英文ppt精品课件cvdand diabetes care the alphabet

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 HIV/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 disease 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 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 hypertension Foot problems Commonest cause of non- traumatic amputation The Audit Commission. Testing Times. A Review of Diabetes Services in England and Wales, 2000. Public Health 317:703713 MI Microvascular endpoint 34% Heart failure 35% Stroke 37% All macrovascular endpoints 44% Retinal photocoagulation 56% Any diabetes-related endpoint 24% 0 -10 -20 -30 -40 -50 % Reduction in risk -24 Significant -34 Significant -21 Non significant -44 Significant -56 Significant -37 Significant -35 Significant Deaths reduced by 32% Primary Prevention Diabetes patients with one other risk factor (hypertension, smoker, micro- albuminuria, retinopathy) Atorvastatin 10mg Placebo 2838 patients Cholesterol CARDS Study Placebo CARDS Study: Treatment Effects 21 (1.5%) 24 (1.7%) 51 (3.6%) 83 (5.8%) Atorva* 48% (11- 69)39 (2.8%)Stroke 31% (-16- 59)34 (2.4%)Coronary revascularisation 36% (9- 55)77 (5.5%)Acute coronary events 37% (17- 52) p=0.001127 (9.0%)Primary endpoint* Hazard Ratio Risk Reduction (CI)Placebo*Event * N (% randomised) .2 .4 .6 .8 1 1.2 Favours Atorvastatin 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 reduction in risk for: MI: 16% p=0.052 Retinopathy: -21% Cataract extraction: -24% Microvascular endpoint: -25% Albuminuria at 12 years: -34% Any diabetes-related endpoint: -12%Significant Significant Borderline significance Borderline significance Significant Significant -12 -25 -16 -21 -34 -24 0 -10 -20 -30 -40 - 50 % Reduction in risk 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 screening 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 Guardian 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 ACEinhibitors and AngiotensinII Receptor Antagonists have a special role in preventing diabetes complications (MICROHOPE, LIFE) ACEinhibitors and AngiotensinII 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 Serum Creatinine P (+ CT) L (+ CT) 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 36P (+ CT) L (+ CT) Months % with event 0 12 24 36 48 0 10 20 30 % with event p=0.006 Risk Reduction: 25% 0 12 24 36 48 0 10 20 30 P L p=0.002 Risk Reduction: 28% P L P L p=0.010 Risk Reduction: 20% P (+ CT) L (+ CT) 751 714 625 375 69 762 715 610 347 42 B.Dahlof (Co-chair), 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 vascular 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 Investigator-led, multinational randomised controlled trial placeboatorvastatin 10 mg Doubleblind ASCOT-LLA10,305 patientsTC 6.5 mmol/L (250 mg/dL) Treatment algorithm to BP targets 140/90 mm Hg or 130/80 mm Hg in patients with diabetes amlodipine 510 mg atenolol 50100 mg perindopril 48 mg bendroflumethiazideK1.252.5 mg doxazosin GITS 48 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 Age 55 years Male Microalbuminuria/proteinuria Smoker Family history of CHD Plasma TC:HDLC 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 diastolic 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 thiazide amlodipine 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 Amlodipine 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 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: Insight into optimal CV prevention Endpoint Amlodipine perindopril + statin Atenolol thiazide + placebo Relative risk reduction Fatal MI and non-fatal CHD 4.8 9.2 48% Fatal and non-fatal stroke 4.6 8.2 44% 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 conventional treatment 80 allocated to intensive treatment Mean age 55.1 years Mean follow-up 7.8 years Steno-2 Targets Steno-2 intensive cohort % JBS/Alphabet Guidelines Advice Standard Standard Blood Pressure 130 / 80 Earlier 140 / 85 140 / 80 Optimal 130/80 GMS Audit 145/80 Cholesterol 4.5 4.0 GMS Audit 5 Diabetes Control : HbA1c% 6.5% 7.0% GMS Audit 7.5% Eyes Annually Annually Feet Annually Annually Guardians : aspirin, ACEI / AIIA All Most Statins most All Steno 2: Event Reduction 53 % 61% 58% 67% 0 10 20 30 40 50 60 70 cardiovascular disease nephropathy retinopathy autonomic neuropathy Number of events Steno-2 : CVD Event Reduction Event Conventional Intensive Cardiovascular Death 7 died earlier! 7 MI : non-fatal 17 5 CABG 10 5 PCI 5 0 Stroke : non-fatal 20 3 Amputations 14 7 Revascularisation for PVD 12 6 P0.002 85 events in 35 patients 44% overall 33 events in 19 patients 24% overall Steno-2 : CVD Deaths at 13 years Event Conventional Intensive Cardiovascular Deaths P0.05 Reduced by 57%! Steno-2 : 13 years follow up data Event Reduction in Intensive Group All Deaths 46% Cardiovascular Deaths 57% Cardiovascular events 59% End Stage Renal Failure 1 versus 6 patients Retinal Laser Rx 55% P0.05 Steno-2 : Conclusion “ A target driven, long-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 Thiazide ACE-I or