Impact of Diabetes on Cardiovascular Risk C.Richard Conti M.D. MACC Oct 16,2004 GWICC Beijing, PRC

Image (Prevention/Vascular) Overlap of Four Common Conditions 25 KB File Type: GIF Source ACCEL image provided by the American College of Cardiology Foundation

Diabetes and Cardiovascular Risk An Association between diabetes mellitus and angina pectoris was first described in 1883, shortly after it was hypothesized that angina pectoris was due to atherosclerosis Vergely P. De l’angine de poitrine dans ses rapports avec le diabete. Gaz hedb de ned (ser 2) 1883;20:364

Clinical Trial (INVEST) Blood Pressure Control

NCEP (ATP III) Definition of Metabolic Syndrome 3 of these 5 factors have to be present: –Increased waist circumference (>102 cm in men or >88 cm in women) –Hypertriglyceridemia (>150 mg/dl) –Low HDL-cholesterol (<40 mg/ml in men and 50 mg/ml in women) –Hypertension (BP >130/80 mm Hg) –Fasting serum glucose >110 mg/dl (Validated with the WOSCOPS data)

Image Abnormalities Associated With the Metabolic Syndrome 114 KB File Type: JPG Source ACCEL image provided by the American College of Cardiology Foundation

IGT Insulin resistance Increased insulin resistance Fasting glucose Hyperglycemia Insulin secretion Hyperinsulinemia, then b-cell failure Adapted from International Diabetes Center (IDC), Minneapolis, Minnesota Insulin Resistance and  -Cell Dysfunction Are Fundamental to Type 2 Diabetes Post- prandial glucose Abnormal glucose tolerance NormalType 2 Diabetes

50% of Type 2 Diabetes Patients Have Complications at the Time of Diagnosis Retinopathy, glaucoma or cataracts Nephropathy Neuropathy MICROVASCULAR MACROVASCULAR Cerebrovascular disease Coronary heart disease Peripheral vascular disease UK Prospective Diabetes Study Group. UKPDS 33. Lancet 1998; 352: 837–853

Microalbuminuria in Metabolic Syndrome (MS) Patients Microalbuminuria mg/24h p = ANOVA Segura et al JASN, 2004

Ryden L, et al. Lancet 2002; Glucose and CV Risk (Oral Glucose Tolerance Test) All patients had experienced an MI; n = 300 At Hospital Discharge 12 Months Later Type 2 diabetics24%36% Impaired glucose tolerance 41%32% Normal glucose tolerance 35%32%

Age and gender adjusted CHD, CVD and total mortality in US adults with metabolic syndrome with and without diabetes and pre existing CVD. n=6255 Follow up 133 patient years. Malik et al Circ 2004;110:

Prevalence of the Metabolic Syndrome Among U.S. Adults Unadjusted prevalence21.8% Age-adjusted prevalence23.7% –Prevalence increased with age –Mexican Americans had the highest prevalence (31.9%) Ford ES, et al. JAMA 2002; 287: 356–9

Seven-year incidence in a Finnish-based cohort *P < vs no prior MI † P < vs no diabetes Adapted from Haffner SM. New Engl J Med 1998; 339: 229–234 Risk of Myocardial Infarction Is Increased in Type 2 Diabetes 0% 20% 40% Risk of Fatal or Non-Fatal Myocardial Infarction No prior myocardial infarction Prior myocardial infarction Non-Diabetic SubjectsType 2 Diabetic Subjects * n = 1,304 * † † 60%

Causes of Mortality in Diabetic Patients Panzram G. Diabetologia 1987; 30: 123–31 % Deaths in Diabetic Patients Not Specified Others Tuberculosis Accident/Suicide Gangrene Renal Insufficiency Diabetic Coma Infections Tumours Stroke Myocardial Infarction

Predicted Growth in the Prevalence of Diabetes WHO. The World Health Report, AfricaAmericasEastern Med EuropeSoutheast Asia Western Pacific Year Estimated Prevalence In Millions

Coronary Event Rates for Diabetic and Nondiabetic Participants Woscops