Downloaded 16 times
Blood sugar- how much low is safe in coronary artery disease- copy
This document discusses the relationship between diabetes, blood sugar control, and cardiovascular disease risk. It reviews observational studies and clinical trials that have examined the effects of intensive glucose control on cardiovascular outcomes. The studies show mixed results, with some finding benefits of tight control for reducing heart attacks and others finding no benefits or even potential harms of very tight control, especially in older patients or those with existing heart disease. The document concludes that an A1C target of less than 7% is generally appropriate for most patients, but that goals need to be individualized based on age, comorbidities, and other factors. Very tight control to A1C levels below 6.5% may not be safe and could potentially increase risks in some high
More Related Content
Similar to Blood sugar- how much low is safe in coronary artery disease- copy
More from https://aiimsbhubaneswar.nic.in/
Blood sugar- how much low is safe in coronary artery disease- copy
- 1. Diabetes &CAD: BloodSugar, How much low is safe. Dr Ramachandra Barik,MD,DNB. Assistant Professor,NIMS.
- 2. ADA-2012 Define DM-II Diabetes mellitus is a state of premature cardiovascular death associated with chronic hyperglycemia and may also be associated with blindness and renal failure. – Miles Fisher.
- 3. 95% of DMpatients are Type 2
- 4. World DM II -21.9 % now and 26.3% by 2030 of total death INDIA Asian Indian Phenotype” - 40-60% of global CVD burden within the next 10-15 years. India, Pakistan and Bangladesh- 3 of the top ten countries in world and together, the highest number of DM DM Type II -related deaths. India - 50.8 million DM , the biggest. x2-4 ↑ risk of CVD. Delhi Diabetes Community (DEDICOM) and DiabCare Asia AusDiab – Sub-optimal Rx-50 % (HbA1c >8%) Aspirin-20% , DM II-(HR 2.6,95%CI:1.4–4.7) Lipid and BP targets- 50%, Severe late-stage complications -55%. IOGTT - (HR 2.5, 95% CI: 1.2–5.1). CVD - 65-75% of deaths in DM II
- 6. The PathoPhysiology. Hyperglycemia and its 2ndary effect. Worsening of atherogenic dyslipidaemia (small LDL, reduced HDL & ↑TG, SNS dysfunction,CKD. Endothelial dysfunction, vasoconstrictive, proinflammatory and prothrombotic processes that contribute to plaque development and rupture. protein kinase C, and the formation of polyols,hexosamine and advanced glycation endproducts. NKF-B & ↑ reactive O2 species- pivotal accelerated CVD . HTN
- 10. DM II Updatesurrounding the relationship between glucose control and the risk of CVD.
- 12. Screen clipping taken:28-Nov-12, 3:36 PM
- 15. Observational Studies 1.Relation betweenglucose & CVD related death Linear ,continuous,“J-shaped” or U shape. 2. In AusDiab Study N=10,000 without DM , reported a continuous ↑ risk for CV mortality with ↑ 2hrs glucose levels after OGTT & increasing HbA1c levels. 3. No association between HbA1c levels < 5.0% and fatal and non-fatal CHD. 4.↑ HbA1c levels were associated with an ↑ HR for CHD events of 1.38 (95% CI:1.22–1.56) when compared with a reference range HbA1c 5.0–5.5%.
- 16. 5. United KingdomProspective Diabetes Study (UKPDS)- a study of subjects with newly DM II shows 1% ↓ HbA1c → 14%(95% CI: 8–21%) decrease in the relative risk MI . 6. UK General Practice Research Database (elderly- 28,000) - “U-shaped” association between HbA1c levels and CV events and lowest at an HbA1c level of approximately 7.5% . These theoretical relationships between glycaemia and CV outcomes have been recently tested in interventional trials of intensive glucose control that have been published over the last two years.
- 17. The United KingdomProspective Diabetes Study (UKPDS) Glucose Interventional Study-10Yrs F/u. N=13867 newly DM II randomised to an intensive glucose control using of SU or insulin and a conventional lifestyle management. Intensively Rx - mean HbA1c of 7.0% compared with conventionally Rx - 7.9%. 1% ↓ HbA1c and a 16% (RR 0.84, 95% CI: 0.71–1.0) ↓ MI compared to conventional Rx which just failed (p = 0.052). No effects of intensive glucose control on any other CVD outcomes. Intensive glucose control reduced the risk of microvascular complications by 25% (95% CI: 7–14, p = 0.01). Non-significant (6%) relative reduction in all-cause mortality associated with intensive glucose control. metformin (N=343) Vs conventional Rx (n = 411) , no significant gap in HbA1c between metformin or placebo , metformins associated with a 39% relative ↓ MI (p = 0.01) and a 36% relative ↓ in all-cause mortality (p = 0.01) without any effect on microvascular complications metformin ↓ CV events that are to some extent independent of glucose control.
- 19. Recent Intensive GlucoseControl Trials As most patients without DM II have an HbA1c level < 6.5%, the question remained after the completion of the UKPDS in 1997 as to whether targeting HbA1c levels close to the non-diabetic range might still result in a significant reduction in CV events. intensive glucose control could reduce the risk of CV outcomes in DM II three large interventional trials published in mid 2008 . Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial , the Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified Release Controlled Evaluation (ADVANCE) and the Veterans Administration Diabetes Trial (VADT) .
- 27. Metaanalysis :Intensive glucoselevel lowering. 1.Only glycemic not enough. 2.Significant ↓ in MI rates with no increase in CV or all-cause mortality despite increased rates of severe hypoglycaemia. 3.↓ microvascular outcomes and that in the setting of newly diagnosed type 2 diabetes→ benefit on CV outcomes. 4.Early strict glycaemic control protects in long run. 5. ADVANCE and VADT :if the correct strategy is used, glucose levels can be safely reduced toHbA1c levels between 6.5% and 7.0%. 6. ACCORD warns detail scanning ,before intensive GLU control for established DM II and at high CV risk, using a combination of multiple- insulin injections and oral agents to rapidly target an HbA1c of <6.5% should be avoided. 7.Younger age and early onset of DM II do tolerate agressive glycemic controls. 8.Metformain has over other hyglycemic agents to ↓ CVD till today in young obese till incretin analogs and DPP-4 inhibitors takes over.
- 28. ADA-2012 Define DM-II Diabetes mellitus is a state of premature cardiovascular death associated with chronic hyperglycemia and may also be associated with blindness and renal failure. – Miles Fisher.
- 29. ARROWING THE TARGET HbA1c levels of <7.0% still remains gold standard 1.In general good GLU control. 2.New Dx DM 3.Young without significant co-morbidities to ↓ microvascular and macrovascular complications. TOO TIGHT FOR AGED AND LONG STANDING DM II IS HARMFUL. Australian Diabetes Society published a position statement on individualisation of HbA1c targets for DM II as below.
- 32. Life’s Simple 7Tips to CV Health.
- 34.
Editor's Notes
- #3 Chart in handout
- #27 intensive glucose control is associated with a reduced risk of MI, without a clear benefit on other CV diseases such as stroke, intensive glucose control is associated with increased rates of severe hypoglycaemia but not increased rates of CV or all-cause mortality. Aiming for HbA1c levels of <7.0% still remains the general target for good glucose control. Under certain circumstances, aiming for lowerHbA1c levels may be appropriate in setting of newly Dx DM in relatively young without significant co-morbidities and in patients treated with agents that minimise the risk of severe hypoglycaemia such as metformin. Whether this also applies to newer glucose lowering agents that target the incretin system will depend on CV outcomes of long-term studies which are in progress.
- #29 Chart in handout