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SYMPOSIUM

DIABETES AND CARDIOVASCUL AR


DISEASES: THE CONTINUUM.
HOW TO PREVENT ?
Badai Bhatara Tisknadi, MD, FIHA

Departemen Kardiologi dan Kedokteran Vaskular


Fakultas Kedokteran Universitas Padjadjaran /
RSUP Dr. Hasan Sadikin Bandung
Introduction

Diabetes…..the CVD equivalent

“From the point of view of


cardiovascular disease it is
appropriate to say, Diabetes is a
cardiovascular disease”

- AHA Scientific Statement Diabetes and Cardiovascular disease


Circulation 1999;100:1134-1146
Introduction

• Penyebab terbanyak kematian (1/2 –


2/3) adalah Kardiovaskular
• Risiko menderita PAK 2-4x lebih besar vs
non diabetes
• Risiko mengalami gagal jantung 5x lebih
tinggi vs non diabetes
• Penderita diabetes semakin bertambah
Introduction

Cardiovascular
disease

Cardiometabolic
Outline
• 1. Definition cardiometabolic and diabetes
• 2. Diabetes continuum
• 3. Etiopathogenesis related to cardiovascular disease
• 4. Diabetes prevention
• 5. Cardiovascular continuum and prevention
• 6. Take home message
Definition cardiometabolic risk
A condition in which the possibilities of developing atherosclerotic
cardiovascular (CV) disease and diabetes mellitus are significantly
enhanced as a consequence of the presence of insulin
resistance and atherogenic dyslipidemia
Sindrom Metabolik (SM)

Suatu klaster dari faktor-faktor risiko penyakit aterosklerosis yang


paling berbahaya, yaitu : diabetes / peningkatan kadar glukosa puasa,
obesitas abdominal, kadar kolestrol tinggi dan hipertensi1

Diestimasikan 20-25% dari seluruh penduduk dunia mengalami


Sindroma metabolik2

1IDFEpidemiology Task Force Consensus Group


2The IDF consensus worldwide definition of the Metabolic Syndrome
Kriteria Sindrom Metabolik (SM)

Karakteristik: obesitas sentral (perempuan > 80cm; laki-laki > 90cm)


ditambah minimal dua dari empat kriteria berikut :
• Trigliserida > 150mg/dl
• HDL < 40mg/dl (perempuan) atau < 50 mg/dl (laki-laki)
• Tekanan darah sistolik > 130 dan diastolik > 85
• Kadar gula darah puasa > 100 mg/dl

The IDF consensus worldwide definition of the Metabolic Syndrome


Diabetes melitus

Diabetes Mellitus is a metabolic disorder, characterized by chronic


hyperglycemia associated with disturbances of carbohydrate, fat and
protein metabolism due to absolute or relative deficiency in Insulin
secretion and/or action
Outline
• 1. Definition cardiometabolic and diabetes
• 2. Diabetes continuum
• 3. Etiopathogenesis related to cardiovascular disease
• 4. Diabetes prevention
• 5. Cardiovascular continuum and prevention
• 6. Take home message
Diabetes
continuum
Development of Type 2 Diabetes
Outline
• 1. Definition cardiometabolic and diabetes
• 2. Diabetes continuum
• 3. Etiopathogenesis related to cardiovascular disease
• 4. Diabetes prevention
• 5. Cardiovascular continuum and prevention
• 6. Take home message
Etiologi Sindrom Metabolik
(SM)
• Perkembangan sindrom metabolik berasal dari dua hal; penambahan
berat badan dan akumulasi lemak ektopik di viseral  asupan kalori
yang tinggi dan inaktifitas fisik
• Variasi individu dan ada faktor epigenetik terhadap komponen
tersebut (komposisi lemak, dislipidemia dan resistensi insulin)

Bouchard C. Genetics and the metabolic syndrome. Int J Obes 1995


Patofisiologi
Sindrom
Metabolik
(SM)

Eckel. The metabolic syndrome.


Lancet. 2005
Patofisiologi
Sindrom
Metabolik
(SM)

Eckel. The metabolic syndrome.


Lancet. 2005
Patofisiologi Sindrom Metabolik (SM)
Advanced Glycation Endproducts
Outline
• 1. Definition cardiometabolic and diabetes
• 2. Diabetes continuum
• 3. Etiopathogenesis related to cardiovascular disease
• 4. Diabetes prevention
• 5. Cardiovascular continuum and prevention
• 6. Take home message
Prevensi diabetes
• Target utama adalah dilakukan pada pasien yang berisiko
yaitu :
• Pasien prediabetes
• Kelebihan berat badan ditambah 1 faktor risiko
• Obesitas

• Prevensi diabetes
• Penurunan berat badan / weight loss
• Latihan / Exercise
• Medikasi
Pengaruh weight loss terhadap
Intra abdominal (Viseral) Fat ?
Medikasi

• Penelitian multisenter (27, USA)


• RCT: Weight loss vs Metformin
• Outcome : Onset DM tipe 2
• Populasi pre diabetes
DPP

Lifestyle
Drug Placebo
intervention

Exercise Weight loss Metformin


150mnt/wk 7% 2x850 mg

58% >60 yrs 31%


25 – 44 yrs old
BMI > 35
Outline
• 1. Definition cardiometabolic and diabetes
• 2. Diabetes continuum
• 3. Etiopathogenesis related to cardiovascular disease
• 4. Diabetes prevention
• 5. Cardiovascular continuum and prevention
• 6. Take home message
The Cardiovascular Disease Continuum Validated:
Clinical Evidence of Improved Patient Outcomes

by Victor J. Dzau, Elliott M. Antman, Henry R. Black, David L. Hayes, JoAnn E. Manson, Jorge Plutzky,
Jeffrey J. Popma, and William Stevenson

Circulation
Volume 114(25):2850-2870
December 19, 2006
Figure 1. The cardiovascular disease continuum.

Victor J. Dzau et al. Circulation. 2006;114:2850-2870

Copyright © American Heart Association, Inc. All rights reserved.


Figure 2. Cardiovascular and renal pathophysiological continuum.

Victor J. Dzau et al. Circulation. 2006;114:2850-2870

Copyright © American Heart Association, Inc. All rights reserved.


Integrated model of tissue
angiotensin and vascular
pathobiology.

Victor J. Dzau et al. Circulation.


2006;114:2850-2870
Vascular aging continuum

menekankan pada
pengerasan dan penuaan
pembuluh darah, serta
abnormalitas mikrosirkulasi
Outline
• 1. Definition cardiometabolic and diabetes
• 2. Diabetes continuum
• 3. Etiopathogenesis related to cardiovascular disease
• 4. Diabetes prevention
• 5. Cardiovascular continuum and prevention
• 6. Take home message
Take home message
• Diabetes dengan dasar patofisiologi resistensi insulin menyebabkan
efek metabolik, dan sangat erat berkaitan dan berpotensi sangat
tinggi menjadi penyakit kardiovaskular
• Usaha preventif terhadap diabetes dan penyakit kardiovaskular harus
dilakukan sedini mungkin, dari sejak tahap prediabetes
• Terapi gaya hidup; latihan fisik rutin, nutrisi seimbang dan penurunan
berat badan menjadi conner stone dari usaha prevensi diabetes dan
penyakit kardiovaskular di kemudian hari