Diabetes-Carmarthenshire

Ischaemic heart disease

Cerebrovascular disease

Peripheral vascular disease

 

Ischaemic heart disease

Background

Lifestyle changes

Risk factor management

Drug therapy

Referral

 

Background

• Mortality rates from coronary heart disease are up to five times higher for people with diabetes compared to the normal population. 50% of people with type 2 diabetes will be killed by coronary heart disease. It can be silent, often accompanied by cardiac failure, and is less amenable to surgical intervention than usual.

• Patients with tablet controlled Type 2 diabetes admitted with a Myocardial Infarction would be commenced on insulin therapy for 3 months. They will be given an appointment to be seen by the Hospital Diabetes Team. At this visit the decision will be made to continue with present treatment, or change back to original treatment. Most patients will then be discharged back to the Primary Care Diabetes Clinic. Some will continue to be seen in the Hospital Diabetes Clinic.

• Thrombolysis for MI should not be withheld due to concern about diabetic retinopathy

• Diabetes is not a contraindication to the use of beta blockerswhich reduce mortality,sudden cardiac death and reinfarction when given after myocardial infarction

• Primary angioplasty may be more effective than thrombolytic therapy in diabetic patients with acute MI.

 

Lifestyle modification

• Stop smoking - consider motivation to quit, referral to cessation service, NRT, bupropion (see smoking in the "Lifestyle Management" section)

• Reduce salt (but caution re potassium in salt alternatives) and saturated fat intake, increase fruit and vegetables . Consider weight loss if BMI> 25. Avoid effervescent/soluble tablets and certain indigestion products - high in salt content (see nutrition within the "Lifestyle Management" Section)

• Restrict alcohol <21 units/week (men) or <14 units/week (women)(see alcohol within the "Lifestyle Management section)

• Recommend appropriate physical activity . This will help to improve risk factors and glycaemic control (see physical activity within the "Lifestyle Management" section). Remember to warn about the risk of hypoglycaemia for those taking sulphonylureas or insulin

 

Risk factor management

• Treat hypertension - maintain blood pressure below 130/80mmHg for diabetics with CHD (see the "Hypertension" Section).

• Lipids - all patients with diabetes and CHD should have a cholesterol measurement. If total cholesterol (TC) is > 5.0 mmol/l, drug therapy should be initiated to reduce TC to <5.0 mmol/l (see the "Lipids" Section)

• Control of diabetes - aim to control blood glucose levels between 4-7mmols, and HbA1c below 7% (see the "Treatment" section)

 

Drug therapy

• Soluble aspirin 75mg daily (no advantages to using enteric coated or modified release aspirin) - unless contraindicated.

• Long term control - patients who require regular symptomatic treatment should be treated initially with a beta -blocker (unless specifically contraindicated) (preferred choice bisoprolol or atenolol). Patients should be warned not to stop b -blockers suddenly or allow them to run out. Patients intolerant of beta blockers and who show no left ventricular systolic dysfunction should be treated with:
  •  a rate limiting calcium channel blocker (verapamil or diltiazem) or
  •  a long acting dihydropyridine (preferred choice, felodipine MR or adalat LA) or
  •  a nitrate (consider twice daily asymmetric dosing before sustained release product) or
  •  a potassium channel activator (nicorandil)
  If symptoms are not controlled in patients taking beta blockers, add:
  •  Isosorbide mononitrate(consider twice daily asymmetric dosing ) or
  •  a long acting dihydropyridine (preferred choice felodipine MR or adalat LA, alternative amlodipine) or
  •  Diltiazem (but observe the caution in the BNF)

• ACE inhibitor (see formulary choice) should be used at maximum tolerated doses for those who have had a myocardial infarction (see ACE inhibitors in the "Medication" Section) or have cardiac failure due to left ventricular systolic dysfunction or are aged >55 who smoke,have hyperlipidaemia, microalbumin or hypertension

• Beta -blockers (preferred choice bisoprolol or atenolol ) should be prescribed for people who have had a myocardial infarction (unless specifically contraindicated).

• Warfarin or soluble aspirin for people over 60 years old who also have atrial fibrillation

 

Referral

Consideration should be given to referral to a cardiologist
•  on initiation of treatment
•  if the patient is perceived to be at increased risk
•  if at any stage medical treatment fails to control symptoms
•  if these symptoms limit the patient's desired activities

 

Cerebrovascular disease

• Cerebrovascular disease (stroke, CVA, Transient ischaemic attack (TIA)) is also more common in people with diabetes - stroke, for example, is three times more common in those with diabetes. In addition, there is increased mortality after a stroke, and increased levels of disability, in people with diabetes compared to those without.

• The major risk factors for stroke in diabetic patients are similar to those in non-diabetic patients, e.g. lifestyle factors, previous history of stroke or TIA, hypertension, dyslipidaemia, atrial fibrillation, CHD and PVD. Poor diabetic control, and nephropathy, are also associated with an increased risk of stroke.

• Stopping smoking, tight control of blood pressure, use of aspirin, and control of dyslipidaemia have all been demonstrated to directly reduce the risk of cerebrovascular disease in clinical trials. Improvement of glycaemic control has not been found to reduce the risk of cerebrovascular disease, but as it reduces the risk of other diabetic complications, it is worth advising patients regarding this.

• Control of other factors can help to reduce the risk of the development of conditions that contribute towards cerebrovascular disease, e.g. physical activity and dietary factors reduce the risk of hypertension, which is an independent risk factor for stroke. To reduce the risk of developing strokes and TIAs, or of recurrence of cerebrovascular disease once it has occurred, it is therefore worth tackling all of these risk factors.

• Soluble aspirin 75mg daily (no advantages to using enteric coated or modified release aspirin) for all patients who have diabetes and evidence of pre-existing vascular disease (IHD, CVA, TIA, PVD or nephropathy), and for all patients with diabetes plus one other risk factor (hypertension, high lipids, smoking, family history of CHD).

• Warfarin to be considered for people over 60 years old who also have atrial fibrillation

• Statin treatment is effective for both primary and secondary prevention of stroke in the diabetic population, even in patients who are not hyperlipidaemic (see HPS study abstract)

• All patients with a carotid territory stroke or TIA within the last six months should have carotid doppler scanning. Carotid endarterectomy should be considered for those patients who are fit for surgery and have a >70% narrowing of the ipsilateral carotid artery on the scan.

 

Peripheral vascular disease

• Peripheral vascular disease (PVD) is more common in those with diabetes. The risk is increased by age, duration of diabetes, smoking, hypertension, hyperlipidaemia and the presence of peripheral neuropathy. It can lead to the symptoms of intermittent claudication (pain in the calf on walking), or if more severe it can lead to pain in the legs at rest. In addition, it can lead to delayed healing of wounds to the feet/legs or the development of ulcers. Ultimately, it can contribute to amputation.

• It should also be remembered that PVD is a marker for systemic arterial disease, and the patient with PVD is at a much higher risk of coronary heart disease and cerebrovascular disease than the general population.

• PVD is asymptomatic in more than 50% of patients. It is important to detect PVD in patients with diabetes, even if it is asymptomatic, firstly so you can detect a patient at high risk of systemic vascular disease, and secondly, so you can treat symptoms of PVD and reduce the risk of PVD complications.

• The diagnosis of PVD involves a careful history, and foot examination (see "Foot Care" section for details). Management of diabetic patients with asymptomatic PVD picked up on foot examination is as detailed in the "Foot Care" section. Routine referral for further assessment by a vascular surgeon should be done if there is symptomatic PVD, whilst anybody with critical limb ischaemia (tissue loss, gangrene, sudden onset pale, cold, pulseless digit or limb) should be referred immediately as an emergency. It is important to remember to tackle risk factors for all other systemic atherosclerosis as well as manage the foot problem.

• The lifestyle modification and risk factor management measures referred to in the ischaemic heart disease and cerebrovascular disease sections also apply to the prevention and management of peripheral vascular disease

• Soluble aspirin 75mg daily (no advantages to using enteric coated or modified release aspirin) - unless contraindicated.

• Statin treatment is also indicated in this patient group

• Referral to podiatry services - all patients with diabetes and PVD must be referred to podiatry services for on-going review, and for provision of preventative foot ware if appropriate (see "Foot Care" section)

• Referral to vascular surgery if there is symptomatic PVD that is not controlled medically, or if there is any evidence of critical limb ischaemia