Renal disease microalbuminuria proteinuria and nephropathy Reduced development of coronary collateral vessels

Recent data shown that the prevalence of DM or impaired glucose tolerance (IGT) may be as high as 70 in patients who have AMI 19 . In 181 consecutive nondiabetics who had AMI, more than two thirds of patients were diagnosed with DM or IGT by oral glucose tolerance testing. Previously undiagnosed DM accounted for one half of all patients who had AMI and an abnormal glucose metabolism. Only one third of subjects met criteria for DM based on fasting blood glucose criteria. Although a random blood...

Role of the renin angiotensin aldosterone system in vascular endothelial function

The endothelium has numerous vital functions. First, it acts as a permeability barrier preventing exocytosis of macrophage and small, dense low-density lipoprotein (LDL) entering the subendo-thelial layer from initiating the genesis of the fatty streak, the first step in atherosclerosis. Second, it is important in maintaining vascular tone by releasing angiotensin II and endothelin, powerful vasoconstrictors, and balancing that release by the release of nitric oxide, a potent vasodilator. The...

Current state of affairs and future directions

Although the wisdom of addressing multiple risk factors seems to be intuitively obvious, this approach is not what transpires in practice. Data from National Health and Nutrition Enhancement Survey 1999-2000 reveal that only 37 of adults with diagnosed diabetes in the United States are achieving the ADA goal of glycosylated hemoglobin levels less than 7 44 . In addition, 37 of adults with diagnosed diabetes have glycosylated hemoglobin levels greater than 8 . Only 36 of individuals with...

The Role of Intensive Glycemic Control in the Management of Patients who have Acute Myocardial Infarction

Division of Cardiovascular Medicine, Department of Medicine, Bridgeport Hospital, 267 Grant Street, Bridgeport, CT 06610, USA Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06510, USA Individuals who have diabetes mellitus (DM) have a twofold to fourfold increased risk of cardiovascular disease and nearly twice the early mortality from acute myocardial infarction (AMI) compared with nondiabetic subjects 1-5 . Furthermore, the mortality difference between diabetics and...

Lipoprotein abnormalities associated with diabetes

Diabetes is associated with multiple disturbances in lipoprotein metabolism that are triggered by insulin deficiency, insulin resistance, and hyperglycemia 6,7 . The diabetic dyslipidemia of type 2 diabetes and insulin resistance is characterized several interrelated abnormalities, including triglyceride-rich lipoproteins (very low density lipoprotein VLDL , intermediate density lipoprotein IDL , and remnant particles), low high-density lipoprotein (HDL) cholesterol, and small, dense...

Significance and treatment of individual risk factors

Hypertriglyceridemia was one of the first metabolic abnormalities recognized as associated with insulin resistance. The mechanism of the hypertriglyceridemia is understood to result from varying sensitivities to insulin in the tissues in the individual's body. Defects in the ability of insulin to mediate muscle use of glucose and to inhibit lipolysis in adipose tissues seem to be the primary abnormalities causing the insulin-resistant state 10 . The resistance at the level of the muscle and...

PCI better

L.o9 - 4.39 o.73 - 2.28 l.o2 - 2.17 o.75 - l.6o Fig. 1. Mortality in diabetics undergoing revascularization. Estimated hazard ratios (and 95 confidence intervals) for mortality at follow-up for initial PCI compared with CABG among diabetic patients with multi-vessel disease. ARTS, Arterial Revascularization Therapy Study BARI, Bypass-Angioplasty Revascularization Investigation CABG, coronary artery bypass grafting CABRI, Coronary Angioplasty versus Bypass Revascularization Investigation DUKE,...

Is lifestyle modification adequate to prevent onset of diabetes

Metabolic syndrome carries with it the underlying pathophysiologic feature of insulin resistance with tissue resistance to insulin action, compensatory hyperinsulinemia, and excessive circulating free fatty acids 78,79 . In addition, cardiovascular risk factors of low HDL and high triglyceride levels, hypertension, and lack of physical activity have all been shown to be predictors of non-insulin-dependent diabetes 80 . The relationships between metabolic syndrome and cardiovascular mortality as...

Evidence from lipid lowering trials in diabetes

Given the heterogeneity of lipoprotein and the complexity of lipoprotein metabolism in patients who have diabetes, the optimal approach for lipid management remains to be determined. Over the past 10 years, a variety of randomized, controlled trials with hydroxymethylglutaryl-coenzyme A reductase inhibitors (statins) established the efficacy of these LDL-lowering agents in reducing cardiovascular outcomes. In four of these large trials (Scandinavian Simvastatin Survival Study 4S , Cholesterol...

Trials examining glycemic targets

The most hotly debated clinical questions in diabetes mellitus are whether glycemic control is associated with a reduction in CVD outcomes and how low a glycemic target should be pursued. Because the risk for severe hypoglycemia increases as lower targets are achieved, there is a floor below which benefits will be counterbalanced by risk. Guidelines suggest that hemoglobin A1c (HbAlc) targets of less than 7 3 , 6.5 4 , or 6.1 5 are appropriate. These goals have been imputed by examining...

References

How to improve the cardiac prognosis for diabetes. Diabetes Care 1999 22(Suppl 2) B89-96. 2 Fagan TC, Deedwania PC. The cardiovascular dys-metabolic syndrome. Am J Med 1998 105(1A) 77S-82S. 3 UK Prospective Diabetes Study Group. Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes UKPDS 38. BMJ 1998 317 703-13. 4 UK Prospective Diabetes Study Group. Intensive blood-glucose control with sulphonylureas or insulin compared with...

Individual drug review

Angiotensin-converting enzyme inhibitors Angiotensin-converting-enzyme (ACE) inhibitors are the initial drug choice for patients who have diabetes and hypertension, especially those who have albuminuria. Although initially recommended based on a small set of data, several recent RCTs clearly support the use of ACE inhibitors based on their favorable impact on CV and renal outcomes. ACE is responsible for the conversion of angiotensin I to angiotensin II, which elevates BP by direct...

No of antihypertensive agents Trial Target BP mm Hg 1234

Multiple antihypertensive agents are needed to achieve target blood pressure. BP, blood pressure DBP, diastolic blood pressure MAP, mean arterial pressure SBP, systolic blood pressure. (Adapted from Bakris GL, Williams M, Dworkin L, et al. Preserving renal function in adults with hypertension and diabetes a consensus approach. Am J Kidney Dis 2000 36(3) 646-61 with permission.) Fig. 4. Multiple antihypertensive agents are needed to achieve target blood pressure. BP, blood pressure DBP,...

Clinical studies on renin angiotensin aldosterone system inhibition and outcomes of new onset diabetes

ACE inhibitors and ARBs have been studied extensively in hypertension, congestive heart failure, coronary artery disease, and renal disease (Table 6). Both drugs consistently reduce risk of coronary events (particularly ACE inhibitors), stroke, and diabetic complications of microvascu-lar disease. In addition, secondary endpoints of some of these studies have suggested reduced incidence of new-onset diabetes. In the Heart Outcomes Prevention Evaluation (HOPE), the incidence of diabetes was 34...