour, ≥ 200mg/dl) CVD and mortality from all causes was significantly higher. remarkably APG There was no difference in mortality between normal and impaired patients. 2nd hour post-loading plasma glucose even after adjustment for other major risk factors CVDand is an independent predictor for all-cause mortality but alone APG It was emphasized that ‘ is not a sufficient indicator. While a linear relationship was found between mortality and post-loading hyperglycemia, this relationship could not be demonstrated with plasma fasting hyperglycemia.
 

Glycemic control and cardiovascular risk

Your glycemic control CVDits importance is well understood. EDIC in his work; with tight glycemic control (HbA1c <7% at 7-10 years) It has been shown that it is possible to reduce cardiac and other macrovascular complications . Thanks to effective glycemic control CVDin mortality and MI and stroke rates from 57% decrease has been reported. Statistically speaking HbA1cworth every %oneof the decline CVDrate 21%reduction was emphasized. HbA1cSignificance of fall in UK Advanced Diabetes Study (UKPDS)has also been shown, Type 2 DMin patients with HbA1cin %one It was determined that the decrease of . In studies evaluating diabetic patients, it has been shown that the risk of developing macrovascular complications is high even with near-normal glycemic values. Plasma glucose levels, especially two hours after glucose load, CVD It has been emphasized that it is a stronger predictor in assessing risk. It has been determined that lowering postprandial glucose values ​​with an alpha reductase inhibitor also causes a decrease in cardiovascular events. The German Diabetes Intervention Study, in which newly diagnosed Type 2 DM patients were enrolled, is to control blood glucose 1 hour after a meal, APGAccording to checking CVD and it is the first study to show that it is more effective on mortality from all causes. In the eleven-year follow-up; APGIt has been shown that high blood pressure is not an important factor in increasing the risk of MI or mortality, but inadequate control of postprandial glucose is closely associated with high mortality. CVDInsulin resistance is another important marker in the assessment of risk. PROACTIVE in his work; both insulin resistance and HbA1ccardiovascular endpoints such as mortality, MI, and stroke. 16%It was found to be associated with a decrease in .

Treatment of cardiovascular diseases
It is known that long-term exposure to hyperglycemia causes microvascular complications in the retina and kidneys, and common macrovascular complications in the heart, brain and lower extremities. Macrovascular complications are seen approximately 10 times more frequently than microvascular complications. even obvious Type 2 DM It has been reported that macrovascular complications have been seen even years before their appearance . Hyperglycemia is just one of the clusters of cardiovascular risk factors called metabolic syndrome. These risk factors are intertwined and are often seen together. Therefore, the importance of patient education and lifestyle changes as well as pharmacological treatment cannot be denied. We can basically collect the treatment of CVD under three headings.
Lifestyle changes.

  • 30 minutes of exercise at least five times a week
  • Limiting calorie intake
  • cessation of smoking
  • Restriction of oil consumption,
  • Promoting olive oil consumption, avoiding trans fats
  • Increasing vegetable fiber intake to 30 g per day
  • Avoiding liquid mono and disaccharides
  • medical treatment
  • Coronary revascularization

UKPDS In the study, non-pharmacological treatment methods were applied to the patients for three months. With 5 kg decrease in body weight after treatment HbA1capprox. %2′ decrease was detected. This study demonstrates the importance of non-pharmacological treatment modalities. Appropriate treatment of other risk factors such as hypertension, dyslipidemia, insulin resistance and visceral obesity is essential in order to treat diabetic patients well. In the shorthand-2 study Type 2 DM The importance of combating multiple risk factors in reducing major macrovascular events was emphasized in patients with . In this study, among the multiple risk factors, including blood pressure and dyslipidemia, it was the most difficult to control criterion. HbA1c found to be. This concept UKPDS It also showed itself in . It was emphasized that the most important goal in comprehensive treatment was to reach the goals, and it was recommended to consider an antiplatelet drug such as acetylsalicylic acid for every diabetic patient with micro or macrovascular complications. In the light of these studies CVDIn patients with high risk, it is recommended to determine the treatment targets well, to try to reach these targets with pharmacological or non-pharmacological treatment methods, and then to follow up closely. DMand CAHRecommended treatment targets for patients with
Table 2:Recommended treatment targets in patients with diabetes and coronary artery disease
 

Parameters Treatment target
Blood Pressure (mmHg) 130/80*
HbA1c (%) ≤6.5
Fasting plasma glucose (mg/dl) <108
Postprandial plasma glucose (mg/dl) <135
Total cholesterol (mg/dl) <175
LDL cholesterol (mg/dl) <70
HDL male/female (mg/dl) >40/46
Triglyceride (mg/dl) <150
Quitting Smoking Mandatory
Physical exercise (min/day) >30
Body mass index (kg/m2) <25
Waist circumference male/female (cm) <94/80
Salt consumption (g/day) <6
Fat consumption (% of dietary energy) <10
Trans fat consumption (% of dietary energy) <2
Polyunsaturated n-3 2g/day linolenic acid and 200mg/day long chain fatty acids

*These treatment targets are from the ESC and EASD 2007 Diabetes, prediabetes and cardiovascular disease guidelines. Hypertension targets have changed in diabetic patients in the new guidelines.This topic is given in detail in the text.
Blood pressure control: In the light of new guidelines; Hypertension treatment strategy has also changed in diabetic patients. Value of starting treatment for hypertension in diabetic patients in previous guidelines 130/80mmHgwas considered. ESC/ESH 2013blood pressure target in diabetics, those with renal dysfunction 140/85systolic blood pressure for overt proteinuria <130mmHg has been suggested. Angiotensin converting enzyme in diabetic patients (ACE)inhibitors or angiotensin receptor blocker (ARB)group drugs are recommended to be preferred first. JNC 8 in ; target in patients with diabetes 140/90mmHg has been determined. No special emphasis was made for overt proteinuria. In this new guideline, there is no drug group specifically recommended for diabetics. Thiazide diuretics, calcium channel blockers, ACEIt has been emphasized that inhibitors or one of the ARB group drugs can be started as the first drug.

Hyperlipidemia control: High-dose statin therapy is recommended for all patients with ST-elevation MI, regardless of their baseline cholesterol level. Already diabetic patients are generally in the guidelines. CAHstatin therapy is recommended. ESC/EAS In the 2011 Dyslipidemia Guide; Diabetic patients are considered to be in the very high risk group (total cardiovascular risk (SCORE) ≥10%) LDL≥70mg/dl Patients are recommended statin therapy. in treatment LDL target <70mg/dl or ≥50% in LDL determined as a decrease. last published ACC/AHA 2013In the Cholesterol Treatment Guide, diabetics were evaluated in a special group and again LDL ≥70mg/dlPrimary prevention is recommended for patients with
 

ACUTE CORONARY SYNDROME AND DIABETES

Acute coronary syndrome due to diffuse and diffuse atherosclerotic involvement, decreased vasodilation ability, decreased fibrinolytic activity, increased platelet aggregation in diabetic patients (AXLE) is common. Multinational epidemiological studies AXLEin patients with DMincidence 19-23% was found among in patients with acute MI OGTTas a result of the screening of patients 65%’ Glucose metabolism disorders were found in Diabetes and Heart

On the European Heart Screening Study AXLEof patients presenting with 22%previously unknown in DMThe finding is also interesting. MIyour prognosis after DMknown to be worse in patients. GRACEin his work AXLEfrom his patients DMhave been shown to have higher hospital mortality. DMIt is known that its presence is also effective on long-term prognosis. AXLE the main complications after; recurrence in myocardial ischemia, left ventricular dysfunction, severe heart failure, electrical instability, reinfarction, stroke and death. All of these complications are more common in diabetic patients. Hyperglycemia leads to an increase in unesterified fatty acid concentration and changes in energy substrate metabolism, including excessive oxidative stress. AXLE The increase in adrenalgic tone occurring during pregnancy also strengthens this negative picture. Another point that clinicians should be careful about is; DM This is because autonomic neuropathy masks the typical findings of coronary ischemia in patients. Prevalence of silent ischemia DMin patients 10-20%while, DMIn patients without 1-4% ‘Stop. Therefore DM Silent infarctions and atypical symptoms are more common in patients with In this case DMof patients AXLEor CAH delays the diagnosis and reduces the success of treatment. Acute coronary syndromes STwith a rise MI, STwithout elevation MIand unstable angina pectoris. AXLEAlthough the general principles are similar in the treatment of STpatients with elevated MI differ in that they require immediate revascularization therapy.
 

CABG:Coronary artery bypass grafting,

PKG:Percutaneous coronary intervention,

MI:Myocardial Infarction

Significant endothelial dysfunction, platelet and coagulation abnormalities, and the progressive nature of atherosclerotic disease are responsible for the poor outcome after revascularization in diabetic patients. All these studies have been done in diabetic multivessel patients. PKG’your or CABG He could not resolve the question marks in their minds about whether . Prevalence of atherosclerotic involvement, suitability for percutaneous intervention, chronic total occlusion, proximal left anterior descending coronary artery involvement, presence of other comorbidities; PKGand CABG are among the factors that will help in choosing between them. Apart from these cases, it would not be very objective to claim the superiority of one method over the other. Most of the studies were inadequate and analyzes were made on diabetic patient subgroups of studies. directly on this DMFurther studies are needed to examine the groups in which comprehensive, randomized, modern revascularization techniques are applied separately.

Conclusion

developed countries in recent years. CVD It is known that there is a significant decrease in mortality. However , it is a fact that this reduction is still not sufficient in diabetic patients . Prevention from these diseases, which have such a high mortality rate, is gaining importance. As a result of studies conducted in recent years, postprandial hyperglycemia is associated with mortality, CVDand Type 2 DM Its value on other complications associated with the disease is better understood. For this reason, it is beneficial to collaborate with diabetologists and cardiologists in reducing mortality in diabetic patients. In addition, the threshold values ​​used in diagnosing hyperglycemia need to be reconsidered. It is recommended to understand the importance of postprandial 2 hour glucose, which is often neglected by clinicians, and to screen in high-risk patients in this direction.

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