Summary
Diabetes Mellitus (DM) and cardiovascular diseases (CVD)are clinical conditions that are closely related to each other. While DM is accepted and examined as an equivalent of coronary artery disease (CAD), most of the patients followed up with a diagnosis of CAD also have DM or its precursor clinical conditions. Therefore, the secret of success in the treatment of this group of patients is that diabetologists and cardiologists work together.
CVD is observed 2-3 times more frequently in diabetic patients and is the most common cause of death in these patients. CVDis. Although there has been a significant decrease in CVD mortality in recent years, it is also a fact that this decrease is still not sufficient in diabetic patients. Therefore, protection from these diseases, which have such high mortality and morbidity, becomes important. As a result of studies conducted in recent years, the value of controlling postprandial hyperglycemia in reducing mortality, CVD and other complications associated with Type 2 DM has been better understood. It is recommended to understand the importance of 2nd hour postprandial glucose, which is often neglected by clinicians, and to perform screenings in this regard in high-risk patients.
DIABETES MELLITUS AND CARDIVASCULAR DISEASES
Summary
Diabetes Mellitus (DM) and cardiovascular diseases (CVD) are so closely related clinical entities. DM is generally accepted and treated as a coronary artery disease (CAD)and also the majority of patients with CAD have DM, or preclinical syndromes associated withDM. Therefore, diabetologists and cardiologists should work together to be successful in the management of patients with DM andCVD. CVD is 2-3 times more common in diabetic patients and the most common cause of death in these patients is also CVD. In the modern era, there is a significant reduction in the mortality ofCVD however the reduction in mortality of the patients with DM and CVD together is still not enough. Thus, prevention of these diseases that have high mortality and morbidity rates, becom 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
DM is defined as; impaired insulin secretion and/or effect. It is a carbohydrate metabolism disorder resulting from a defect and resulting in chronic hyperglycemia. While some of the patients develop Type 2 DM, others have impaired fasting glucose (BAG) and impaired glucose tolerance (BGT), which are thought to be prediabetic metabolic disorders. can be seen. BAGand BGT, which are considered as intermediate disorders of carbohydrate metabolism in various guidelines; They are considered independent risk factors for the development of metabolic syndrome, Type 2 DM and cardiovascular disease. According to ADA (American Diabetes Association) criteria; Diagnostic criteria for DM, BAG and IGT are given in Table 1. Clinical DM has not yet emerged in BAG and IGT patients; Most of them are euglycemic in their daily lives. Although HbA1c values are generally at normal levels, there is an increased cardiovascular risk independent of HbA1c.
Plasma hunger blood glucose ogtt 2 hours plasma glucose
Normal <100 mg/dl <140 mg/dl
corrupted Fasting Glucose (FGR) ; 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 It was concluded thatIGT rather than BAG is a more important risk factor forCVD. In the Chicago Heart Study, which examined approximately 12,000 men with no history of diabetes; It has been emphasized that men with asymptomatic hyperglycemia (1st hour glucose ≥ 200mg/dl) have a higher risk of CVD than those without. The relationship between fasting plasma glucose (FPG) and post-load plasma glucose values and CVD risk has been examined in several studies. Shaw et al. reported that the mortality of patients with isolated fasting hyperglycemia (≥126mg/dl)and postload hyperglycemia (2nd hour, ≥ 200mg/dl) was significantly higher. It has been shown that the CVD mortality of patients with isolated post-load hyperglycemia is twice as high as that of non-diabetic individuals. The most convincing evidence showing the relationship between glucose tolerance disorder and CAD; It is the DECODE study, in which data from 10 prospective European cohort studies were examined and more than 22,000 patients were evaluated. As a result of this study; (2nd hour, ≥ 200mg/dl) CVD and mortality from all causes were found to be significantly higher in patients diagnosed with post-load DM. Remarkably, there was no difference in mortality between those with normal and impaired FPG. Post-load 2-hour plasma glucose is an independent predictor of CVD and all-cause mortality even after adjustment for other major risk factors, but FPG alone is not a sufficient marker. highlighted. Load with mortality While a linear relationship was found between post-meat hyperglycemia, this relationship could not be shown with plasma fasting hyperglycemia.
Glycemic control and cardiovascular risk
Glycemic control CVD is well understood. In the EDICstudy; It has been shown that it is possible to reduce cardiac and other macrovascular complications with tight glycemic control (HbA1c <7% in 7-10 years). Thanks to effective glycemic control, a 57% reduction in CVD mortality and MI and stroke rates has been reported. It has been emphasized that statistically, every 1% decrease inHbA1c value corresponds to a 21%decrease in CVD rate. The importance of the decrease in HbA1c has been shown in the UK Prospective Diabetes Study (UKPDS), and HbA1c in patients with Type 2 DM It has been determined that a 1% decrease in causes a significant decrease in mortality rates from MI and other causes. Studies evaluating diabetic patients have shown that the risk of developing macrovascular complications is high even at glycemic values close to normal. It has been emphasized that plasma glucose levels, especially two hours after glucose load, are a stronger marker in assessing CVD risk. It has been found that lowering postprandial glucose levels with an alpha reductase inhibitor also causes a decrease in cardiovascular events. The German Diabetes Intervention Study, which enrolled newly diagnosed Type 2 DM patients, found that controlling blood glucose 1 hour after a meal was more effective on CVD and all-cause mortality than controlling FPG. This is the first study to show that it is effective. In the eleven-year follow-up, it has been shown that high FPG 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. Another important marker in assessing CVD risk is insulin resistance. In the PROACTIVE study ; Reducing both insulin resistance and HbA1c was associated with a 16% reduction in cardiovascular endpoints such as mortality, MI, and stroke.
Treatment of cardiovascular diseases
It is known that long-term exposure to hyperglycemia causes microvascular complications in the retina and kidneys, and widespread macrovascular complications in the heart, brain and lower extremities. Macrovascular complications are approximately 10 times more common than microvascular ones. Macrovascular complications have been reported to occur even years before overt Type 2 DM occurs. Hyperglycemia is just one of a cluster of cardiovascular risk factors called metabolic syndrome. These risk factors are intertwined and often occur together. Therefore, the importance of patient education and lifestyle changes in addition to pharmacological treatment cannot be denied. We can basically categorize the treatment of CVD under three headings.
Lifestyle changes.
- 30 minutes of exercise at least five times a week
- Limiting calorie intake
- Cutting smoking
- Restricting fat consumption,
- Encouraging olive oil consumption, avoiding trans fats
- Increasing vegetable fiber intake per day Increasing to 30g
- Avoiding liquid mono and disaccharides
- Medical therapy
- Coronary revascularization
UKPDS In his study, non-pharmacological treatment methods were applied to patients for three months. After the treatment, an approximately 2% decrease in HbA1c values was detected, along with a 5 kg decrease in body weight. This study shows the importance of non-pharmacological treatment methods. In order for diabetic patients to be treated well, it is essential to appropriately treat other risk factors such as hypertension, dyslipidemia, insulin resistance and visceral obesity. The Steno-2 study emphasized the importance of combating multiple risk factors in reducing major macrovascular events in patients with Type 2 DM. In this study
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