Smoking, lipids and lifestyle

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Smoking, lipids and lifestyle

• Dr Shirley Copland
• Associate Specialist

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Normal heart and coronary artery
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Diseased coronary artery
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Diabetes and cardiovascular risk

• Adults with diabetes have a reduced life
  expectancy of some 5-10 years
• Most deaths are due to circulatory diseases
• Heart attacks rates are 3 -5 fold increased
• Stroke risk is increased 2-3 fold
• After 15 years duration of type 2 diabetes more
  than 20 of patients have had a heart attack ( UK
  prospective diabetes study)

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DIABETES AND CARDIVASCULAR DISEASE

• AGE DIABETES
• 45-54 24.8
• 55-64 37.9
• 65-74 40.5
• Incidence of MI per 1000 women

• NO DIABETES
• 4.3
• 12.6
• 22.6

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Why the excess risk in Diabetes ?

• Thought that raised blood glucose levels are
  toxic to the lining of blood vessels
• Vessels are then more susceptible to damage from
  all the other risk factors e.g. high blood
  pressure, smoking
• Low density lipoprotein (LDL) is more densely
  packed with triglyceride which is more readily
  taken up into the vessel walls causing atheroma
  plaques

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Coronary Risk Factors

• Modifiable
• Smoking
• High blood pressure
• Cholesterol levels
• Excess weight
• Lack of exercise
• High glucose levels

• Unmodifiable
• Being male
• Family history
• Age
• Diabetes mellitus
• Proteinuria

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Risk Factors - Smoking

• Widely recognised to accelerate coronary artery
  disease and to increase risks of certain cancers
• Smoking gt20 per day more than doubles the risk
  of coronary disease
• Scottish Diabetes Survey 2004 showed 18
  patients with diabetes in Grampian remain smokers

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Risk Factors - Smoking

• Simple advice to stop smoking has a small but
  significant effect
• Nicotine replacement therapy can double quitting
  success rates
• Zyban also helps more people to be successful but
  can increase the BP
• No definite evidence for benefit of acupuncture
• Many people need several attempts to stop
  encourage to keep trying!
• Monitor for relapse !

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Risk Factor - Lifestyle

• A 10 kg weight loss in obese patients with
  diabetes has been shown to reduce mortality by
  25
• Exercise helps control weight, blood pressure and
  lowers blood sugar
• In the UK 60-70 of the adult population is
  considered to be physically inactive
• Moderate exercise works - taking a brisk walk
  most days reduces coronary risk by up to 50

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Risk Factors - Cholesterol

• Cholesterol is essential in the body
• Component of all cell membranes, needed for
  manufacture of steroid hormones, used to make
  bile salts which are necessary for digestion
• Excess dietary saturated fat increases blood
  lipids
• Liver is involved in cholesterol manufacture

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Risk Factors - Cholesterol

• Cholesterol is carried in the blood in particles
  called lipoproteins.
• Lab tests report the total cholesterol (TC) and
  the amounts of the component particles
• HDL the good
• LDL the bad
• TC to HDL ratio the ugly
• In type 2 diabetes the ratio is often raised due
  to low HDL

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How to reduce Cholesterol

• We all know the healthy eating messages - reduced
  saturated fats, more fruit and veg and oily fish
  - emphasis is on a balanced diet.
• Fish oil supplements shown to be
  cardio-protective in the short term in high risk
  patients. No long term overall benefits.
• Benecol and Flora pro-active margarines do lower
  the LDL cholesterol - probably beneficial but no
  long term studies to date.

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How to reduce Cholesterol

• Weight loss
• Exercise
• Good blood sugar control
• Exclude secondary causes e.g. hypothyroidism
• However despite best efforts the cholesterol
  levels often remain relatively too high

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Heart Protection Study 2002/3

• Major recent trial studying gt20,000 subjects aged
  over 40 with vascular disease, hypertension or
  diabetes
• Patients had normal cholesterols at entry
• In diabetes patients taking simvastatin
• 27 reduction in major coronary events
• 25 reduction in strokes
• Note - need to treat 100 people for 5 years to
  prevent 7 events but benefits would accrue

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CARDS 2004

• Almost 3000 patients with type 2 DM
• Patients had no known vascular disease but had
  either retinopathy, microalbuminuria,
  hypertension or were smokers
• LDL lt 4.14 on entry
• Showed atorvastatin prevented 37 vascular events
  per 1000 people treated for 4 years

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Statin drug therapy

• Most effective lipid lowering medications
• Many large studies have now shown consistent
  reductions in cardiovascular risks
• Do more than just reduce the cholesterol -
  protect the circulation
• Low incidence of side effects in clinical trials

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Potential benefits of statins

• Reduce major coronary events
• Reduce stroke risk
• Reduce mortality from heart disease
• Reduce need for coronary procedures
  (angioplasty, coronary artery bypass grafts)
• Reduce total mortality

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STATINS

• Simvastatin, pravastatin, atorvastatin,
  fluvastatin and most recently rosuvastatin
• Act on the liver enzyme (HMG Co A reductase)
  involved in cholesterol synthesis hence lowering
  blood levels
• Not used in active liver disease
• Few drug interactions (but avoid combination with
  clarithromycin /erythromycin, ketoconazole,
  antivirals, ciclosporin)
• Grapefruit juice avoidance with simvastatin

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STATINS

• Few side effects
• Most common are GI effects or headache
• Rare side effects include muscle or liver
  inflammation (lt 1 in 10,000 patient years)
• Liver tests checked before starting treatment and
  periodically thereafter and patients are advised
  to report any new muscle pain
• Contra -indicated in pregnancy

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Guidelines - shifting the goalpost

• Grampian Diabetes Guidelines - Feb 2004
• GP contract targets - April 2004
• Joint British Societies 2 - November 2005

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Joint British Societies Guidelines (JBS 2)

• All patients with diabetes should receive
  lifestyle advice and lipids monitored
• All patients with known vascular disease should
  be offered statin therapy
• For primary prevention if patients with diabetes
  meet the following criteria then statin therapy
  should be offered
• Treat to a target of TC ? 4 and LDL ? 2

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Joint British Societies Guidelines (JBS 2)

• All patients with diabetes aged ? 40 years
• Patients with diabetes aged 18-39 years who have
  at least one of
  -retinopathy (severe, prolif. or
  maculopathy) -nephropathy (incl.
  microalbuminuira) -poor
  glycaemic control (HBA1c gt9)
  -hypertension
  -TC ? 6 or features of
  metabolic syndrome -FH of premature IHD

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Joint British Societies Guidelines (JBS 2)

• Low dose aspirin
• All people with type 2 DM aged ? 50 years
• Younger patients with diabetes with either
  -more than 10 years duration
  -treatment for
  hypertension or
  -evidence of complications
  e.g. retinopathy or nephropathy

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Mr JD 69 years

• Type 2 DM onset 2005
• Ex smoker 1989 BMI 27 HBA1c 6.9
• BP 158/78
• Left calf claudication
• No retinopathy MA screen normal
• TC 5.2 LDL 2.9
• Rx Metformin

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Mr JD 69 years

• Encourage activity increase within limits
• Update on foot self care and refer to podiatry
• Aspirin
• Statin - simvastatin 40 mgs
• Ace inhibitor as first line anti-hypertensive

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Mrs SD 38 years

• Type 2 DM onset 2001
• Smoker BMI 33 HBA1c 7.2
• BP 140/86
• Check out assistant
• No retinopathy MA screen normal
• TC 4.2 LDL 2.3 TRIGs 1.2
• Rx Metformin

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Mrs SD 38 years

• Smoking cessation support
• Reinforce dietary advice
• Consider Xenical
• ?Exercise class

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Mr J S 38 years

• Type 2 DM onset 2000
• Ex smoker BMI 35 HBA1c 8.5
• On anti-hypertensive Rx BP 148/78
• Erectile dysfunction 2003
• No retinopathy MA screen normal
• TC 4.8 LDL 2.6
• Rx Insulin, metformin, ramipril, sildenafil

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Mr J S 38 years

• Review advice on weight reduction and activity
  level
• Insulin and metformin
• Ace inhibitor and other agent to lower BP
• Sildenafil
• Statin
• Aspirin

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Mr AF 49 years

• Type 1 DM since 1994
• Non smoker BMI 27 HBA1c 8.5
• BP 128/76
• Fit joiner
• No retinopathy MA screen normal
• TC 4.3 LDL 2.5
• Rx Basal bolus insulin regime

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Mr AF 49 years

• Basal bolus insulin regime
• Review education
• Simvastatin 20 mgs
• Aspirin (nearly 50 years)

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Miss C D 34 years

• Type 1 DM since 1980
• Smoker BMI 27 HBA1c 7.5
• BP 135/78
• Moderate retinopathy
• Microalbuminuria present
• TC 4.8 LDL 2.7

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Miss C D 34 years

• Basal bolus regime of insulin
• Support re smoking cessation
• Ace inhibitor
• Statin
• Aspirin
• Contraception!