1、CVD and Diabetes Care: The Alphabet Strategy Vinod Patel BSc (Hons) MD FRCP MRCGP DRCOG Consultant Physician, Diabetes and Endocrinology Associate Professor in Clinical Skills University of Warwick Medical School,Leading causes of mortality,Adults, 2002,5823 4692 2399 1398 929 754 735 606 496 478,HI
2、V/AIDS Ischaemic heart disease Tuberculosis Road traffic accidents Cerebrovascular disease Self-inflicted injuries Violence Cirrhosis of the liver Lower respiratory infections Chronic obstruc. pulmonary disease,2279 1331 1037 811 783 672 475 382 352 343,Ischaemic heart disease Cerebrovascular diseas
3、e Chronic obstruc. pulmonary disease Lower respiratory infections Trachea, bronchus, lung cancers Diabetes mellitus Hypertensive heart disease Stomach cancer Tuberculosis Colon and rectal cancers,1559,60 and over,World Health Report 2003,(thousands),Diabetes Care: The Complications,Retinopathy Most
4、common cause of blindness in people of working age,Nephropathy 16% of all new patients needing renal replacement therapy,Erectile dysfunction May affect up to 50% of men with long-standing diabetes,Macrovascular disease 24 fold increased risk of coronary heart disease and stroke, 75% have hypertensi
5、on,Foot problems Commonest cause of non-traumatic amputation,The Audit Commission. Testing Times. A Review of Diabetes Services in England and Wales, 2000.,Diabetes Chronic Disease Management,Single Team,A POETIC vision of Healthcare,P: Patient-centred, Patient Safe, Public Health-Driven O: Objectiv
6、e-clear, what is it that we desire to achieve and why E: Evidence-based, audit-informed, research will be desirable T: Team orientated, multidisciplinary, well-trained, validated I: Integrated, primary, secondary care, schools, community, councils C: Cost-effective, cost efficient, but clinically go
7、verned,Need a Swiss Army Knife Approach!,Alphabet Strategy: QoF Standards,Advice: exercise, diet, not smoking, regular testing & clinics Blood Pressure: aim less than 140/80 Cholesterol: Creatinine Care less than 5 Diabetes Control: HbA1c% less than 7.5% Eyes: check yearly at least Feet: check yearl
8、y at least Guardian Drugs: Aspirin 75mg ACE inhibitors, ARBs,Lifestyle changes reducing progression to DM,Blood Pressure UKPDS 38: 154/87 versus 144/82,UK Prospective Diabetes Study (UKPDS) Group (38). BMJ 1998;317:703713,-24 Significant,-34 Significant,-21 Non significant,-44 Significant,-56 Signif
9、icant,-37 Significant,-35 Significant,Deaths reduced by 32%,Primary Prevention Diabetes patients with one other risk factor (hypertension, smoker, micro-albuminuria, retinopathy),Cholesterol CARDS Study,Placebo,CARDS Study: Treatment Effects,* N (% randomised),.2,.4,.6,.8,1,1.2,Favours Atorvastatin
10、Favours Placebo,*Fatal MI ,Other acute CHD death, non fatal MI, Unstable angina, CABG, Fatal stroke, non fatal stroke,Diabetes Control UKPDS 33: HbA1c% 7.9% versus 7.0%,Intensively-treated patients: HbA1C = 7.0% Conventionally-treated patients: HbA1C = 7.9% This 0.9% decrease is associated with redu
11、ction in risk for:,Risk of diabetes complications,The risk of diabetes complication based on the UKPDS Study. From Mogensten C-E . Diabetic nephropathy:evidence for renoprotection and practice. Heart 2000; 84(suppl): i26 -28 . Reproduced with permission from the BMJ Publishing Group.,E is for Eye sc
12、reening,Diabetic Maculopathy: Commonest cause of blindness in UK under 65 Haemorrhages and/or hard exudates within one disc diameter of the macula, with or without visual loss Treatment: clinical risk factors (BP, Glycaemia, cholesterol) and focal laser photocoagulation,F is for .,FOOT SCREENING,Gua
13、rdian Drugs,Aspirin 75mg od: JBS 2 (2005) advocates considering aspirin 75mg od against CVD events in: Any established atherosclerotic disease 50 years, or those younger but have had diabetes for 10 years, or hypertenisve Retinopathy or nephropathy Once BP 150/90,ACE-inhibitors and Angiotensin-II Re
14、ceptor Antagonists have a special role in preventing diabetes complications (MICRO-HOPE, LIFE) ACE-inhibitors and Angiotensin-II Receptor Antagonists may have a special role in preventing diabetes Statins are guardian drugs,Guardian Drugs,RENAAL Primary Components,ESRD,ESRD or Death,Doubling of Seru
15、m Creatinine,Months,% with event,0,12,24,36,48,0,10,20,30,40,50,751,714,625,375,69,762,715,610,347,42,Months,751,692,583,329,52,762,689,554,295,36,P (+ CT),L (+ CT),Months,% with event,0,12,24,36,48,0,10,20,30,P,L,p=0.010,Risk Reduction: 20%,751,714,625,375,69,762,715,610,347,42,B.Dahlof (Co-chair),
16、 P.Sever (Co-chair), N. Poulter (Secretary) H. Wedel (Statistician), G. Beevers, M. Caulfield, R. Collins S. Kjeldsen, A. Kristinsson, J. Mehlsen, G. McInnes, M. Nieminen E. OBrien, J. stergren, on behalf of the ASCOT Investigators,A randomised controlled trial of the prevention of CHD and other vas
17、cular events by BP and cholesterol lowering in a factorial study design,Study design,atenolol bendroflumethiazide,amlodipine perindopril,19,257 hypertensive patients,PROBE design,ASCOT-BPLA,Treatment algorithm to BP targets 140/90 mm Hgor 130/80 mm Hg in patients with diabetes,amlodipine 5-10 mg,ate
18、nolol 50-100 mg,perindopril 4-8 mg,bendroflumethiazide-K 1.25-2.5 mg,doxazosin GITS 4-8 mg,add,add,add,additional drugs, eg, moxonidine/spironolactone,add,All patients in ASCOT have hypertension plus 3 risk factors for CHD,Patients with risk factor (%),0,10,20,30,40,50,60,70,80,90,100,Hypertension A
19、ge 55 years Male Microalbuminuria/proteinuria Smoker Family history of CHD Plasma TC:HDL-C 6 Type 2 diabetes Certain ECG abnormalities LVH Previous cerebrovascular events Peripheral vascular disease,84,77,61,30,27,24,24,14,13,11,6,ASCOT patient population risk factor profile,100,Systolic and diastol
20、ic blood pressure,mm Hg,60,80,100,120,140,160,180,Time (years),Baseline,0.5,1,1.5,2,2.5,3,3.5,4,4.5,5,5.5,atenolol thiazideamlodipine perindopril,137.7,136.1,79.2,77.4,Mean difference 1.9,Last visit,Mean difference 2.7,SBP,DBP,163.9,164.1,94.8,94.5,Fatal and non-fatal stroke,Number at risk Amlodipin
21、e perindopril 9639 9483 9331 9156 8972 7863 Atenolol thiazide 9618 9461 9274 9059 8843 7720,0.0,1.0,2.0,3.0,4.0,5.0,Years,0.0,1.0,2.0,3.0,4.0,5.0,Amlodipine perindopril (No. of events 327),Atenolol thiazide (No. of events 422),HR = 0.77 (0.660.89) p = 0.0003,%,CV mortality,Number at risk Amlodipine
22、perindopril 9639 9544 9441 9322 9167 8078 Atenolol thiazide 9618 9532 9415 9261 9085 7975,0.0,1.0,2.0,3.0,4.0,5.0,Years,0.0,0.5,1.0,1.5,2.0,2.5,3.0,3.5,Amlodipine perindopril (No. of events 263),Atenolol thiazide (No. of events 342),HR = 0.76 (0.650.90) p = 0.0010,%,ASCOT: BPLA and LLA combined: Ins
23、ight into optimal CV prevention,Rates / 1000 patient years,Doing all this polypharmacy will poison our patients!,Blood pressure, Cholesterol, Diabetes control, ACE-I, Aspirin!,The Steno-2 Study : A Summary,Steno Diabetes Centre Copenhagen, Denmark,160 with T2D and microalbuminuria 80 allocated to co
24、nventional treatment 80 allocated to intensive treatment Mean age 55.1 years Mean follow-up 7.8 years,Steno-2 Targets,Steno 2: Event Reduction,Steno-2 : CVD Event Reduction,Steno-2 : CVD Deaths at 13 years,Reduced by 57%!,Steno-2 : 13 years follow up data,Steno-2 : Conclusion,“ A target driven, long
25、-term, intensified intervention aimed at multiple risk factors in patients with type 2 diabetes and microalbuminuria reduces the risk of cardiovascular and microvascular events by about 50%.”,Diabetes Passport,Diabetes Polypill? X? Y? Z? A? B?,BMJ Polypill Paper,SAMTA Pill Statin Aspirin Metformin T
26、hiazide ACE-I or ARB,Diabetes Polypill Approach?,Indo-linguistically: “equality” ie in terms of reducing morbidity and mortality esp. CVD,Single approach,Alphabet Strategy: QoF Standards,Advice: exercise, diet, not smoking, regular testing & clinics Blood Pressure: aim less than 140/80 Cholesterol: Creatinine Care less than 5 Diabetes Control: HbA1c% less than 7.5% Eyes: check yearly at least Feet: check yearly at least Guardian Drugs: Aspirin 75mg ACE inhibitors, ARBs,
