Cardiovascular Risk Reduction in Diabetic Mellitus. Presenter: Dr. Martin N. Wanyoike MB.CHB., M. Med.(internal med) Physician / Cardiologist

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1 Cardiovascular Risk Reduction in Diabetic Mellitus Presenter: Dr. Martin N. Wanyoike MB.CHB., M. Med.(internal med) Physician / Cardiologist

2 Cardiovascular Risk Reduction in Diabetic Mellitus Disclosures International Conferences sponsorship Merck Serono Boehringer Ingelheim

3 Clinical manifestation of CVD 1. Coronary artery diseasec Acute coronary syndrome ST segment elevation acute MI (STEMI) Non ST segment elevation acute MI (NSTEMI) Unstable angina pectoris (troponin ve) Chronic stable angina pectoris Ischaemic cardiomyopathy Sudden cardiac death 2. Cerebral vascular disease 3. Peripheral artery disease 4. Heart failure

4 Diabetic Mellitus: Is it a Blood Vessel or an Endocrine Disease? Diabetes Mellitus (endocrine disease) Metabolic disease characterized by elevated blood sugar (hyperglycemia) resulting from defects in insulin secretion, action or both Diabetes Mellitus (blood vessel disease) A cardiovascular disease characterized by arterial inflammation, endothelial dysfunction, atheroma formation and resultant complications of hypertension, coronary artery disease, ischaemic stroke and PVD

5 Initiation, Progression and Complication of Atherosclerosis: Diabetes is a Major CVD Risk Factor

6 Ref: Circulation. 1999;100: Cardiovascular Risk Factors Modifiable Hypertension Diabetes Mellitus Cigarette smoking Dyslipidaemia Metabolic syndrome Physical inactivity Microalbuminurea or chronic renal failure (cre. > 135 mol/l) Non modifiable Age Gender Post menopausal status Family history (PCAD, M<55. F<65)

7 Metabolic Syndrome: Clustering of CVD Risk factors Excess calorie intake Obesity Reduced physical activity Dyslipidaemia Proinflammatory FFA, TNF, IL6 Thrombogenicity Insulin resistance Glucose intolerance Excess insulin in circulation Type 2 diabetes Salt & Water Sympathetic tone Retention Hypertension Ref: Circulation. 2004;110: Vascular smooth muscle hypertrophy

8 Metabolic Syndrome: Associated Factors and Complications Despres, J.-P. et al. BMJ 2001;322:

9 Prognosis of Diabetic and Non Diabetic Patients with and without MI (7 year follow up) 3.5% 18.85% 20.2% 45.0% Ref: N Engl J Med 1998;339:

13 Cardiovascular risk profile of antidiabetes medications. Muhammad Abdul-Ghani et al. Dia Care 2017;40:

15 Criteria for the diagnosis of diabetes FPG > 126 mg/dl (7.0 mmol/l). Fasting is defined as no caloric intake for at least 8 h. OR 2-h PG > 200 mg/dl (11.1 mmol/l) during an OGTT. OR HBA1C > 6.5% (48 mmol/mol). OR In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis, a random plasma glucose > 200 mg/dl (11.1 mmol/l). Ref: Diabetes Care Volume 40, Supplement 1, January 2017

19 Statins and the Expected LDL-C Reductions Drug Dose(mg/d) % LDL Reduction Atorvastatin (atocip, lipitor) Rosuvastatin (crestor) Lovastatin (lostatin) Simvastatin (zocor) Pravastatin (lipostat) Fluvastatin (lescor) High Triglycerides and Low HDL: Fibrates Fenofibrate (lipicard) REF: Am J Cardiol 2003;93: Cholesterol absorbtion inhibitors:- Ezetimibe 10mg Od

20 Choice of Antihypertensives 1. Renin angiotensin antagonists ACE inhibitors Peridopril (coversyl) Lisinopril (zestril) Enalapril (renitec) Ramipril (tritace) Captopril (capoten) Angiotensin receptor blockers Telmisartan (micardis) Valsartans (diovan) Irbesartan (aprovel) Losartan (losartas, cozaar) Candesartan (atacand) 2 B-blockers Bisoprol (concor) Carvedilol (dilatrend) Nebivelol (nebilet) Atenolol (tenormin) Metoprolol (betaloc) Propranolol (inderal) 3. Calcium channel blockers Felodipine (felodil, plendil) Amlodipine (amlocip,norvasc) Nifedipine (adalat) Verapamil (isorptin) Diltiazem (monotildium)

21 Choice of Antihypertensives 4. Thiazide diuretics Hydrochlorothiazide Bendroflumethiazide Indapamide (natrilix) Moduretic (Hydrochlorothiazide + amiloride) metolazone Loop diuretics Frusemide (lasix) Torsemide (diuride) 6. Alpha blockers Prazosin (minipress) 7. Direct vasodilators Hyrallazine (apresoline) Minoxidil (loniten) Sodium nitroprusside Aldosterone antagonists Spironolactone (aldactone) Eplerenone (Inspra) 5. Central acting Methyldopa (aldomet) Reserpine 8. Fixed dose combination Comicardis Logimax Amzart codiovan Ternoret Bipreterax Atacand plus atecard D Twynsta

25 Cardiovascular Risk Reduction in Diabetes: Conclusions and Take Home Message 1. Diabetic patients should be managed as if cardiovascular disease is already present 2. Management targets in diabetes should be achieved to reduce cardiovascular risk 3. Blood sugar targets in diabetes are postprandial blood sugar, FBS, HbA1C and insulin resistance 4. B.P. & cholesterol management are important in reduction of cardiovascular risk in diabetic 5. Sympathetic overdrive occur in patients with metabolic syndrome and diabetes mellitus

ACEBUTOLOL HCL 100MG TABLET GENERIC BETA BLOCKERS ALISKIREN 150MG TABLET RASILAZ RENIN INHIBITOR

S/N ME OF MEDICATIONS BRANDED/GENERIC DRUG CLASS * UNIT PRICE RANGE (SGD$) 1 ACEBUTOLOL HCL 100MG CAPSULE SECTRAL BETA BLOCKERS 0.50 2 ACEBUTOLOL HCL 100MG TABLET GENERIC BETA BLOCKERS 0.33 3 ALISKIREN