งานนำเสนอเรื่อง: "Management of diabetes"— ใบสำเนางานนำเสนอ:
1Management of diabetes Dr.Thongchai Pratipanawatr MD.
2Atherosclerosis in Diabetes ~80% of all diabetic mortality75% from coronary atherosclerosis25% from cerebral or peripheral vascular disease>75% of all hospitalizations for diabetic complicationsNational Diabetes Data Group. Diabetes in America. 2nd ed. NIH;1995.
3Framingham Study: DM and CHD Mortality 20-Year Follow-up 1717DMNon-DMAnnual CHD Deaths per Persons8Framingham Study: DM and CHD Mortality: 20-Year Follow-upIn this 20-year follow-up from the Framingham Heart Study, coronary heart disease (CHD) death is increased twofold in diabetic men relative to nondiabetic men. Among women, there is an even greater excess in CHD death, fourfold higher in diabetic women compared with nondiabetic women, which may in part be due to more adverse cardiovascular risk factors, particularly low high-density lipoprotein (HDL) cholesterol, in diabetic women. In addition, this slide shows that the absolute CHD death rate in diabetic women is the same as in diabetic men, suggesting that diabetes leads to the abolishment of the female protection against CHD. However, most studies show a diminution but not complete abolishment of the sex difference between diabetic women and diabetic men.Reference:Kannel WB, McGee DL. Diabetes and cardiovascular disease: the Framingham study. JAMA 1979;241:4MenWomenKannel WB, McGee DL. JAMA 1979;241:
4Age-adjusted CVD death rate per 10,000 person-years Influence of Multiple Risk Factors* on CVD Death Rates in Diabetic and Nondiabetic Men: MRFIT ScreeneesNo diabetesDiabetesAge-adjusted CVD death rate per 10,000 person-yearsInfluence of Multiple Risk Factors on CVD Death Rates in Diabetic and Nondiabetic Men: MRFIT ScreeneesIncluded among 347,978 screenees for the Multiple Risk Factor Intervention Trial (MRFIT) were 5163 men who reported taking medication for diabetes. In both diabetic and nondiabetic men, the number of risk factors--serum cholesterol >200 mg/dL, cigarette smoking, and systolic blood pressure >120 mm Hg--independently predicted cardiovascular disease (CVD) mortality. What is also striking, however, is that men with diabetes had a higher CVD death rate than nondiabetics with one or even two other cardiovascular risk factors. This finding suggests that, at least in the MRFIT data, type 2 diabetes was more powerful as a single risk factor than hypertension, total cholesterol, or smoking.Reference:Stamler J, Vaccaro O, Neaton JD, Wentworth D. Diabetes, other risk factors, and 12-yr cardiovascular mortality for men screened in the Multiple Risk Factor Intervention Trial. Diabetes Care 1993;16:NoneOne onlyTwo onlyAll three*Serum cholesterol >200 mg/dl, smoking, SBP >120 mmHgStamler J et al. Diabetes Care 1993;16:
5Targets Glycemic control Hb A1c<7% Hypertension control BP<130/80mmHgDyslipidemia LDL<100 mg/dlHDL>40mg/dl(male)HDL>40mg/dl(female)Aspirin ASA mg/day
31Even decrease per 10 mmHg -13% for microvascular -12% for MI -19% for CVA
32ScreeningEvery visitIf ≥130/80 mmHg, should be confirmed on a separated day.Goal >130/80 mmHg
33Treatment 130-139/80-89 mmHg, non pharmaco for 3 months before med ≥140/90 mmHg start medicationInitial drugs: ACE, ARB, B-blocker, diuretic and CCBACE or ARB if fail add HCTZACE or ARB monitor renal and K
46Risk Similar in Patients With Type 2 Diabetes and No Prior MI vs Nondiabetic Subjects With Prior MI 1008060Survival (%)40Nondiabetic subjects without prior MI (n=1,304) Diabetic subjects without prior MI (n=890) Nondiabetic subjects with prior MI (n=69) Diabetic subjects with prior MI (n=169)2012345678YearHaffner SM et al. N Engl J Med. 1998;339:
47Management of dyslipidemia Diet controlWeight reductionExerciseImprove glycemic controlLipid lowering medication
48Screening Annually More ofter if need LDL < 100 HDL> 40 TG <150 may be repeated every 2 years
49Treatment: LDL Without CVD With CVD Age<40 LDL <100 mg/dl Cholesterol ≥135: Start StatinAim 30-40% reduction and LDL<100With CVDAim 30-40% reduction and LDL<70