Smoking, lipids and lifestyle Dr Shirley Copland Associate Specialist

Normal heart and coronary artery

Diseased coronary artery

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)

DIABETES AND CARDIVASCULAR DISEASE AGE DIABETES Incidence of MI per 1000 women NO DIABETES

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

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

Risk Factors - Smoking Widely recognised to accelerate coronary artery disease and to increase risks of certain cancers Smoking >20 per day more than doubles the risk of coronary disease Scottish Diabetes Survey 2004 showed 18% patients with diabetes in Grampian remain smokers

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 !

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%

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

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

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.

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

Heart Protection Study 2002/3 Major recent trial studying >20,000 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

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 < 4.14 on entry Showed atorvastatin prevented 37 vascular events per 1000 people treated for 4 years

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

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

‘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

‘STATINS’ Few side effects Most common are GI effects or headache Rare side effects include muscle or liver inflammation (< 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

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

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

Joint British Societies Guidelines (JBS 2) All patients with diabetes aged  40 years Patients with diabetes aged years who have at least one of: -retinopathy (severe, prolif. or maculopathy) -nephropathy (incl. microalbuminuira) -poor glycaemic control (HBA1c >9%) -hypertension -TC  6 or features of metabolic syndrome -FH of premature IHD

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

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

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

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

Mrs SD 38 years Smoking cessation support Reinforce dietary advice Consider Xenical ?Exercise class

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

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

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

Mr AF 49 years Basal bolus insulin regime Review education Simvastatin 20 mgs Aspirin (nearly 50 years)

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

Miss C D 34 years Basal bolus regime of insulin Support re smoking cessation Ace inhibitor Statin Aspirin Contraception!