How should we protect the diabetic heart

1
How should we protect the diabetic heart?

• Miles Fisher
• Royal Alexandra Hospital, Paisley

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WHO Definition of Diabetes Mellitus

• Diabetes mellitus is a state of chronic
  hyperglycaemia which may result from many
  environmental and genetic factors, often acting
  jointlyWHO Expert Committee on Diabetes
  Mellitus 1980

3
Re-definition of Diabetes

• Diabetes is a state of premature cardiovascular
  death which is associated with chronic
  hyperglycaemia and may also be associated with
  blindness and renal failureMiles Fisher,
  Dublin 1996

4
Haffner - Results
incidence
Haffner et al. N Engl J Med 1998 339 229-34
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Diabetes and heart abnormalities

• Coronary heart disease
• Specific heart disease of diabetes
• Diabetic autonomic neuropathy

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Coronary heart disease and diabetes

• Studied using
• epidemiology
• post-mortem
• electrocardiography
• angiography
• Coronary heart disease more prevalent, more
  extensive, more diffuse
• High prevalence of silent ischaemia

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Myocardial infarction

• Mortality twice the non-diabetic
• Increased silent or painless infarction
• Delay in receiving treatment
• Increased congestive cardiac failure, cardiogenic
  shock, rupture, re-infarction

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How should we protect the diabetic heart?

• Treat the diabetes (primary prevention)
• Treat the cardiovascular risk factors
• Other preventative measures
• Treat the heart disease
• Miles Fisher Dublin 1996

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Management of diabetic cardiovascular disease
SIGN Guideline 19

• Primary prevention and risk factor management
• Treatment of acute myocardial infarction and
  secondary prevention
• Implementation of the guideline
• Review of the guideline and recommendations for
  research
• August 1997

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Treatment of Type 1 Diabetes and Heart Disease -
DCCT

• Reduction by 41 in risk of all major
  cardiovascular and peripheral vascular events
  combined
• Mortality not significantly different between the
  treatment groups

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Treatment of Type 2 Diabetes and Heart Disease -
UKPDS

• Significant reduction in retinopathy,
  microvascular end-points and diabetes related
  end-points
• Non-significant reduction by 16 in risk of
  myocardial infarction (p0.052)
• Mortality not significantly different between the
  treatment groups

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How should we protect the diabetic heart?

• Treat the diabetes (primary prevention)
• Treat the cardiovascular risk factors
• Other preventative measures
• Treat the heart disease

13
Cardiovascular Risk Factors and Diabetes

• Data from epidemiological studies including
  Framingham
• Usual risk factors apply - smoking, obesity,
  hypertension, hyperlipidaemia, fibrinogen
• Unique role for diabetes as an independent
  factor
• Evidence supporting response to risk factor
  reduction in diabetes now available for
  hypertension and hyperlipidaemia

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HBP Studies in Diabetes

• Completed
• ABCD
• FACET
• HDS
• HOT
• SHEP
• Syst-Eur

• Ongoing
• ALLHAT
• Multiple ongoing studies including large numbers
  of patients with diabetes

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Hypertension and Diabetes

• Of proven benefit
• ACEI
• B-blockers
• Diuretics
• Calcium channel blockers (felodipine,
  nitrendipine)

• Caution required
• Amlodipine
• Doxazosin
• Isradipine
• Nisoldipine

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Lipid Studies in Diabetes

• Completed
• 4S
• CARE
• LIPID
• VA-HIT
• DAIS

• Ongoing
• ALLHAT
• CARDS
• FIELD
• LDS
• etc

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How should we protect the diabetic heart?

• Treat the diabetes
• Treat the cardiovascular risk factors
• Other preventative measures (primary
  prevention)
• Treat the heart disease

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Other Preventative Measures

• Proven
• Aspirin
• Ramipril (HOPE)

• Uncertain
• Weight loss
• Exercise
• HRT

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Aim of the HOPE Study

• To evaluate the efficacy of the ACE inhibitor
  ramipril and the anti-oxidant vitamin E in
  reducing the incidence of MI, stroke, or CVD
  death in people considered to be at high risk of
  CVD

HOPE Study Investigators. Can J Cardiol, 1996
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Inclusion Criteria 1

• Patients ?55 years of age
• Previous myocardial infarction, PTCA or CABG
• Stable or unstable angina
• Peripheral vascular disease
• Stroke

HOPE Study Investigators. Can J Cardiol, 1996
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Inclusion Criteria 2

• Diabetes combined with
• BP gt160mmHg, diastolicgt90mmHg, or on treatment
• Total cholesterol gt5.2mmol/L or HDL lt0.9mmol/L
• Smoking
• Microalbuminuria
• Any evidence of previous vascular disease

HOPE Study Investigators. Can J Cardiol, 1996
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Primary Endpoint

• All CVD events
• Defined as a combined endpoint of
• CVD death or
• MI or
• Stroke

HOPE Study Investigators. Can J Cardiol, 1996
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Effect of Ramipril on CV Events in Patients With
Diabetes
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Survival Curves on Primary Outcome - DM
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How should we protect the diabetic heart?

• Treat the diabetes
• Treat the cardiovascular risk factors
• Other preventative measures (primary
  prevention)
• Treat the heart disease

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CHD and diabetes

• Proven
• Aspirin
• Beta blockade
• ACE inhibition (CCF)
• CABG

• Uncertain
• Other anti-anginal therapy
• ACE receptor antagonists
• Other treatments for CCF
• PTCA?
• Heart transplantation?

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MI and diabetes

• Proven/Certain
• Aspirin
• Thrombolysis
• Beta blockade
• ACE inhibition

• Uncertain/
• Controversial
• Intravenous insulin / subcutaneous insulin
• Primary angioplasty

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Unanswered questions?

• Should we be screening all patients for CHD?
• How to implement guidelines?
• How to avoid polypharmacy/encourage compliance
  (OHAs, statin, ACEI, aspirin, etc)?
• What is the role of intravenous insulin following
  myocardial infarction?

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Conclusions

• Evidence-based medicine provides information on
  protecting the diabetic heart
• Further studies will expand the evidence base
• Evidence-based guidelines are available
• Implementation is the big challenge