Preventing Ischemic Stroke in Patients With Prior Stroke

Your Heart and Nutrition

Your Heart and Nutrition

Prevention is better than a cure. Learn how to cherish your heart by taking the necessary means to keep it pumping healthily and steadily through your life.

Get My Free Ebook


Natural Secrets For Healing Your Heart

This eBook is devoted to exposing the secrets that cardiologists and surgeons don't want you to know, and how to take control of your own heart and heal yourself. Eight out of every ten coronary bypasses will not actually help the patient. So why risk being in the 80% that will get no benefit from a bypass? Learn to heal your own heart and keep yourself healthy with this eBook guide. Bob Livingston has poured years of research into his findings, and is now sharing the methods that he has developed from careful, methodical research that the medical industry would never allow. It would make them go bankrupt! You will learn what supernutrient doctors don't want you to know about, and how to make an all-natural, chemical and drug-free blood thinner And even more information that doctors don't want revealed to the public. You don't have to be one of the 70% of Americans diagnosed with heart disease. You can heal your heart!

Natural Secrets For Healing Your Heart Overview

Rating:

4.6 stars out of 11 votes

Contents: Ebook
Author: Bob Livingston
Price: $19.95

Download Now

Benefits Of Early Detection Of Coronary Artery Disease

The benefits of early detection of coronary artery disease in the diabetic population include implementation of medical therapy targeted at prevention of further morbidity and mortality from coronary artery disease, identification of patients who would gain survival benefits from revascularization, and modification of lifestyle and other factors which may impact on disease progression. Implementation of Medical Therapy Modification of Other Cardiovascular Risk Factors Modification of cardiovascular risk factors beside diabetes may reduce morbidity and mortality from future events. Perhaps the most striking example is the recent demonstration of mortality reduction in lipid lowering trials. In the Scandinavian Simvastatin Survival Study, 2200 patients with coronary artery disease receiving simvastatin were compared to patients receiving placebo. Lowering cholesterol was associated with a 42 reduction in cardiovascular mortality and a 30 reduction in overall mortality. In the 5 of...

Unique Characteristics Of Coronary Artery Disease In The Diabetic Population

Several features distinguish coronary artery disease in the diabetic population from the non-diabetic population. Factors such as premature presentation, greater extent of disease, coagulation abnormalities, and autonomic dysfunction may contribute to the higher morbidity and mortality of coronary heart disease in the diabetic patients (Table 1). Diabetic patients often present with premature coronary artery disease. In type 1 diabetic patients, the duration of diabetes is the most important predictor of premature coronary artery disease, and coronary artery disease may present as early as the third or fourth decade of life. TABLE 1 Unique Characteristics of Cardiovascular Disease in the Diabetic Patient Premature presentation Extensive disease upon initial presentation Multiple coronary arteries diseased Distal coronary artery disease Small vessel disease Impaired autoregulation in vessels Increased risk of developing heart failure Acceleration of coronary thrombosis Endothelial...

What Is Coronary Artery Heart Disease

Coronary artery disease is characterized by a narrowing of the major arteries in the heart, a situation that leads to reduced blood flow and, in effect, slow starvation of cells forming the heart. The narrowing is caused by several factors, including lesions made up of cholesterol, abnormal growth of smooth muscle cells, and accumulated platelet cells. A heart attack occurs when a lesion grows large enough to completely block blood flow to the heart, or when part of a lesion breaks off and blocks an artery. Theories describing the cause of coronary artery (heart) disease often become fashionable and then, after a number of years, unfashionable. Elevated levels of cholesterol were long seen as a major cause of heart and other cardiovascular diseases. The cholesterol theory oversimplifies the multifactorial causes of heart disease, and is being replaced by other theories, though you could not tell that by the large numbers of cholesterol-lowering drugs prescribed.

Diabetes as a coronary heart disease riskequivalent

Based on the observations from several epidemiologic studies, diabetes is designated a coronary heart disease (CHD)-risk equivalent by the National Cholesterol Education Program's Adult Treatment Panel III (ATPIII) 1 . The 10-year risk of major CHD events in patients who have diabetes is greater than 20 this is comparable to the rates that are observed in nondiabetic patients who have established CHD. This inference has been borne out, particularly by data from a population study in Finland 2 and a multi-national study, the Organization to Assess Strategies for Ischemic Syndromes 3 , of patients who had type 2 diabetes who frequently had multiple, coexisting risk factors for cardiovascular disease (CVD). The increased risk for CHD may precede the clinical diagnosis of diabetes by many years. This was documented best in the long-term study of more than 117,000 women in the Nurses' Health Study nearly 6000 women developed diabetes during 20 years of follow-up. There was an approximately...

Cardiovascular Disease And Proteinuria

Urinary albumin excretion has been linked to all-cause and, especially, cardiovascular mortality in patients with diabetes and in the general population 56, 66, 110-119 . The Framingham Heart Study identified the direct correlation between diabetes and the morbidity and mortality associated with coronary heart disease. The total number of deaths from cardiac causes in diabetic patients is greater than that from the next five most common causes of death combined. The net effect of diabetes increases the risk of coronary death and coronary events approximately two fold, regardless of whether or not coronary disease is a pre-existing condition in these populations. Studies in diabetic patients with proteinuria at all levels have demonstrated an increased risk of cardiovascular events in these patients, and this risk increases with the severity of the underlying nephropathy. In fact, proteinuria might be considered to be a marker for generalized endothelial damage and atherosclerosis 100,...

Effect of glycemic control on cardiovascular disease

The Diabetes Mellitus Insulin Glucose Infusion in Acute Myocardial Infarction (DIGAMI) trial is particularly relevant to the impact of glycemic control for cardiology practice. A total of 620 patients were studied 306 were randomized to treatment with insulin-glucose infusion that was followed by multi-dose subcutaneous insulin for at least 3 months and 314 were randomized to conventional therapy. After 1 year, 57 subjects (18.6 ) in the infusion group and 82 subjects (26.1 ) in the control group had died (relative mortality reduction 29 , P 0.027). The mortality reduction was particularly evident in patients who had a low cardiovascular risk profile and no previous insulin treatment (3-month mortality rate was 6.5 in the infusion group and 13.5 in the control group relative reduction 52 , P 0.046 1-year mortality rate was 8.6 in the infusion group and 18.0 in the control group relative reduction 52 , P 0.020 ). Insulin-glucose infusion that was followed by a multi-dose insulin...

Criteria For Type Diabetes And Cardiovascular Disease

The chronic hyperglycemia of diabetes is associated with long-term complications, especially in the eyes, kidneys, nerves, heart, and blood vessels. Individuals with undiagnosed type 2 diabetes are at high risk of coronary heart disease, stroke, and peripheral vascular disease. More than half of type 2 diabetic patients die of cardiovascular causes (29). From the perspective of cardiovascular complications of DM the diagnostic criteria have been too high. Already the Whitehall study showed an increased risk of cardiovascular disease when the 2-hour level exceeded 5.5mmol L, albeit after a 50 g glucose load (30). This study and several other population-based studies indicated that the risk for macrovascular complications starts at considerably lower levels of glycemia than has been included in the definition of diabetes. Early diagnosis of diabetes aims to prevent long-term complications. Because cardiovascular disease is the main complication of type 2 diabetes recent studies have...

Effect Of Hypoglycaemia On Cardiovascular Disease

Acute hypoglycaemia provokes an intense haemodynamic response secondary to activation of the autonomic nervous system with the secretion of epinephrine (adrenaline) (DeRosa and Cryer, 2004). The heart rate increases over a period of 15 to 20 minutes, but rarely rises above 100 beats minute. A modest but significant increase in systolic blood pressure is accompanied by a slight but significant fall in diastolic blood pressure (Fisher et al., 1987 Russell et al., 2001). The pulse pressure widens, with a substantial increase in cardiac output and a fall in total peripheral vascular resistance (Figure 12.5). These haemodynamic changes are relatively short-lived, and exert no significant after-effects on the 24-hour heart rate or blood pressure (Avogaro et al., 1994). In a person with a normal heart these haemodynamic changes are probably of no great significance, but in a patient who has underlying coronary heart disease the profound increase in cardiac workload may provoke a cardiac...

Introduction diet and cardiovascular disease

Cardiovascular disease (CVD) is still a major cause of death in Western populations and is becoming an important cause of morbidity and mortality worldwide. Thanks to advanced medical knowledge and treatments, many patients survive an initial event. Because of that, prevention of secondary CVD is a growing task for nutritionists and other health professionals. Cardiovascular risk can be reduced by lifestyle changes, one of which is diet. There is now substantial evidence from epidemiological and clinical studies that a diet rich in fruits, vegetables, unrefined grains, fish and low-fat dairy products, and low in saturated fats and sodium, can reduce the risk of coronary heart disease and hypertension.1 People who have adopted such diets have benefited by way ofamuch lower risk of heart disease (see Table 1.1).1-4 However, such a prudent diet is not typical of what consumers in Western countries eat.3 5 It appears that consumers today are less likely to invest in long-term health if...

Gender and cardiovascular risk in diabetes

In contrast mortality from heart disease in the general population is higher in men than women at all ages, and premenopausal women have a degree of cardioprotection as CHD rates remain low at this age. This premenopausal protection appears to be completely lost in young women with type 1 diabetes and CHD mortality rates are the same as for men. This accords with incidence data from Pittsburgh (Lloyd etal., 1996b), in which similar rates of new coronary artery disease events were found in males and females under 40 years, and from the WHO study (Morrish etal., 2001), which showed similar incidence rates for new myocardial infarctions in men and women. Even though the rates fall behind those of men in the older age groups, at all ages the rates in women with type 1 diabetes are higher than those for men in the general population. Women with type 2 diabetes appear to fare only slightly better and studies suggest that some of this survival advantage may also be lost. Data from Although...

Comprehensive Risk Reduction of Cardiovascular Risk Factors in the Diabetic Patient An Integrated Approach

Cardiovascular (CV) diseases are the leading cause of morbidity and mortality in the general population. This baseline risk of CV disease is multiplied two- to fourfold in persons with diabetes mellitus, and the case fatality rate is higher than in nondiabetic patients 4 . CV disease accounts for 65 of deaths in persons with type 2 diabetes mellitus. Much of the morbidity and mortality is from atherosclerotic coronary artery disease, congestive heart failure, and sudden cardiac death. Efforts to reduce the mortality and morbidity related to CV diseases have borne fruit with substantial reduction in CV mortality over the past few decades. Advances in medical therapy and interventional techniques have resulted in only modest improvements in mortality from CV disease in men with diabetes, however, and during the last decade mortality rates of diabetes and CV disease have risen for women (Fig. 1) 5 . Fig. 1. Change in age-adjusted 8- to 9-year CV mortality in National Health and Nutrition...

Cardiovascular Disease In Type Diabetes

Type 2 diabetes is very different from type 1 diabetes in its underlying etiology and its natural history. Insulin resistance, which is defined as a less than normal effect of insulin on in vivo glucose uptake and metabolism, occurs in a high proportion of the population of societies embracing western culture (10,26). Factors responsible for the development of insulin resistance are only partially understood. Fetal malnutrition predisposes to insulin resistance in postnatal life (27). Excess calorie intake and reduced physical activity lead to exaggerated lipid deposits and obesity. The proportion of excess calories deposited as lipids in subcutaneous adipose tissue relative to visceral adipose tissue is both genetically and hormonally determined (28). An increase in visceral adiposity but not subcutaneous adiposity is highly correlated with insulin resistance and the components of the metabolic syndrome (29,30). There is a significant correlation between visceral adiposity and both...

Screening for coronary heart disease

To identify the presence of CHD in patients with diabetes without clear or suggestive symptoms of coronary artery disease (CAD), a risk factor-based ACE inhibitors even in the absence of hypertension or albuminuria (in patients > 55 years old) Beta-blockers for patients with CHD (watch for masking of hypoglycemia symptoms) TZDs are associated with fluid retention and their use can be complicated by the development of CHF. Caution is required in prescribing TZDs in the setting of known CHF or other heart diseases, as well as in patients with preexisting edema or concurrent insulin therapy.

Diabetes And CardiovASCuLar Risk Factors In Women

There is emerging evidence that DM2 is an important risk factor for the development of CvD, with some difference between women and men. As discussed in more detail in Chap. 3, death rates for coronary heart disease (CHD) are 3-7 times greater among diabetic than nondiabetic women, whereas rates are twice or three times greater in diabetic vs. nondiabetic men (45). Furthermore, evidence suggests that the positive association between adiposity and risk for DM2 is stronger for women com In general, estimates of CHD incidence in patients with diabetes vary across studies and countries, mainly because of differences in selection criteria and risk assessment. In a recent study performed in a large cohort of 6,032 women and 5,612 men, sampled from a nationwide network of hospital-based diabetes clinics in Italy and followed up for 4 years, it was reported that the age-standardized rate (per 1,000 person-year) of the first CHD event was 28.0 (95 CL 5-4-32.2) in men and 23.3 (20.2-26.4) in...

Lifestyle Changes Also Work for Other Heart Disease Risk Factors

One of the reasons that preventing diabetes is so important is that people with diabetes have a higher risk of developing heart disease. Observational studies have found various lifestyle factors that are associated with an increase in risk of heart disease, and many overlap with factors that increase the risk of diabetes Low activity levels are associated with increased risk of atherosclerosis and death from heart disease and stroke. Higher activity levels are associated with decreased risk of cardiovascular disease and death. In most studies, those who exercise regularly have a 23 to 29 percent reduction in death compared with those who exercise least. Any combination of obesity, sedentary lifestyle, smoking, and high-fat, low-fiber diets increases the apparent risk of developing diabetes and heart disease. Smoking increases risk for heart disease, stroke, and especially vascular disease affecting the lower extremity. Based on the results of observational studies, noted previously,...

Vitamin E and Heart Disease

The role of vitamin E in preventing and reversing cardiovascular diseases was first reported by Canadian physicians Evan V. Shute, M.D., Wilfrid Shute, M.D., and their colleagues in the 1940s. At that time no one understood the role of inflammation in cardiovascular diseases, and C-reactive protein had not yet been discovered. Indeed, until the 1990s, the medical establishment was generally skeptical that a single vitamin could play a pivotal role in reversing heart disease. Today, with a clearer picture of the role of inflammation in heart disease and good documentation for the anti-inflammatory and heart-protective role of vitamin E, the early successes of the Shute brothers are better understood. Certainly, vitamin E has important health roles beyond that of just a mild and safe anti-inflammatory nutrient. It is the body's principal fat-soluble antioxidant and, as such, blocks free-radical oxidation to cholesterol, which stimulates inflammation and is one of the initiators of heart...

Mortality from Coronary Heart Disease

Heart disease is well recognised as a chronic complication of diabetes, and is the major cause of morbidity and mortality in patients from middle-age onwards. Type 2 diabetes is associated at the onset with risk factors for heart disease such as hypertension and obesity, raising the question of whether diabetes per se is an independent risk factor for heart disease. Type 1 diabetes is not associated with risk factors for heart disease at the time of diagnosis although these develop later. Both types of diabetes are also characterised by hyperglycaemia and abnormal protein and lipid metabolism (Chapter 2). The majority of cardiovascular deaths are specifically due to heart disease (Morrish etal., 2001) and it is becoming apparent that heart disease is the major cause of morbidity and mortality at young as well as older ages. Heart disease, however, is such a broad term that unless the conditions included are made clear it is difficult to interpret the results. A number of studies have...

Arrhythmias and Coronary Heart Disease

Occasional cardiac arrhythmias have been demonstrated in normal subjects during experimental hypoglycaemia studies. It would now be considered unethical to perform hypogly-caemia studies in patients with known heart disease, but many studies were performed in an earlier era both in diabetic and non-diabetic patients with coronary heart disease to examine the effects of acute hypoglycaemia (Fisher and Frier, 1993). Sinus bradycardia has been reported in a very small number of cases (Pollock et al., 1996 Navarro-Gutierrez et al., 2003). Atrial fibrillation has been described in some patients and in addition there are several case reports of atrial fibrillation following hypoglycaemia in insulin-treated patients who had no overt evidence of heart disease (Collier et al., 1987 Baxter et al., 1990 Odeh et al., 1990 Navarro-Gutierrez et al., 2003). There is a single report of a transient ventricular tachycardia occurring during experimental hypoglycaemia in a non-diabetic patient with...

Cardiovascular Risk Factors

The role of exercise and the prevention of coronary heart disease in the general population have been well documented, but there is less evidence of a similar effect in people with diabetes. Modification of risk factors for CHD, including decreased total and LDL (low-density lipoprotein) cholesterol and triglyceride concentrations, have been demonstrated in Type 1 diabetes (20). People with Type 2 diabetes have two to four times the cardiovascular risk of those without diabetes and low cardiorespiratory fitness has been shown to be a predictor of mortality in men with diabetes (21).

Nafld As A Cardiovascular Risk Factor

Data is emerging that NAFLD is an independent risk factor for vascular disease, which is the most common cause of death among patients with diabetes (1). Patients with NAFLD have a greater carotid intima-media thickness as well as a higher prevalence of carotid atheromatous plaques (51). The presence of NAFLD among patients with type 2 diabetes is associated with an increased risk of developing vascular disease, which is only partly associated with the presence of the metabolic syndrome (52,53). Similarly, ALT is independently predictive of the development of coronary heart disease (54). The mechanisms through which NAFLD may result in increased vascular disease are unclear and it is difficult to distinguish whether this is an association with the abnormal metabolic milieu that occurs in association with NAFLD or whether it is related to the increased lipid oxidation, inflammation and abnormal hepatic lipid metabolism that occurs with NAFLD. Certainly, lipid profiles among diabetics...

Heart Disease And Prediabetic States

The duration of diabetes influences the development of CAD in patients with type 1 diabetes, but such a relationship has not been demonstrated in those with type 2. Therefore, it is unclear whether the duration of asymptomatic hyperglyce-mia, or the state of impaired glucose tolerance, may have an important role on the development of CAD preceding the overt manifestations of type 2 diabetes (31,32). Several studies have shown that the mortality rate due to CAD was higher in patients with impaired glucose tolerance compared to normoglycemic men, although it was smaller when compared to that of patients with overt diabetes. At least one study has demonstrated that the risk of CAD increases linearly with fasting blood glucose levels in patients with impaired glucose tolerance, whereas the fasting insulin level has been implicated as a possible independent risk factor for CAD mortality in another study. Early impairment of LV diastolic function has been documented not only in patients...

Isoflavones and coronary heart disease

The increase in coronary heart disease (CHD) incidence associated with decreased ovarian function at the menopause (McGrath et al., 1998 Bittner, The oestrogenicity of isoflavones was first documented over 50 years ago, when isoflavones present in the diet of sheep were found to be responsible for the permanent infertility induced in these animals. Subsequent epidemiological evidence in humans suggested that high soy consumption, the main dietary source of isoflavones, was cardioprotective, in part attributed to the ability of the isoflavones in soy to act as oestrogen mimics. Demonstration of the ability of soy products to bring about a beneficial change in the blood lipoprotein profile led the US Food and Drug Administration (FDA, 1999) to approve a claim that '25g of soy protein a day, as part of a diet low in saturated fat and cholesterol, may reduce the risk of heart disease'. It is currently uncertain whether soy isoflavones contribute to the cholesterol-lowering effects that...

HRT and Risk of Cardiovascular Disease in Women With Diabetes

And ischemic heart disease (IHD), MI, and total number of deaths among a cohort of almost 20,000 Danish nurses aged 41 years and older (173). The data showed that current users of HRT smoked more, consumed more alcohol, had lower self-rated health, but were slimmer and had a lower prevalence of diabetes than never users. In current users without diabetes, HRT had no protective effect on IHD or MI compared with never users. However current users with diabetes had an increased risk of death, IHD and MI compared with never users with diabetes. These findings suggest that HRT does not protect women against IHD. Rather the effect of treatment is modified by diabetes, with an increased risk among women with diabetes using HRT.

Cardiovascular Disease

Hyperhomocysteinaemia (tHcy) is another independent risk factor for coronary heart disease (27). Both Type 1 and Type 2 diabetic patients with renal failure have approximately fourfold higher tHcy levels than controls prior to transplantation. These levels can fall by a third after a successful renal transplant and further falls have been reported with folic acid, B6 and B12 supplements (28). The routine place of these dietary supplements in diabetic renal transplant patients awaits further studies.

Risks of heart disease to diabetic patients

Coronary artery disease (CAD) is the term for the progressive closure of the arteries, which supply blood to the heart muscle. When one or more of your arteries closes completely, the result is a heart attack (or myocardial infarction). In diabetes, the incidence of CAD is increased even in the young type 1 patient. The duration of time with diabetes promotes CAD in type 1 patients. CAD affects males and females with type 1 diabetes in the same way. If a heart attack occurs, the risk of death is much greater for the person with diabetes. More than half of all people with diabetes die of heart attacks. If people without diabetes have heart attacks, they die 15 percent of the time, but people with diabetes die 40 percent of the time. The death rate is worse for the person with diabetes who was in poor glucose control before the heart attack. That same poorly controlled person has more complications, such as shock and heart failure, from a heart attack than the person without diabetes....

Coronary Artery Disease

Atherosclerosis and fatal myocardial infarction occurs three times more frequently in women with diabetes. In women with preexisting cardiovascular disease, the physiologic changes of pregnancy and delivery can result in inadequate myocardial oxygenation resulting in myocardial infarction and heart failure. The physiologic changes associated with pregnancy increased cardiac output, decreased systemic vascular resistance with shunting of blood from the coronary arteries, increased oxygen consumption combined with the intrapartum changes of increased vascular return during contractions followed by the acute blood loss at delivery can combine with decreasing blood flow to the myocardium and failure to meet the heart's demands. Additionally, these women are extremely susceptible to pulmonary edema and myocardial damage in the immediate postpartum period. Immediately after vaginal delivery, there is a 60 to 80 increase in cardiac output due to autotransfusion of uteroplacental blood,...

Coronary Heart Disease

Reduced incidence of myocardial infarction metabolic profile of Type 2 diabetes, together with small dense LDL and low concentrations of HDL cholesterol. Hypertriglyceridaemia is an independent risk factor for coronary artery disease especially for people with Type 2 diabetes reduction of alcohol intakes tight glycaemic control and weight loss can help to reduce this risk (29). In subjects with alcohol-induced hypertriglyceridaemia, alcohol withdrawal has beneficial effects on the LDL profile by shifting the particle size from small to large, thus reducing susceptibility to oxidation. With moderate alcohol consumption the increase in HDL becomes the predominant feature in the reduction of CHD risk and maximal benefit appears to be at the level of one drink per day (30). In irregular binge drinkers the increase in HDL cholesterol is not seen, adverse changes in LDL are acquired (31) and cardiovascular risk increases (Table 13.3). Antioxidants in alcoholic beverages, especially...

Pathophysiology of coronary artery disease in type diabetes see also Chapter

Knowledge from basic mechanisms of atherothrombosis to findings from clinical trials are needed to change evidence-based treatment guidelines of cardiovascular disease in patients with type 2 diabetes. Our understanding of the pathophysiology of atherothrombosis has substantially increased during recent years, and potential new mechanisms and risk factors for atherosclerosis and thombosis have been identified. For example, the role of inflammation in atherosclerosis has been officially accepted as an important risk factor for cardiovascular disease (Beckman etal., 2002). However, not all risk factors are easy or even possible to measure, and therefore their impact on CAD is difficult to prove. For example, it is quite easy to assay C-reactive protein (CRP) but more difficult to measure endothelial dysfunction. If a risk factor cannot be measured, it cannot have the status of a 'proven' risk factor for cardiovascular disease. In addition, a cardiovascular risk factor needs to be tested...

Insulin resistance and cardiovascular disease

Various studies have shown that hyperinsulinaemia is a predictor of cardiovascular disease. The Quebec Study showed that fasting insulin concentrations are independent predictors of CHD. Haffner and colleagues found that people who developed diabetes had higher fasting glucose and insulin concentrations along with elevated blood pressure, lower HDLc and higher TG than in those whose glucose metabolism remained normal. Thus, for the macrovascular complications of type 2 diabetes like stroke or myocardial infarction, the period of increased risk begins or 'the clock starts ticking' even before the onset of hyperglycaemia (Haffner et al., 1990). Yudkin et al. (1999) showed that inflammatory markers like C-reactive protein (CRP), pro-inflammatory cytokines, IL-6 and TNF-a correlate with obesity and IR. In a prospective study, Pradhan et al. (2001) followed 27 628 women free of diagnosis of diabetes and cardiovascular disease for 4 years and found that baseline elevated markers of systemic...

Potential beneficial effects of insulinsensitizing agents on cardiovascular risk factors

Several epidemiologic studies showed that hyperinsulinemia is an independent risk factor for cardiovascular disease 18 . Correction of insulin resistance clearly is important in the management of type 2 diabetes mellitus and may decrease the risk for cardiovascular disease. In the UKPDS, patients who had type 2 diabetes melli-tus and were treated with metformin, which decreases hyperinsulinemia and insulin resistance, had a 30 reduction in cardiovascular disease events and mortality compared with those who received conventional treatment 11 . The thiazo-lidinediones also improve insulin sensitivity and may exert numerous nonglycemic effects in patients who have type 2 diabetes mellitus 19,20 . Additional clinical trials are being conducted to evaluate whether treatment of diabetes mellitus with agents that reduce insulin resistance, such as the thiazolidinediones, is superior to treatment with agents that stimulate insulin secretion, such as the sulfonylureas.

Cardiovascular Disease in Women with Diabetes

Cardiovascular disease (CVD) is the leading cause of morbidity and mortality in women in the USA. Women with diabetes are at a greater risk of CVD than men with diabetes. In this chapter we review the various mechanisms by which hyperglycemia potentiates this increased CVD risk, including coagulation abnormalities as well as endothelial dysfunction. Where applicable, sex-specific differences in these mechanisms are highlighted. Finally, the impact and burden of diabetes on CVD as well as screening for CVD in women are discussed. Key words Diabetes mellitus Coagulation abnormalities Hyperglycemia Endothelial dysfunction Insulin resistance Oxidative stress Metabolic syndrome Cardiovascular disease Sex differences.

Introduction oxidative stress and cardiovascular disease

This chapter will focus on the potential roles of fat-soluble nutrients and fat-soluble antioxidants in preventing cardiovascular disease (CVD). Two fat-soluble vitamins will be discussed in detail, i.e. vitamin E and vitamin D. Vitamin E (tocopherols and tocotrienols) is generally considered an antioxidant nutrient, although it may have important functions unrelated to its antioxidant functions (as discussed below). Antioxidant nutrients function by preventing damage to biological systems caused by reactive oxygen species (ROS) and or reactive nitrogen oxide species (RNOS). Vitamin D (calciferols) is not a true vitamin since it is not required in our diet, can be produced in skin tissue, and is generally not present in plants. Vitamin D is, perhaps, best described as a steroid hormone precursor. Although vitamin D may function as a membrane antioxidant under in vitro conditions (Wiseman, 1993), its primary biological role is to maintain plasma calcium and phosphorus homeostasis. The...

Prevention and reduction of cardiovascular risk

It used to be thought that glucose concentrations were not directly linked with large vessel disease. However, the DCCT (see p. 29) showed a reduction in plasma cholesterol concentrations in the intensively treated patients and a trend towards less cardiovascular disease in those with near normoglycaemia. In UKPDS (see p. 29) patients with intensive glucose control on metformin had a lower risk of fatal myocardial infarct than these on conventional glucose control. However, the sulphonyl-urea and insulin groups did not show a significant reduction in cardiovascular events with intensive glucose lowering. Diabetic smokers have a similarly increased risk of cardiovascular disease to non-diabetics. Overweight, hypertensive diabetic women who are taking oral contraceptives Cholesterol Total cholesterol is more likely to be raised in Type 2 patients than Type 1. HDL cholesterol has the same inverse relationship to coronary heart disease and other conditions due to atheroma as in...

Therapeutic Strategies in Diabetes and Cardiovascular Disease

Prakash Deedwania, who has had a long and productive interest in diabetes and cardiovascular disease, was willing to organize and contribute to articles on this topic. This broad topic has been divided between two issues of the Cardiology Clinics. The first issue (November 2004) dealt with pathophysiology, clinical epidemiology, and the relationship between diabetes and other diseases such as heart failure and hypertension. The second issue deals with management strategies for preventing and treating the cardiovascular complications of diabetes. I am indebted to Dr. Deedwania and the group of experts he has assembled for these two important issues. Editing one issue is a big job, let alone two. However, Dr. Deedwania has had a long-standing academic and clinical interest in diabetes and metabolic syndrome in cardiovascular disease. His dedication to improving care for these individuals is evident in these two issues of the Cardiology Clinics.

Nutrients And Cardiovascular Risk Factors

With the advent of the DCCT and a focus on intensive blood glucose control, the glycemic effect of the diet has been the central focus in the nutritional management of diabetes. Clearly, optimizing blood glucose levels is paramount to preventing the microvascular and macrovascular complications of diabetes, yet the risk of cardiovascular disease in diabetes is great. Elevated triglycerides, low high-density lipoprotein (HDL), and elevated LDL levels are common in untreated type 1 diabetes but normalize with intensive glucose control. Normal LDL concentrations generally characterize Individuals with type 1 diabetes respond to lipid lowering as well as persons without diabetes therefore, the National Cholesterol Education Program (NCEP) and ADA nutrition guidelines for altering dietary fat intake seem prudent (see Table 1). Dietary fat, however, is not the only nutrient impacting cardiovascular risk. Dietary fiber has shown a slight correlation with serum cholesterol levels and reduced...

Hyperglycaemia as a Risk Factor for Cardiovascular Disease

Our understanding of the role of traditional risk factors for cardiovascular disease (CVD), such as hypertension, hypercholesterolemia, smoking and diabetes, has evolved significantly over the last decade. Rather than viewing these risk factors as 'all or nothing' phenomena with pathogenic thresholds at particular levels, we now regard them as continuous variables, each contributing to overall CVD risk. In this paradigm, 'targets' for risk factor reduction are artificial, since they do not describe a clinically relevant threshold, and should vary depending on the cumulative risk for individual patients. However, this method of approaching CVD risk assessment runs into difficulties when one considers diabetes and hyperglycaemia. Unlike type 1 diabetes, where chronic hyperglycaemia is the hallmark of the disease process, type 2 diabetes (T2D) exhibits much more complex pathophysiology while glucose levels still define the diagnosis, hyperglycaemia is only one of several metabolic...

Maternal Diabetes and Cardiovascular Disease Risk

GDM confers a sixfold risk for future maternal diabetes, independent of other significant risk factors such as weight, visceral adiposity and physical activity (58, 59). Up to a third of women with diabetes may have been affected by prior GDM (60). Additionally, GDM is associated with vascular dysfunction and future cardiovascular disease. Heitritter et al. found that women with a GDM history had greater vascular resistance, lower stroke volume and lower cardiac output than women without a GDM history (61). In a cross-sectional study, Carr et al. found that women with a GDM history were more likely to have metabolic syndrome and to experience cardiovascular events than women without a GDM history and, moreover, that these cardiovascular events occurred at a younger age (8). Shah et al. found that this increased risk of cardiovascular events, although

Cardiovascular disease risk factors

A number of cohort studies have examined cardiovascular disease (CVD) risk profiles in children (Daniels et al., 1999 Freedman et al., 1999b Morrison et al., 1999a, b Sinaiko et al., 1999). One impressive study is the Bogalusa Heart Study which began in 1973 and is a cross-sectional and longitudinal study of the early natural history of atherosclerosis (Berenson et al., 1980). The survey has included school age children and young adults in a biracial (one-third African-American) cohort. This study has published a number of papers that have highlighted the link between overweight and obesity and an abnormal CVD risk profile even in young children. This includes changes in lipid, blood pressure and insulin profiles (Bao et al., 1996 Freedman et al., 1999b). The Bogalusa Heart Study demonstrated that insulin resistance tracked strongly from childhood to adulthood and resulted in a 36-fold increase in the prevalence of obesity, a 2.5-fold increase in hypertension and a 3-fold increase in...

Antioxidants cardiovascular disease and oxidative modifications of lowdensity lipoprotein

Both lipid-soluble and water-soluble antioxidants present in blood may be important in preventing cardiovascular disease owing to their ability to prevent the oxidation of lipid-protein complexes called lipoproteins. Lipoproteins are extremely important in cardiovascular disease since we know with certainty that high levels of LDL-C cause atherosclerosis, which is the underlying cause of most cardiovascular disease. In contrast, high levels of HDL-C are a negative risk factor for CVD. Atherosclerosis is the gradual build-up of 'plaque' in the arterial wall. LDL-C is the major source of the lipids occurring in these plaques.

Vitamin E and other antioxidants in the prevention of cardiovascular disease

On the basis of these data almost all the trials have been based on the assumption that supplementation with vitamin E would represent a useful approach for preventing cardiovascular disease. However, candidates for antioxidant treatment were not accurately defined any patient at risk of cardiovascular events has been indiscriminately enrolled in those trials. We argue that antioxidant status represents an important marker of oxidative stress,7 its determination may be useful for better identifying candidates for antioxidant treatment. In order to substantiate this hypothesis, data inherent to oxidative stress and antioxidant status in patients at risk for cardiovascular disease and in patients included in observational and interventional trials have been reviewed. As antioxidant vitamin E has been the subject of the most important research in this field, our analysis is essentially concentrated on the clinical relevance of this vitamin in patients with cardiovascular disease.

The impact of cardiovascular disease

Owing to the enormous worldwide impact of cardiovascular disease it must be emphasized that even very modest reductions in risk factors, brought about by the appropriate design and use of functional foods, can have very important health related and economic significance. Statistics from the American Heart Association (see http www.americanheart.org statistics 03cardio.html) indicate the enormous impact of CVD. Over 61 million Americans have one or more types of CVD. CVD causes more mortality each year than the next seven leading causes of death combined and the estimated cost of cardiovascular diseases and stroke in the United States in 2003 was 352 billion. In developed countries, childhood obesity has reached epidemic proportions and this will certainly translate into a dramatic increase in type 2 diabetes which is characterized by elevated levels of triglycerides, LDL-C (low-density lipoprotein-cholesterol) and decreased levels of HDL-C (high-density lipoprotein-cholesterol), i.e....

The metabolic syndrome and cardiovascular risk

Interesting comparisons between the cardiovascular risk associated with the diagnosis of the metabolic syndrome have been made. While there is no doubt that the application of both sets of criteria identifies at-risk individuals, there remains debate about the best method of factoring insulin resistance as a discrete variable. Insulin resistance is best measured using the euglycaemic hyperinsulinaemic clamp, which is labour and time intensive. Clearly this is not suitable for inclusion as a key criterion in diagnostic criteria because it is only measured in certain specialised centres. The NCEP criteria include fasting plasma glucose > 6.1 mmol l, whereas the WHO criteria allow this or hyperinsulinaemia (fasting insulin in the upper quartile for patients without diabetes), which may mean that this favours the inclusion of patients who are insulin resistant. The application of the NCEP criteria to 443 individuals with formal measurements of insulin sensitivity identified only 46 of...

The Patient with Myocardial Infarction

Not only are diabetic patients more susceptible to myocardial infarction, they are also at greater risk from its consequences in both the short term and long term. For example, one-quarter of diabetic patients admitted to hospital with acute infarction do not survive to discharge (Malmberg and Ryden 1988). Compared with non-diabetics, the overall mortality of diabetics after infarction is four times higher among men and seven times higher among women (Lundberg et al 1997). Poor pre-infarction cardiac status and greater damage resulting from the infarct, together with the diabetic state itself, all seem to contribute to the relatively poor prognosis. Fatal reinfarction is a particular concern, being over twice as common in diabetic than in non-diabetic people (Malmberg and Ryden 1988). Rehabilitation programs that aim to improve the long-term prognosis for people after myocardial infarction have been described and evaluated. They tend to be exercise-based, though some also aim to...

Incidence Of Asymptomatic Coronary Artery Disease In The Diabetic Patient

Patients with type 2 diabetes had ST depression consistent with ischemia during treadmill stress testing. Approximately half of these patients had nuclear scans consistent with coronary artery disease (94,97). Additional smaller studies have reported asymptomatic coronary artery disease by coronary angiography in approximately 8 to 12 of diabetic patients. In addition to silent ischemia, diabetic patients also have a higher incidence of silent MI (98-100). The utility of noninvasive screening was examined in a study of 1900 asymptomatic diabetic patients, in which stress testing with dipyridamole myocardial contrast echocardiography followed by coronary angiography in those with perfusion defects, was performed. The positive predictive value of stress testing was best in those patients with two or more risk factors (as compared to patients with one or less risk factor), with significantly higher rates of three-vessel disease (33 vs. 8 ), diffuse disease (55 vs. 18 ), and vessel...

Polycystic Ovary Syndrome and Cardiovascular Risk

PCOS is associated with an increase in cardiovascular risk factors (189). In addition to obesity that is commonly present and independently associated with increased cardiovascular risk, women with PCOS have dyslipedemia, hypertension and elevated PAI-1 levels. Obesity is a prominent feature in women with PCOS as about half of the patients are obese. Also, obesity appears to confer an additive and synergistic effect on the mani Women with PCOS have higher serum triglycerides, total and LDL cholesterol and lower HDL cholesterol levels than weight-matched regularly menstruating women (190). These findings however, vary and depend on the weight, diet and ethnic background. In a large study of non-Hispanic white women, elevated LDL-C was the predominant lipid abnormality in women with PCOS (191). An additional parameter contributing to the elevated cardiovascular risk is hypertension. Obese women with PCOS have an increased incidence of hypertension and sustained hypertension is threefold...

Coronary Artery Disease in Type Diabetes Epi demiologi cal and cli ni cal findi ngs

Compared to non-diabetic individuals all clinical manifestations of CAD, myocardial infarction (MI), acute coronary syndrome, sudden death and angina pectoris are at Figure 9.1 Kaplan-Meier estimates of the probability of death from coronary heart disease in 1059 subjects with type 2 diabetes and 1378 nondiabetic subjects with and without prior myocardial infarction. Reproduced from HaffnerSM, Lehto S, Ronnemaa T, Pyorala K, Laakso M (1998). Mortality from coronary heart disease in subjects with type 2 diabetes and in nondiabetic subjects with and without prior myocardial infarction. New England Journal of Medicine 339 229-34. MI denotes myocardial infarction. least twofold more common in patients with type 2 diabetes (Laakso and Lehto,1997) (see also Chapter 3). Type 2 diabetes eliminates the usual female protective advantage for CAD mortality. A 20-year follow-up study of the Nurses' Health Study, including 121046 diabetic women aged 30-55 years, showed that age-adjusted relative...

Myocardial Infarction

Myocardial infarction has rarely been documented as a consequence of hypoglycaemia (Fisher and Frier, 1993). In a series of non-diabetic patients with schizophrenia who were treated with hypoglycaemic shock therapy in the 1930s, 12 of 90 deaths were ascribed to cardiac causes, with the majority of deaths being caused by cerebral damage. It should be emphasised that this long-abandoned form of treatment of psychiatric disease necessitated prolonged and profound hypoglycaemia. Only a few cases have been published of myocardial infarction and hypoglycaemia in diabetic patients (Purucker et al., 2000 Chang et al., 2007). This possible association is very difficult to establish because of the problems described above. In addition, the release of stress hormones such as glucagon, cortisol and epinephrine will raise blood glucose and make the contribution of preceding hypoglycaemia almost impossible to confirm.

The prevalence of the metabolic syndrome of cardiovascular risk factors is increasing in many parts of the world

The explanation for the continuing poor prognosis in the diabetic patient may lie, in part, in the secretion of counter-regulatory hormones that ensue after acute myocardial infarction these result in adverse changes in cellular metabolism that are exacerbated by diabetes (see Chapter 1). Hyperglycaemia - secondary to acutely exacerbated insulin resistance and insulin deficiency - is accompanied by acceleration of adipocyte lipolysis, the latter resulting in release of non-esterified fatty acids (NEFAs). Myocardial glucose uptake and metabolism are reduced by insulin deficiency. Under these circumstances, the oxygen consumption of the ischaemic myocardium is increased by reliance on NEFA oxidation this results in myocardial dysfunction that can be reduced if cellular glucose uptake and metabolism can be improved (see below). A chronic diabetic cardiomyopathy has also been described, which may contribute to the excess risk of heart failure after myocardial infarction in diabetic...

Myocardial Infarction or Stroke

The DIGAMI study (Malmberg K et al 1995, 1997) showed that after myocardial infarction an insulin glucose infusion with subsequent basal bolus regimen improved survival in the diabetic person with Type 2 diabetes. This study is slightly complicated by several factors (Fisher 1998). Many of the control group went on to insulin, many of the intervention group came off insulin, some of the subjects may have had stress hyperglycaemia rather than diabetes. Nonetheless, many would now recommend an insulin-glucose infusion for acute myocardial infarction in diabetic subjects with appropriate blood glucose control afterwards, not necessarily with insulin. The DIGAMI protocol is given in Table 5.6, but many units use their own, less complicated glucose-insulin-potassium infusion schemes.

Revascularisation for Acute Coronary Syndromes Revascularisation in STEMI

Invasive management of patients who have experienced an acute STEMI is with revascularisation, a superior form of reperfusion therapy (Global Use of Strategies to Open Occluded Coronary Arteries in Acute Coronary Syndromes (GUSTO IIb) Angioplasty Substudy Investigators, 1997 Grines etal., 1999 Keeley etal., 2003). However, STEMI patients with diabetes have a worse prognosis than those without diabetes, even when treated by primary PCI (Harjai etal., 2003) Diabetic patients with cardiogenic shock have a particularly high risk of early mortality (Shindler etal., 2000) (Figure 4.2). The GUSTO IIb study was a larger trial of percutaneous transluminal coronary angioplasty (PTCA) vs. thrombolysis (with t-PA) (Global Use of Strategies to Open Occluded Coronary Arteries in Acute Coronary Syndromes (GUSTO IIb) Angioplasty Substudy Investigators, 1997). The GUSTO IIb study tested whether primary PCI could be superior to systemic thrombolysis with alteplase in 1138 patients with acute STEMI...

Dietary strategies to prevent the development of heart disease

In 1987, we proposed that inflammation and leucocytes play a role in the onset of acute CHD events. This has recently been confirmed. It is now accepted that one of the main mechanisms underlying the sudden onset of acute CHD syndromes, including unstable angina, myocardial infarction and SCD, is the erosion or rupture of an atherosclerotic lesion,32 33 which triggers thrombotic complications and considerably enhances the risk of malignant ventricular arrhythmias.34,35 Leucocytes have been also implicated in the occurrence of ventricular arrhythmias in clinical and experimental settings,84 85 and they contribute to myocardial damage during both ischaemia and reperfusion.86 Clinical and pathological studies showed the importance of inflammatory cells and immune mediators in the occurrence of acute CHD events,29,86 and prospective epidemiological studies showed a strong and consistent association between acute CHD and systemic inflammation markers.88,89 A major question is to know why...

Etiology Of Hyperglycemia In Acute Ischemic Stroke

Several mechanisms have been proposed to account for hyperglycemia after stroke. Most likely multiple mechanisms are interacting together at the same time. We will consider the most important mechanisms proposed (Fig. 1A). Critical illnesses, including stroke, are accompanied by a generalized stress reaction with the activation of the hypothalamo-hypophyseal-adrenal axis (HPA axis). This activation leads to a subsequent increase in glucocorticoids (cortisol), and the activation of the sympathetic division of the autonomic nervous system, resulting in an increase in catecholamines (22). Indeed, in the acute phase till the first week after stroke, increased levels of cortisol and catecholamines have been shown since the 1950s (23,24). Stress hormones are known to enhance both glycogenolysis and gluconeogenesis

Traditional Cardiovascular Risk Factors

Hypertension, dyslipidemia, obesity and smoking, that is, the classic cardiovascular risk factors, each contribute to the risk profile in the patient with type 2 DM. Hypertension develops in about half of the patients with type 2 DM. This is important, not only because increased systemic blood pressure is a cardiovascular risk factor, but also because of the association between hypertension and accerated renal function loss. Moreover, effective blood pressure control is associated with a slower disease progression, possibly because of a concomitant amelioration of intracapillary hypertension and protein ultrafiltration in the kidneys. Thus, patients in the IDNT who had lower systolic blood pressure levels during treatment also had a markedly lower risk to reach a renal endpoint 28 . Although the study was not designed to compare the renal effects of different levels of achieved blood pressure control, the findings do favour an important effect of lowering systolic blood pressure in...

Role of the reninangiotensin system in cardiovascular disease in diabetes

As reviewed elsewhere in this book, multiple factors, including hyperglycemia, insulin resistance, dyslipidemia, hypercoagulability, and inflammation contribute to the pathogenesis of atherosclerosis in DM. Although there is considerable evidence for a role of the RAS in vascular remodeling, inflammation, thrombosis, and atherogeneis (81-83), the role of this system in atherosclerosis in the context of the other diabetes-associated cardiovascular risk factors is not fully understood. There is a growing body of evidence from both clinical studies and experiments in diabetic rodent models suggesting that the RAS contributes to CVD in both type 1 and type 2 diabetes.

Cardiovascular Risk in PCOS Women

PCOS is considered a pathological condition at high risk for CVDs. This is not only due to the presence of androgen excess, insulin resistance, obesity, DM2, and dyslipidemia, but also because of many other risk factors (120) (Table 2). These cardiovascular risk factors are often evident at an early age, suggesting that women with PCOS represent a large population at increased risk for developing Classic and Newer Risk Factors for Cardiovascular Diseases in PCOS early-onset CVD, even if this has not yet been confirmed in prospective studies (121). The risk of CHD and myocardial infarction has been reported to be increased in patients with PCOS compared with regularly cycling women (122), although, to date, no prospective study of cardiovascular mortality in PCOS has been performed (123). On the other hand, several studies reported alterations in intermediate end-points for CVD in this population (120). In fact, endothelial (124) and diastolic (125) dysfunction have been demonstrated...

Microalbuminuria And Cardiovascular Disease In Type Diabetes

Microalbuminuria is strongly predictive of the development of overt diabetic nephropathy and its associated excess of coronary, cerebrovascular and peripheral arterial disease in type 1 diabetes 17 . In prospective studies those with microalbuminuria have a significantly higher risk of dying from a cardiovascular cause. In a twenty three year follow up study of patients with type 1 diabetes and microalbuminuria those with microalbuminuria had a significantly higher mortality from a cardiovascular cause (Relative Risk 2.94 95 Confidence Interval 1.18 - 7.34) 18 . Rossing et al confirmed this in a ten-year observational follow up of 939 patients with type 1 diabetes, 593 with normal AER, 181 with microalbuminuria and 165 with overt nephropathy 19 . Age, smoking, microalbuminuria and overt nephropathy were significant predictors of cardiovascular mortality. Myocardial involvement may even be present at the stage of microalbuminuria, aerobic work capacity is reduced in patients with...

Risk of Cardiovascular Disease in Prediabetes

Of course, we should be able to glean useful information about the relative contribution of hyperglycaemia to cardiovascular risk from intervention studies designed to demonstrate significant delay or prevention of diabetes, defined by glycaemic thresholds. These studies will be summarised in detail in the next section. If an intervention were simply to reduce blood glucose levels then any associated reduction in cardiovascular outcomes could be ascribed to a glucose effect. However, as we will go on to discuss, most of the published studies in pre-diabetic subjects involve interventions that impact on other facets of the metabolic syndrome, potentially resulting in reduced cardiovascular risk via glucose-independent mechanisms.

Silent myocardial infarction and ischaemia

In view of the increased prevalence of coronary artery disease (CAD) in diabetic patients, it is difficult to differentiate between the impact of coronary ischemia and CAN on cardiac autonomic function. In other words, silent ischemia in diabetic patients may either result from CAN or from autonomic dysfunction due to CAD itself, or both. In the Framingham study, the rates of unrecognised myocardial infarctions were 39 in diabetic subjects and 22 in non-diabetic subjects, but the difference was not significant (Margolis et al. 1973). In a survey from the National Registry of Myocardial Infarction 2 (NRMI-2), of 434,877 patients with myocardial infarction, 33 did not have chest pain on presentation. The rates of patients with diabetes were 32.6 among those presenting without chest pain vs 25.4 among those with (Canto et al. 2000). It has been suggested that features such as sympathovagal balance (see below), impaired fibrinolysis and altered hemostasis, which are commonly clustered...

Considering Heart Disease

The major cause of death in the elderly person with diabetes is a heart attack. Strokes and loss of blood flow in the feet are also much more common Diabetics are at the same high risk of having a first heart attack as nondiabet-ics are of having a second heart attack. Blood pressure drugs called beta blockers have been shown to reduce second heart attacks in nondiabetics. Along with aspirin, beta blockers should be considered as standard treatment for diabetics before a heart attack ever occurs. Talk to your doctor about getting on these drugs.

Diabetes and myocardial infarction

Diabetes is associated with a two- to fourfold increase in risk of cardiovascular disease relative to the general population. Cardiovascular mortality is doubled in diabetic men and the relative risk is even higher in women with diabetes. Data from Finland have suggested that mortality rates are comparable to those of non-diabetic people who have previously suffered a myocardial infarction. Acute myocardial infarction accounts for 30 per cent of all deaths in the whole diabetic population. More than 50 per cent of all patients admitted to coronary care units with acute myocardial infarction have some impairment of glucose tolerance. Epidemiological studies demonstrate an increased risk of early and late mortality in diabetic patients. Cardiac failure is the main cause of death following myocardial infarction in patients with diabetes. In patients with diabetes, myocardial ischaemia may present without pain - so-called 'silent ischaemia', which is thought to result, at least in part,...

Hyperglycemia in Acute Stroke

Background Stroke Stroke and Hyperglycemia Hyperglycemia After Stroke Etiology of Hyperglycemia in Clinical Outcome After Stroke Glucose Levels and Lesion Volume How Does Hyperglycemia Affect Hyperglycemia is frequently found (40-60 ) after all kinds of stroke and it has been related to increased lesion size and poor clinical outcome. In this chapter, we will primarily focus on ischemic stroke we will outline the incidence and natural course of post-stroke hyperglycemia and discuss the possible etiologies of post-stroke hyperglycemia. Subsequently, we will present an overview of various mechanisms that could explain how hyperglycemia is detrimental after ischemic stroke. Finally, we will address the question whether inhospital hyperglycemia should be treated in stroke patients, and if so decided, the glucose levels that should be targeted and the difficulties that arise in achieving this. Keywords Acute stroke Ischemic stroke Hyperglycemia Stress response Diabetes mellitus Insulin...

Riddle Mc Hart J. Hyperglycemia Recognised And Unrecognised As A Risk Factor For Stroke And Transient Ischemic Attacks.

Antiplatelet Trialists' Collaboration (1994). Collaborative overview of randomised trials of antiplatelet therapy - I Prevention of death, myocardial infarction, and stroke by prolonged antiplatelet therapy in various categories of patients. British Medical Journal 308 81-106. Demchuk AM, Morgenstern LB, Krieger DW, Chi TL, Hu W, Wein TH, Hardy RJ, Grotta JC, Buchan AM (1999). Serum glucose level and diabetes predict tissue plasminogen activator related intracerebral haemorrhage in acute ischemic stroke. Stroke 30 34-9. Diaz R, Ernesto A, Paolasso A, etal. (1998). Metabolic modulation of acute myocardial infarction. The ECLA Glucose Insulin-Potassium Pilot Trial. Circulation 98 2227-34. Eastern Stroke and Coronary Heart Disease Collaborative Research Group (1998). Blood pressure, cholesterol and stroke in eastern Asia. Lancet 352 1801-7. Fath-Ordoubadi F, Beatt KJ (1997). Glucose-insulin-potassium therapy for treatment of acute myocardial infarction an overview of randomised placebo...

Cardiovascular Disease and Diabetes

Epidemiological Evidence for Increased Risk of Cardiovascular Disease in Diabetic Patients It has been known for many years that diabetes mellitus is a potent independent risk factor for cardiovascular disease (CVD). In the Framingham Study the risk of CVD for diabetic subjects at baseline was higher by about 2 times for men and 3 times for women after adjustment for other risk factors (dyslipidemia, hypertension and smoking). More recently, the NAHANES 1 (for acronyms, see table 1) also showed that the diabetic population was twice as likely to develop coronary artery disease as the nondiabetic population, with 75 of the excess mortality in men with diabetes due to coronary artery disease. These data indicate that the diabetic population should be a prime target for all efforts toward primary prevention of CVD, and this attitude has been clearly taken by the new European guidelines for prevention of CVD, in which distinct risk charts for nondiabetic and diabetic patients have been...

Macroalbuminuria And Cardiovascular Disease

Although the prevalence of microalbuminuria is similar in type 1 and type 2 diabetes,64 the rate of progression to overt DN is slower in elderly Caucasian patients with type 2 diabetes, being of the order of 20 over a decade, compared with approximately 80 within a decade for patients with type 1 diabetes in the original studies published in the early 1980s.87 The cumulative risk of ESRD is also less in patients with type 2 diabetes, with one early study showing a cumulative risk of ESRD of 11 .88 The main reason for this disparity is that most Caucasian patients with type 2 diabetes die from cardiovascular disease before developing DN,89,90 therefore leading to survivor bias in published studies (Figure 3.3). Microalbuminuria has been identified as a predictor of increased mortality from cardiovascular disease in both type 191 and type 2 diabetes13,35,92 and also in non-diabetic subjects.37 In some but not all of these studies, microalbuminuria predicted mortality independently of...

Role of Insulin Secretagogues and Insulin Sensitizing Agents in the Prevention of Cardiovascular Disease in Patients

Cardiovascular disease is the leading cause of death among patients who have diabetes mellitus. Patients who have diabetes mellitus have a greatly increased relative risk of cardiovascular disease when compared with patients who do not have diabetes mellitus 1 . Furthermore, in patients who have established cardiovascular disease, the rate of subsequent cardiovascular events is significantly higher than in individuals who do not have diabetes mellitus 2 and is associated with greatly increased morbidity and mortality. Epidemiologic studies showed that diabetic patients are more prone to develop complications following cardiovascular events 3 . Moreover, diabetic patients who have ischemic heart disease have a substantially worse outcome after coronary interventional procedures compared with nondiabetic patients 4 . The basis for these differences in outcome remained unclear. In most animal studies, diabetic myocardium demonstrates an enhanced sensitivity to the detrimental effect of...

Sometimes requires discontinuation Contraindicated in active hepatic renal and coronary artery disease

In the UKPDS, treatment with metformin (another drug that decreases hyperinsulinemia and insulin resistance) produced greater reduction in cardiovascular disease events and mortality than sulfonylureas and insulin 8 . The latter drugs decreased blood glucose level to a similar degree as metformin but did not decrease plasma insulin concentrations. This effect may have been mediated through a decrease in insulin resistance, although other effects of metformin, such as improvement in lipid profile, improved fibrinoly-sis, and prevention of weight gain, may be important 8 . Metformin has a favorable, albeit modest, effect on plasma lipids, particularly in decreasing triglycerides and low-density lipopro-tein (LDL) cholesterol however, it had little, if any, effect on HDL cholesterol levels 78 . Met-formin use was associated with decreased plas-minogen activator inhibitor (PAI-1) activity which led to improved endothelial dysfunction (see Table 1). 86 . Epidemiologic studies have...

CoQIO in heart disease

Variety of cardiovascular disorders, e.g. congestive heart failure, angina pectoris, coronary artery disease, cardiomyopathy, hypertension, mitral value prolapse (Singh et al., 1998). In the apoE gene knockout mice (an excellent model of human atherosclerosis) supplementation with both vitamin E and CoQ10 was found to inhibit atherosclerosis better than with vitamin E or CoQ10 alone (Thomas et al., 2001). It is not known, however, if CoQ10 supplementation in humans can decrease atherosclerosis. Although ubiquinol may inhibit the formation of oxidized and atherogenic forms of LDL, it is likely that the primary mechanism whereby CoQ10 could prevent heart disease is through its ability to improve ATP synthesis in cells with a high ATP demand such as cardiac myocytes. As an antioxidant, ubiquinol could also inhibit the free radical damage to the myocardium that arises during ischemia-reperfusion injury. Heart failure (due to cardiomyopathy and congestive heart failure), as discussed...

Nature of Coronary Heart Disease in Diabetes

Case-control studies have demonstrated that diabetic patients with angiographically normal coronary arteries have smaller calibre coronary arteries than non-diabetic control subjects (Mosseri etal., 1998). Diabetes is an aetiological factor for the pathogenesis of coronary heart disease (CHD) and an adverse prognostic marker (Kip etal., 1996). Diabetic patients with coronary disease have a higher prevalence of other risk factors for CHD, and related vascular co-morbidity (Kip etal., 1996).When CHD is present diabetic patients typically have more severe disease as evidenced by more extensive coronary artery calcification compared with non-diabetic patients (Wong etal., 1994 Arad etal., 2001), with more arteries involved (Dortimer etal., 1978 Moise etal., 1984 Abaci etal., 1999 Melidonis etal., 1999 Waldecker etal., 1999 Cariou etal., 2000 Natali etal., 2000) and a higher prevalence of left main stem disease. These features have also been found at postmortem investigations (Waller...

Stents for Coronary Artery Disease in Diabetes

3.6 STENTS FOR CORONARY ARTERY DISEASE IN DIABETES 3.6 STENTS FOR CORONARY ARTERY DISEASE IN DIABETES Figure 3.2 Cumulative survival following coronary bypass surgery (CABG) and coronary angioplasty (PTCA) after initial CABG and PTCA, according to patients with diabetes (DM) and without diabetes (noDM). Reproduced from van Domburg RT, Foley DP, Breeman A, van Herwerden LA, Serruys PW (2002). Coronary artery bypass graft surgery and percutaneous transluminal coronary angioplasty. Twenty-year clinical outcome. European Heart Journal 23 543-9. Figure 4, p. 547. By permission of the European Society of Cardiology.

Improvement of Cardiovascular Risk Profile by Metformin

During the last two decades a number of studies showed beneficial effects of metformin on traditional and non-traditional cardiovascular risk factors 11,47-58 . Metformin reduces fasting and postprandial insulin levels 3 , insulin resistance 4-6 and has beneficial effects on lipids, thrombosis and blood flow. Metformin has a weight-lowering effect 11,13,15 and reduces hypertriglyceridaemia 11 , elevated levels of PAI-1 47 , factor VII 49 , C-reactive protein 51,52,54 and intact proinsulin and des 31,32 proinsulin concentrations 48 . In randomized head-to-head comparisons (Fig. 2) of oral anti-diabetic drugs metformin treatment reduced triglycerides by 10 and increased HDL-cholesterol by 7 , whereas pioglitazone reduced triglycerides by 19 and increased HDL-cholesterol by 14 11 . By contrast, LDL-cholesterol decreased by 4 under metformin therapy, but increased by 8 under pioglitazone. Remarkably, HbA1c improvement was very similar and the prognostically important total cholesterol...

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

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 nondiabetics continues to increase throughout the first year 4 . For more than 70 years it has been recognized that glucosuria is present frequently in nondiabetic patients who have AMI 6 . Acute hyperglycemia is documented in up to half of all patients who have AMI, whereas previously diagnosed DM is present in only 20 to 25 of these patients 7,8 .

Heart Disease

Type 2 diabetes increases the risk of coronary artery disease, and therefore you should get an evaluation for heart disease prior to starting an exercise program. Older people with type 2 diabetes who are just planning moderate activity such as walking may not need any special evaluation. However, if you were previously inactive and are planning a vigorous exercise program, or you have autonomic neuropathy or previous heart problems, you should get a cardiac stress test. Your doctor may do a test called thallium-201 scintigraphy, which looks for areas of the heart that have insufficient blood flow. You can estimate your risk for heart disease using the ADA Diabetes Personal Health Decisions online questionnaire (see Resources).

After Stroke

A retrospective study by Melamed (7, 15) showed in 1976 that hyper-glycemia after stroke is frequent and relates to the severity of the stroke and in-hospital mortality. Since then many studies have reported similar associations and showed that this association is more pronounced if hyperglycemia persists during the first 24 h (18) or week (50, 51). Capes et al. performed a systematic review including a total of 33 studies and demonstrated that after stroke of either subtype (ischemic or hemor-rhagic), the unadjusted relative risk of short-term mortality associated with admission glucose levels greater than 6-8 mmol L was 3.1 95 confidence interval (95 CI), 2.5-3.8 in non-diabetic patients and 1.3 (95 CI, 0.5-3.4) in diabetic patients (8). For non-diabetic patients, glucose levels greater than 6.1-7.0 mmol L were associated with a 3.3-fold higher risk of short-term mortality in patients with ischemic stroke - but not in non-diabetic patients with hemorrhagic stroke (2.4 95 CI,...

Heart Health

To improve heart health, the first steps of course would be to go off caffeine and to kill parasites and bacteria. This alone could drop the pulse from 120 to 80 in a few days. Obviously, the need for a drug is gone. Cut the drug dosage in half immediately. Don't wait for a doctor's appointment to O.K. it. If you waited another day the pulse could be below 60.

Diabetes And Circulatory Problems

People with diabetes, especially those with type 2 diabetes, are two to five times more likely to have problems with circulation to the heart, the legs, and the head when compared to individuals without diabetes. This is because diabetes predisposes a person to a condition called atherosclerosis. If you imagine a blood vessel as a water or drainage pipe, then atherosclerosis is buildup in the pipe narrowing the channel and impairing the flow. In the case of the blood vessel the buildup, called plaque, consists of a core of inflammatory cells, cholesterol, and lipids with a fibrous cap of smooth muscle cells (see Figure 3-1). The plaque can narrow the blood vessel, impairing blood flow. Occasionally the fibrous cap can rupture, and when this happens a blood clot forms, causing an acute blockage of the blood vessel. If the acute blockage happens in one of the blood vessels to the heart, it results in a heart attack. If it occurs in one of the blood vessels supplying brain tissue, it...

Diabetic Cardiomyopathy Does It Exist

In addition to the epidemiological data mentioned above, there are a host of other observations, both clinical and experimental, that point toward cardiomyopathic manifestations specifically related to the presence of diabetes. (In reviewing clinical data for this purpose, it is important to search for evidence of cardiomyopathy in the absence of the confounding presence of coronary artery disease and hypertension, both of which can cause CHF by themselves.) The occurrence of dilated cardiomyopathy in patients with diabetes who do not have coronary disease or hypertension is well documented. In an individual patient, it is impossible to know whether this represents a specific diabetic cardio-myopathy or simply the chance occurrence of two common diseases. Stronger evidence of a specific, underlying cardiomyopathic process comes from studies of patients with diabetes, typically younger, who do not have clinical signs or symptoms of heart disease. These subjects have normal contraction...

Macrovascular complications

These involve several organs, but predominantly the heart, where coronary artery disease is very common and is associated with decreased morbidity and mortality. Diabetes has been called a cardiovascular risk equivalent due to increased risk of heart disease, even in patients without known prior cardiovascular disease. In addition, congestive heart failure is much more common in patients with diabetes and of greater severity. Brain Several vascular diseases, including transient ischemic attack, stroke, and cognitive impairment, have also been described with greater frequency in patients with diabetes.

The Inflammation Syndrome Connection

Research on the inflammatory nature of homocysteine and oxidized LDL cholesterol has helped establish coronary artery disease as an inflammatory process. The role of inflammation in heart disease has become better understood by the commercialization of a highly sensitive C-reactive protein (CRP) test and a shift in the medical perception of CRP. In the past high blood levels of CRP were seen as a marker of the body's inflammatory response after traumatic injury. The view today, which is more accurate, is that CRP is also a promoter of inflammation. It is a direct by-product of interleukin-6, perhaps the most inflammatory of the cytokines. Although CRP levels reflect a general level of inflammation in the body, elevated CRP levels are a far more reliable predictor of heart disease than either cholesterol or homocysteine. People with high CRP levels are 4V2 times more likely to experience a heart attack than are people who have normal levels. Arterial lesions containing CRP are unstable...

Nutrients That Can Help

Many nutrients inhibit the inflammatory process in blood vessel walls and provide a variety of improvements in heart function. Several B vitamins lower homocysteine levels and appear to reduce the risk of heart attack. One study, published in the November 29,2001, New England Journal of Medicine, found that modest supplements of folic acid, vitamin B6, and vitamin B12 significantly lowered homocysteine levels and clearly reversed coronary artery disease in heart patients. Reducing homocysteine levels eliminates a major cause of blood vessel inflammation. As discussed in chapter 9, vitamin E supplements lower CRP levels and, several clinical trials have found, reduce the risk of heart disease and heart attack. Vitamin E also reduces the tendency of LDL cholesterol to oxidize, which in turn keeps white blood cells from attacking LDL. In addition, vitamin E prevents the stiffening of blood vessel walls (en-dothelial dysfunction), which reduces blood flow and increases the risk of heart...

Significance and treatment of individual risk factors

Dyslipidemia associated with the metabolic syndrome is characterized by increased conversion of HDL-C from large, buoyant HDL2-C particles to more dense HDL3-C particles and conversion of large, buoyant LDL-C particles to small, dense LDL particles. A decrease in plasma levels of cardioprotective HDL2-C accompanied by increase in atherogenic small, dense LDL is associated with a higher risk of coronary artery disease. Stratification of risk factors for coronary artery disease in type 2 diabetes shows that LDL-C and HDL-C levels are the best predictors of coronary heart disease (Table 2). In the diabetic population, Coronary Artery Disease (n 280) Data from Turner RC, Millns H, Neil HA, et al. Risk factors for coronary artery disease in non-insulin dependent diabetes mellitus United Kingdom Prospective Diabetes Study (UKPDS 23). BMJ 1998 316 823-8. Data from Turner RC, Millns H, Neil HA, et al. Risk factors for coronary artery disease in non-insulin dependent diabetes mellitus United...

No of antihypertensive agents Trial Target BP mm Hg

Beta-blockers are recommended for patients with established CV disease, particularly in the presence of coronary artery disease or prior history of myocardial infarction. Findings from the Anti-hypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial suggest that alpha-blockers may have less benefit and could even be harmful when compared with diuretics, amlodi-pine, or lisinopril 32 . Individuals who have supine hypertension along with significant orthostasis can possibly be treated with short-acting antihyperten-sive agents such as captopril or oral clonidine at bedtime. A causal relationship between hyperglycemia and microvascular disease is well established. Studies have also documented that glycemic control delays or prevents the manifestations of microvascular disease. The relationship between hyperglycemia and macrovascular disease has been a subject of constant debate, however. The largest study addressing this issue, the UKPDS, was designed to show whether...

Monitoring Lipids Cholesterol Levels

Heart disease is a risk factor in people with diabetes, especially if you have type 2 diabetes, long-standing type 1 diabetes, or complications from type 1 diabetes. In type 2 diabetes, the risk of heart attack is increased twofold. This is the same frequency as nondiabetic individuals who have already had a previous heart attack. Under these circumstances, your LDL cholesterol should be below 100 mg dl ideally around 70 mg dl. Have your lipid levels checked annually by your physician, and more frequently if you are getting treated. If you are a young patient with type 1 diabetes and your lipid profile is normal, measuring your lipids every two years is fine.

Kidney Disease As A Window To The Circulation

Development of kidney disease in diabetes reflects processes operative at distant sites that have a major impact on risks of adverse outcomes. In the chapters by Sowers et al. and Stehouwer et al., hypertension, CVD, and endothelial dysfunction in diabetes are reviewed in depth. This section will address how early and late indicators of CKD provide insight into global circulatory dysfunction. Albuminuria is the earliest clinical indicator of CKD in diabetes. However, albuminuria also increases risk of CVD events and death independent of traditional risk factors (32,33). Although this relationship is particularly apparent in diabetes, albuminuria also appears to increase CVD risk in other groups, including those with essential hypertension and the general population (34,35). In a study of persons undergoing elective coronary angiography, we found a direct correlation between albuminuria levels and severity of coronary artery disease (36). This relationship was most pronounced in the...

Why do you need to take care of your diabetes

After many years, diabetes can lead to serious problems in your eyes, kidneys, nerves, and gums and teeth. But the most serious problem caused by diabetes is heart disease. When you have diabetes, you are more than twice as likely as people without diabetes to have heart disease or a stroke. If you have diabetes, your risk of a heart attack is the same as someone who has already had a heart attack. Both women and men with diabetes are at risk. You may not even have the typical signs of a heart attack. You can reduce your risk of developing heart disease by controlling your blood pressure and blood fat levels. If you smoke, talk with your doctor about quitting. Remember that every step toward your goals helps

Morbidity from Diabetes

The main argument in favour of detection of diabetes in its early stages is to reduce or prevent its complications, which otherwise would lead to further morbidity (Samos and Roos 1998). Elderly diabetic persons have much higher use of ambulatory services than those without diabetes. Poor vision and blindness due to diabetic eye disease, lower limb amputation due to periph'eral vascular disease, neuropathy and infection, ischaemic heart disease, cerebrovascular accidents and chronic renal failure can all severely limit an elderly person's mobility, independence and quality of life. Chronic complications are often present in elderly people with newly diagnosed diabetes at diagnosis, 10-20 have established retinopathy or nephropathy and 10 have cardiovascular disease and neuropathy (Harris et al 1992 Muggeo 1998). Hypertension and Q-wave myocardial infarction are more prevalent, and the subsequent risk of developing retinopathy, peripheral vascular insufficiency and peripheral...

Vitamin E and atherosclerosis in clinical studies

Observational studies just look at the association between vitamin E status (either in the diet or in blood samples) and clinical measures of heart disease such as myocardial infarction (MI) or stroke. These studies are summarized in Table 4.1 and generally support the idea that vitamin E helps prevent heart disease. Observational studies do not, however, show cause and effect and have many major limitations. For example, people who are health conscious in general may exercise, maintain an ideal body weight, have a low-fat diet, and also take vitamin E supplements. In this case, vitamin E consumption is just a marker for a healthy lifestyle. The ultimate experimental design for testing the potential efficacy of vitamin E (or the other nutrients reviewed in this chapter) on atherosclerosis and heart disease is the randomized, double-blind, placebo-controlled clinical trial. These trials are very expensive and therefore often limited to participants who already have documented...

Efficacy of treatment

Data from the pivotal DIGAMI trial 8 demonstrated that an intensive treatment with insulin-glucose infusion, targeted to achieve a tight control of blood glucose in patients with acute myocardial infarction, is associated with a lower long term morbidity and mortality. However, control of glucose metabolism does not appear as the sole strategy to follow to prevent the progression of cardiovascular disease and its consequences in diabetic patients in large prevention studies such as UGPD, DCCT and UKPDS, although tight glucose control was associated with a reduction of microvascular complications in both type 1 (DCCT) and type 2 (UKPDS) diabetes, the reduction of macrovascular complications did not always reach statistical significance, or was limited to specific patients or treatment groups (overweight patients treated with metformin in UKPDS), indicating that targeting abnormalities other than glucose metabolism is a key step in attempting to ameliorate prognosis of diabetics with...

Type diabetes and CHD

Type 2 diabetes predisposes to macrovascular complications such as myocardial infarction, peripheral vascular disease and stroke. Epidemiological studies have shown that the risk of CHD is increased two- to six-fold in patients with type 2 diabetes compared with non-diabetic subjects (Pyorala et al., 1987 Stamler et al., 1993). Indeed, in the non-diabetic subjects, there has been a substantial decline in mortality from coronary heart disease in many parts of the world in recent years. The effect was considerably less in adults with diabetes with perhaps even an increase in women with diabetes (Gu et al., 1999). More than 50 per cent of diabetic patients have evidence of CHD at diagnosis, which does not take into account the high prevalence of sub-clinical CHD in the diabetic population (Kuller et al., 2000). Conversely, among people with established CHD, there is a high prevalence of diabetes. In fact, one-quarter of patients who had myocardial infarction in the PROCAM Study have...

Diagnostic Testing for Diabetes or Prediabetes Impaired Glucose Tolerance [IGT or Impaired Fasting Glucose [IFG

Patients presenting with symptoms of diabetes should be tested. Possible screening tests for these conditions include a fasting plasma glucose or an oral glucose tolerance test. Testing patients with hypertension, dyslipidemia, and heart disease is also recommended. Other patients at risk for diabetes are also appropriate for testing (American Diabetes Association, 2003h). See the ICSI Hypertension Diagnosis and Treatment guideline, the ICSI Lipid Screening guideline, the ICSI Preventive Services in Adults guideline and the Stable Coronary Artery Disease guideline.

Mortality from Diabetes

Cardiovascular disease is the most common complication of hyperglycaemia and the major cause of death in elderly people with diabetes, and ischaemic heart disease may account for up to half the number of deaths in this group (Vilbergsson et al 1998 Waugh et al 1989). Persons with diabetes have 1.5 times the inhospital mortality rate after acute myocardial infarction and 1.4 times the post-discharge mortality rate compared with non-diabetic persons (Sprafka et al 1991). It is imperative, therefore, that diabetes be diagnosed early to reduce, delay or prevent its morbidity, mortality and cost in this age group.

Special Problems In The Elderly

Increased age is known to increase postoperative morbidity, and possibility mortality, in general. This includes diabetic patients, but again there is no convincing evidence in the literature that the effect is significantly greater among such patients. In general, however, diabetic surgical patients are frequently older and 'sicker' than their non-diabetic counterparts (Sandler et al 1986) (e.g. amputees, coronary bypass surgery etc.) but when these factors are taken into account, any increased morbidity amongst diabetics becomes insignificant or much less significant. When preparing the elderly for surgery, preoperative assessment should be particularly thorough because of comorbidity and polypharmacy. The patient may not be able to give an accurate history because of memory problems or communication difficulties. Ischaemic heart disease may be underestimated as the patient may not give a typical history of chest pain on exertion if exercise is limited by another pathology such as...

Fish Oils Protect the Heart

Early Arctic explorers made note of the rarity of coronary artery disease in Eskimos, despite their consumption of a high-fat and high-cholesterol diet. It wasn't until 1973 that two Danish researchers compared the diets of Arctic Eskimos to that of Greenland Eskimos, who ate diets similar to other Danes. The Greenland Eskimos, who consumed more saturated fat and cholesterol from meat and dairy products, had a higher rate of heart disease. Since then, many other studies have confirmed the heart-protective effect of omega-3 fatty acids, especially EPA. For example, a twenty-five-year study of dietary and health data of almost thirteen thousand men in seven countries found that elevated blood cholesterol levels were associated with heart disease only in areas where intake of omega-3 and omega-9 fatty acids were low. A separate study of four hundred people, conducted by Michel de Lorgeril, M.D., of Saint- tienne, France, found that adoption of a Mediterranean-style diet can greatly lower...

What is the effect of hypertension in diabetic patients

Both hypertension and DM constitute extremely important risk factors for the development of cardiovascular events (coronary artery disease, strokes, peripheral obstructive arteriopathy). However, the coexistence of these two abnormalities has a multiplicative effect on the risk, rather than a simple additive effect. The effects of hypertension on the risk of coronary heart disease mortality in diabetic individuals are increased two to five times, compared to non-diabetics. The frequency of strokes, the appearance of cardiac failure and the probability of peripheral obstructive arteriopathy are also significantly increased in hypertensive diabetic individuals.

Management Strategies

Regular exercise improves bodyweight, plasma lipids, blood pressure, insulin sensitivity and glucose tolerance. It also maintains general fitness, balance, mobility and sense of well-being. Prior to starting regular exercise, the patient should be assessed with respect to cardiovascular, respiratory and musculo-skeletal systems by the physician. A stress electrocardiogram is indicated in those with suspected ischaemic heart disease. Ideally, moderate exercise should be done for at least 20 minutes each time, three or four times a week, but the actual duration, frequency and progression of exercise should be individualized. Avoidance of injury during exercise should be taught. Macrovascular disease. Treatment of hypertension, dyslipidaemia and cessation of smoking are essential in the prevention or management of macrovascular disease. Low-dose aspirin should be considered in these patients, especially in those with known coronary artery disease, unless contraindications are present...

Macrovascular Disease

Cardiovascular disease, that includes coronary heart disease (CHD) rebrovascular disease, and peripheral vascular disease, is the leading cause of mortality in people with diabetes. The majority of deaths are due to CHD, where the risk is two- to fourfold greater in patients, especially women with diabetes, when compared with age-matched subjects without diabetes (11). The relative importance of the problem has been highlighted by recent studies. Gu et al. compared adults with diabetes with those without diabetes for time trends in mortality from all causes, heart disease, and ischemic heart disease. They based the data on the First National Health and Nutrition Examination Survey (NHANES) conducted between 1971 and 1975 and the NHANES follow-up conducted between 1982 and 1984. The nondiabetic men had a 36.4 decline in age-adjusted heart disease mortality compared with a 13.1 decline in diabetic men. In the nondiabetic women it declined 27 but in the diabetic women the rate increased...

Ramachandiran Cooppan

Another major issue that challenges our strategies and overall approach to therapy has to do with the long-term complications of diabetes. While microvascular disease affecting the eye, kidney, and nerves can occur in both type 1 and type 2 diabetes, patients with type 2 disease have a greater risk of developing macrovascular disease, especially coronary artery disease. Cardiovascular disease is the most important cause of death in patients with type 2 diabetes and the risk starts very early during the stage of impaired glucose tolerance well before the clinical diagnosis of diabetes mellitus (4). These clinical issues therefore have important implications as we address the issue of glycemic control and the goals we set for our patients. If controlling the blood glucose to normal levels resulted in preventing the development and progression of both microvascular and macrovascular disease then the situation would be clear. We could approach our patients with confidence and encourage...

Chapter Carbohydrates

A recent large (15,792 participants) study looked at the amounts of fruits, vegetables, and whole grains U.S. adults ate and looked for connections between their diets and the occurrence of certain diseases. Not surprisingly, those people who ate more whole grains had a lower total mortality (they were less likely to die) and a lower risk of heart disease. Those who ate more fruits and vegetables also had a lower total mortality. African-Americans who ate more fruits and vegetables were less likely to have heart disease than other African-Americans, but this association was not seen in whites. Intakes of whole grains, fruits, and vegetables did not seem to affect the risk of stroke. This report provides more support for recommendations to eat more whole grains, fruits, and vegetables--in other words, a more plant-based diet. Reference Steffen LM, Jacobs DR, Jr, Stevens J, et al. 2003. Associations of whole-grain, refined-grain, and fruit and vegetable consumption with risks of...

Dietary antioxidants and the prevention of CHD epidemiological evidence

A large number of epidemiological studies have evaluated potential relationships between dietary intake of antioxidants and coronary heart disease (CHD). These are summarised in Table 5.1. Among these, the Nurses' Health study,36 included over 87 000 female nurses 34 to 59 years of age, who completed dietary questionnaires that assessed their consumption of a wide range of nutrients, including vitamin E. During follow-up of up to 8 years 552 cases of major coronary disease were documented. As compared with women in the lowest fifth of the cohort with respect to vitamin E intake, those in the top fifth had a relative risk of major coronary disease of 0.66 after adjustment for age and smoking. Further adjustment for a variety of other coronary risk factors and nutrients, including other antioxidants, had little effect on the results. Similarly, the Health Professionals' Follow-up study, among almost 40 000 males of 40-75 years, followed up for four years, showed a lower risk of coronary...

Obesity and dyslipidaemia

In the PROCAM study, involving 4407 German men aged between 40 and 65 years, without cardiac disease at the start of the study, the combination of high TG, TC and low HDL levels for example was associated with the increased risk of coronary heart disease. In men with plasma cholesterol levels above 6.5 mmol l with HDLc less than 0.9 mmol l, the risk of myocardial infarction over 6 years was as high as 20-30 per cent (Assmann and Schulte, 1992). Although there is an inverse relationship between low HDL and elevated triglyceride levels, triglyceride concentration as an independent risk factor of coronary heart disease remains controversial. Studies such as the PROCAM, the Stockholm Prospective Study and the Paris Prospective Study showed positive correlations between TG and CHD risks (Carlson et al., 1979 Cambien et al., 1986 Assmann et al., 1998). Despite the controversy, there is a growing consensus that TG directly causes atherosclerotic cardiovascular disease, or at least acts as a...

Impact Of Lipidlowering On Cardiovascular Endpoints

Cardiovascular disease (CVD) is a major cause of morbidity and mortality in patients with diabetes, and their risk is similar to that of non-diabetics with prior myocardial infarction (MI) (24). Improved glycemic control alone seems not to be sufficient to improve the CVD risk profile of patients with diabetes. In this regard, in the UKPDS, more intensive hypoglycemic therapy was associated with a 25 risk reduction in microvascular end points compared with conventional therapy (p 0.01), whereas risk reductions in fatal or nonfatal MI did not reach significance (fatal MI, 6 risk reduction, p 0.94 nonfatal MI, 21 risk reduction, p 0.06) (25). TABLE 1 Coronary Heart Disease (CHD) Prevention Trials with Statins in Subgroup Analyses of Patients with Diabetes Mellitus TABLE 1 Coronary Heart Disease (CHD) Prevention Trials with Statins in Subgroup Analyses of Patients with Diabetes Mellitus