Assist. lect. dr.

Ariel Florentiu
 MACROVASCULAR COMPLICATIONS
Diabetic
MICROVASCULAR COMPLICATIONS

Stroke
retinopathy Two- to four-fold
Leading cause increase in CV
of blindness mortality and
in adults1 stroke2

Diabetic
nephropathy Cardiovascular
Leading cause of disease
endstage renal 65%of individuals
disease2 with diabetes die
from CV events2
Diabetic
neuropathy Peripheral
Leading cause
of non- arterial Disease
traumatic Prevalence of 29% in
lower extremity diabetic people
amputations2 > 50 years3

Most complications arise from damage to small blood vessels and narrowing of
large arteries (atherosclerosis) associated with chronic hyperglycaemia.
Tight control of glycaemia may prevent these complications.
The concept of risk
Risk: the probability a (healthy) person will be afected
by a certain condition over a period of time (short-
term<10 yrs, long-term>10 yrs)
Absolute risk
Relative risk: expressed as a ratio of the persons absolute
risk to a certain baseline/comparator
Residual risk: the persistent risk after maximal
treatment of modifiable risk factors
Cardiovascular risk factors
Characteristics (variables) present in the healthy
population that are independently and non-randomly
associated with the risk of developing cardiovascular
disease
Examples
Anthropometric determinations (e.g. weight, waist
circumference)
Diseases (e.g. arterial hypertension, diabetes)
Life style factors (e.g. smoking)
Genetic or environmental
The purpose of indentifying risk factors is to modify them
in order to prevent disease
Modifiable risk factors
Diabetes mellitus/prediabetes
Insulin resistance
Arterial hypertension
Hyperlipidemia
Obesity
Smoking
Sedentary lifestyle
Nutritional factors
Non-modifiable risk factors
Age
Male sex
Family history of premature cardiovascular disease
(genetic background)
Diabetes duration
Novel cardiovascular risk factors
Abdominal obesity
Microalbuminuria
Reduced renal function (glomerular filtration rate)
Endothelial dysfunction
Biomarkers of chronic low-grade inflamation and
plasmatic viscosity (e.g. hsCRP)
Identification of risk factors and risk
estimation
History taking (including family history, hystory of
smoking, duration of diabetes)
Physical examination (including BMI, waist
circumference, BP)
Biochemistry: blood lipids, HbA1c, serum creatinine
(eGFR), albuminuria
Absolute risk estimation using risk scores/engines
Framingham risk score
American population
Takes into account 6 risk factors: sex, age, smoking, total
and HDL-cholesterol, SBP
Estimates the absolute 10-yrs risk of coronary death and
non-fatal MI
Risk:
low(<10%);
moderate (10-20%);
high(>20%)
 Years Points
20-34 -7
35-39 -3
40-44 0
45-49 3
50-54 6
55-59 8
60-64 10
65-69 12
70-74 14
75-79 16
Step 2: Total Cholesterol

15
SCORE risk diagrams
European population, low and high-risk diagrams
(high-risk for Romania)
5 risk factors: sex, age, smoking, total cholesterol,
SBP
Estimates the absolute 10-yrs risk of CV death
Risk:
low(<1%);
moderate (1-5%);
high (>5%)
SCORE diagram
UKPDS risk engine
Type 2 diabetes specific
10 risk factors
Estimates the absolute 10-yrs risk of coronary and
cerebrovascular morbidity and mortality
Risk:
low (<15%),
moderate (15-30%)
high (30%)
UKPDS risk engine
Therapeutic means for preventing
macrovascular disease in diabetes
Lowering LDL-C with statin treatment (primary prevention
in all diabetic patients >40 yrs)
Lowering BP to <140/90 mmHg (using ACEi or ARBs as
first line agents)
Stoping smoking
Lowering HbA1c<7% (in most patients)
Other desirable lipid targets (HDL-C>40 mg/dl in men and
>50 mg/dl in women, TG<150 mg/dl)
Aspirin/clopidogrel for primary prevention (if 10-yrs risk
>10%)
Introduction
2-3 fold increase in diabetic patients compared to
the general population
First cause of death in diabetes (65%);
2-4 fold increase in mortality rate of established
CV disease in diabetes as compared to general
population
The relative increase in risk from diabetes is
greater in premenopausal women than in men
Atherosclerotic lesions histology in diabetes is
identical to non-diabetic patients. The lesions
often appear at an earlier age, progress more
quickly and are more diffuse
Coronary heart disease
Manifests at a younger age (7-10 yrs earlier)
Lesions are often diffuse (proximal and distal) with
involvement of all coronary arteries, with more
calcification and poorer collateral circulation
Frequent silent ischemia or atypical angina (in patients
with long-standing diabetes complicated by autonomic
neuropathy)
Acute coronary syndromes
More frequent
Sometimes with atypical or no pain
At the same extension of infarction diabetic patients
have an increased mortality (secondary to acute HF
and rhythm disturbances)
30% of patients presenting with an ACS have diabetes.
Antecedent MI is an indication for diabetes screening
 What about RCA?

66 yr, , inferolateral STEMI

D1 culprit?...or LAD or OM
Peripheral arterial disease
2 fold increase in risk in diabetic patients
Typical lesions are diffuse, situated below the knee
on the medium calibre arteries (calf trunks).
Diabetes does not cause obligatory diffuse disease
of the small vessels
Sometimes with no intermitent claudication (in
diabetic patients that also have peripheral
polineuropathy)
Diabetes is the leading cause of non-traumatic
lower-limb amputation
Cerebrovascular disease
Strokes are 2-4 times more frequent in diabetic
patients and have a higher mortality
The frequency increases with age and diabetes
duration
Cardiovascular disease
management
Risk factor control as in primary prevention, but often
more aggressive
Other specific medical treatments
Antiplatelet treatment for secondary prevention
Beta-blockers at least 2 yrs post-MI

Specific cardiologic and surgical therapeutic

procedures (e.g. revascularisation)
Thank you!