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Global Disparities

Global

Disparities inin Metabolic

Metabolic

Diabetes and

and

Syndrome, Diabetes

Syndrome,

Cardiovascular Disease

Cardiovascular

Disease

Nathan D.

Nathan

D. Wong,

Wong, PhD,

PhD, FACC,

FACC, FAHA

FAHA

Professor Professor and and Director, Director, Heart Heart Disease Disease

Prevention

Prevention Pro

Pro ramram

Division

Division of

of

Global Distribution

Global

Distribution ofof CVDs

CVDs asas

Causes ofof Death,

Causes

Death, WHO

WHO 2011

2011

Distribution Global of of CVDs as as of of Death, Causes WHO 2011

Worldwide Mortality from Ischemic Heart Disease and Cerebrovascular Disease 2011

Worldwide Mortality from Ischemic Heart Disease and Cerebrovascular Disease 2011 Ischemic Heart Disease Cerebrovascular Disease

Ischemic Heart Disease

Cerebrovascular Disease

Development of Atherosclerotic Plaques Fatty streak Normal Lipid-rich plaque Foam cells Fibrous cap Lipid core Thrombus
Development of Atherosclerotic
Plaques
Fatty streak
Normal
Lipid-rich plaque
Foam cells
Fibrous cap
Lipid core
Thrombus

Ross R. Nature. 1993;362:801-809.

Age-Adjusted Coronary

Age-Adjusted

Disease

Disease Rates

Coronary Heart

Heart

Rates byby Country

Country

Age-Adjusted Coronary Age-Adjusted Disease Disease Rates Coronary Heart Heart Rates by by Country Country

Age-Adjusted

Age-Adjusted Death

from Stroke,

from

Death Rates

Rates

Stroke, byby Country

Country

CVD

CVD will

will bebe the

the top

top cause

cause for

for future

future total

total

DALY lost

DALY

lost inin China

China

(Per

(Per 1000

1000 Population)

Population)

Morbidity

Mortality

Approaches toto Primary

Approaches

Secondary Prevention

Secondary

CVD CVD

Primary and

and

Prevention ofof

Primary

Primary prevention

prevention involves

involves prevention

prevention of

of

onset of

onset

of disease

disease inin persons

persons without

without

symptoms.

symptoms.

Primordial

Primordial prevention

prevention involves

involves the

the prevention

prevention

of

of risk

risk factors

factors causative

causative oo the

the disease,

disease,

thereby reducing

thereby

reducing the

the likelihood

likelihood of

of

development of

development

of the

the disease.

disease.

Secondary

Secondary prevention

prevention refers

refers toto the

the prevention

prevention

of

of death

death or

or recurrence

recurrence of

of disease

disease inin those

those

who

who are

are already

already symptomatic

symptomatic

Risk

Risk Factor

Factor Concepts

Concepts inin

Primary Prevention

Primary

Prevention

• Nonmodifiable

Nonmodifiable risk

risk factors

factors include

include age,

age, sex,

sex,

race, and

race,

and family

family history

history of

of CVD,

CVD, which

which can

can

identify

identify high-risk

high-risk populations

populations

• Behavioral

Behavioral risk

risk factors

factors include

include sedentary

sedentary

lifestyle, unhealthful

lifestyle,

unhealthful diet,

diet, heavy

heavy alcohol

alcohol or

or

cigarette consumption.

cigarette

consumption.

• Physiological

Physiological risk

risk factors

factors include

include hypertension,

hypertension,

obesity, lipid

obesity,

lipid problems,

problems, and

and diabetes,

diabetes, which

which

may bebe aa consequence

may

consequence of

of behavioral

behavioral risk

risk

factors.

factors.

Major Risk

Major

Risk Factors

Factors

Cigarette

Cigarette smoking

smoking (passive

(passive smoking?)

smoking?)

Elevated total

Elevated

total or

or LDL-cholesterol

LDL-cholesterol

Hypertension

Hypertension (BP

(BP 140/90

140/90 mmHg

mmHg or

or onon

antihypertensive medication)

antihypertensive

medication)

Low Low HDL HDL cholesterol cholesterol (<40 (<40 mg/dL) mg/dL) ††

Family history

Family

history of

of premature

premature CHD

CHD

CHD

CHD inin male

male first

first degree

degree relative

relative <55

<55

years

years

CHD inin female

CHD

female first

first degree

degree relative

relative <65

<65

years

years

Age (men

Age

(men 4545 years;

years; women

women 5555 years)

years)

HDL cholesterol 60 mg/dL counts as a “negative” risk factor; its presence removes one risk factor from the total count.

Other Recognized

Other

Factors

Recognized Risk

Risk

Factors

Obesity:

Obesity: Body

Body Mass

Mass Index

Index (BMI)

(BMI)

Weight

Weight (kg)/height

(kg)/height (m(m 22 ))

Weight

Weight (lb)/height

(lb)/height (in(in 22 )) xx 703

703

Obesity

Obesity BMI

BMI

>>3030 kg/m

kg/m 22 with

with overweight

overweight

defined

defined asas 25-<30

25-<30 kg/m

kg/m 22

Abdominal

Abdominal obesity

obesity involves

involves waist

waist

circumference

circumference >>4040 in.

in. inin men,

men, >>3535 in.

in. inin

women

women

Physical

Physical inactivity:

inactivity: most

most experts

experts

recommend

recommend at

at least

least 3030 minutes

minutes moderate

moderate

activity

activity at

at least

least 4-5

4-5 days/week

days/week

Cardiovascular Risk Factors are the

Top 6 Leading Causes of Death

Cardiovascular Risk Factors are the Top 6 Leading Causes of Death
Global Global Distribution Distribution of of Diabetes, Diabetes, WHO WHO 2011 2011
Global
Global
Distribution
Distribution
of
of Diabetes,
Diabetes,
WHO
WHO 2011
2011

Risk ofof Cardiovascular

Risk

Cardiovascular Events

Events inin Diabetics

Diabetics

Framingham Study

Framingham

Study

________________________________________________________________

Age-adjusted

Age-adjusted

_

Biennial Rate

Biennial

Rate

Age-adjusted

Age-adjusted

Cardiovascular

Cardiovascular Event

Event

Per 1000

Per

1000

Men Women

Men

Women

Risk Ratio

Risk

Ratio

Men

Men

Women

Women

Coronary Coronary Disease Disease 3939 2121 1.5** 1.5** 2.2*** 2.2***

Stroke Stroke 1515 66 2.9*** 2.9*** 2.6*** 2.6***

Peripheral Peripheral Artery Artery Dis. Dis. 1818 1818 3.4*** 3.4*** 6.4*** 6.4***

Cardiac Cardiac Failure Failure 2323

All All CVD CVD Events Events 7676

2121 4.4*** 4.4*** 7.8*** 7.8***

6565

2.2***

2.2***

3.7***

3.7***

________________________________________________________________

Subjects

Subjects 35-64

35-64

36-year

36-year Follow-up

Follow-up

**P<.001,***P<.0001

**P<.001,***P<.0001

_

Age-adjusted prevalence

Age-adjusted

prevalence of

of physician-diagnosed

physician-diagnosed diabetes

diabetes inin

adults ≥20

adults

≥20 years

years of

of age

age

byby race/ethnicity

race/ethnicity and

and sex

sex (NHANES:

(NHANES: 2005–2008).

20052008).

prevalence Age-adjusted of physician-diagnosed diabetes inin adults ≥20 adults ≥20 years years of of age

Source: NCHS and NHLBI. NH indicates non-Hispanic.

©2010 American Heart Association, Inc. All rights reserved.

Roger VL et al. Published online in Circulation Dec. 15, 2010

Global Prevalence

of Obesity, WHO

2011

Global Prevalence of Obesity, WHO 2011

Age-adjusted prevalence of obesity in adults 20–74 years of age, by sex and survey year (NHES: 1960–62; NHANES: 1971–74, 1976–80, 1988–94, 1999-2002 and 2005-08)

Age-adjusted prevalence of obesity in adults 20–74 years of age, by sex and survey year (NHES:

Data derived from Health, United States, 2010: With Special Feature on Death and Dying. NCHS, 2011.

©2011 American Heart Association, Inc. All rights reserved.

Roger VL et al. Published online in Circulation Dec. 15, 2011

Trends in the prevalence of obesity among US children and adolescents by age and survey year (National Health and Nutrition Examination Survey: 1971-1974, 1976-1980, 1988-1994, 1999- 2002 and 2005–2008)

Trends in the prevalence of obesity among US children and adolescents by age and survey year

Data derived from Health, United States, 2010: With Special Feature on Death and Dying. NCHS, 2011.

©2011 American Heart Association, Inc. All rights reserved.

Roger VL et al. Published online in Circulation Dec. 15, 2011

Causes ofof Mortality

Causes

Patients With

Patients

Mortality inin

With Diabetes

Diabetes

Diabetes and

Diabetes

and CVD

CVD

Atherosclerotic

Atherosclerotic complications

complications responsible

responsible for

for

80%

80% of

of mortality

mortality among

among patients

patients with

with diabetes

diabetes

75%

75% of

of cases

cases due

due toto coronary

coronary artery

artery disease

disease (CAD)

(CAD)

Results

Results inin >75%

>75% of

of all

all hospitalizations

hospitalizations for

for diabetic

diabetic

complications

complications

50% of

50%

of patients

patients with

CAD.

with type

type

22 diabetes

diabetes have

have

may bebe less

preexisting

preexisting

CAD. (This

(This number

number may

less now

now that

that

more younger

more

younger people

people are

are diagnosed

diagnosed with

with diabetes.)

diabetes.)

1/3 of

1/3

of patients

patients presenting

presenting with

with myocardial

myocardial

infarction

infarction have

have undiagnosed

undiagnosed diabetes

diabetes mellitus

mellitus

Lewis GF. Can J Cardiol. 1995;11(suppl C):24C-28C Norhammar A, et.al. Lancet 2002;359;2140-2144

Mechanisms byby which

Mechanisms

which Diabetes

Diabetes

Mellitus

Mellitus

Leads

Leads toto Coronary

Coronary Heart

Heart Disease

Disease

Hyperglycemia

by by which Mechanisms Diabetes Mellitus Mellitus Leads to to Coronary Coronary Heart Heart Disease

Insulin Resistance

Dyslipidemia HTN Endothelial dysfunction  LDL  TG Thrombosis  HDL  PAI-1  TF
Dyslipidemia
HTN
Endothelial
dysfunction
 LDL
 TG
Thrombosis
 HDL
 PAI-1
 TF

tPA

Inflammation

 AGE  IL-6  CRP  SAA
 AGE
 IL-6
 CRP
 SAA

stress

Oxidative

Infection

Defense mechanisms

Pathogen burden

Subclinical Atherosclerosis

by by which Mechanisms Diabetes Mellitus Mellitus Leads to to Coronary Coronary Heart Heart Disease

Disease Progression

by by which Mechanisms Diabetes Mellitus Mellitus Leads to to Coronary Coronary Heart Heart Disease

Atherosclerotic Clinical Events

AGE=Advanced glycation end products, CRP=C-reactive protein, CHD=Coronary heart disease HDL=High-density lipoprotein, HTN=Hypertension, IL-6=Interleukin-6, LDL=Low-density lipoprotein,

PAI-1=Plasminogen activator inhibitor-1, SAA=Serum amyloid A protein, TF=Tissue factor, TG=Triglycerides, tPA=Tissue plasminogen activator Biondi-Zoccai GGL et al. JACC 2003;41:1071-

1077.

Most Cardiovascular

Most

Cardiovascular Patients

Patients Have

Have

Abnormal Glucose

Abnormal

Glucose Metabolism

Metabolism

GAMI

EHS

CHS

n = 164 31% 35% 34%
n = 164
31%
35%
34%
Most Cardiovascular Most Cardiovascular Patients Patients Have Have Abnormal Glucose Abnormal Glucose Metabolism Metabolism GAMI EHS

Normoglyc

n = 1920 18% 37% 45% Prediabet
n = 1920
18%
37%
45%
Prediabet
n = 2263 27% 37% 36%
n = 2263
27%
37%
36%

Type 2

es

Diabetes

emia

GAMI = Glucose Tolerance in Patients with Acute Myocardial Infarction

study; EHS = Euro Heart Survey; CHS = China Heart Survey

Anselmino M, et al. Rev Cardiovasc Med. 2008;9:29-38.

Risk of

Risk

of Cardiovascular

Cardiovascular Events

Events

inin Patients

Patients with

with Diabetes:

Diabetes:

Framingham Study

Framingham

Study

________________________________________________________________

Age-adjusted

_

Age-adjusted

Biennial Rate

Biennial

Rate

Age-adjusted

Age-adjusted

Cardiovascular

Cardiovascular Event

Event

Per 1000

Per

1000

Men Women

Men

Women

Risk Ratio

Risk

Ratio

Men

Men

Women

Women

Coronary Coronary Disease Disease 3939 2121 1.5** 1.5** 2.2*** 2.2***

Stroke Stroke 1515 66 2.9*** 2.9*** 2.6*** 2.6***

Peripheral Peripheral Artery Artery Dis. Dis. 1818 1818 3.4*** 3.4*** 6.4*** 6.4***

Cardiac Cardiac Failure Failure 2323 2121 4.4*** 4.4*** 7.8*** 7.8***

All All CVD CVD Events Events

7676

6565

2.2***

2.2***

3.7***

3.7***

________________________________________________________________

Subjects

Subjects 35-64

35-64

36-year

36-year Follow-up

Follow-up

_

**P<.001,***P<.0001

**P<.001,***P<.0001

Diabetes

Diabetes Across

Across USUS Ethnic

Ethnic

Groups

Groups

From 2007-2009 National Survey Data

prevalence of diabetes:

8.4% of Asian-Americans

7.1% in non-Hispanic whites

11.8% of Hispanics

12.6% of non-Hispanic blacks.

Source: AHA Heart and Stroke Facts 2013

Prevalence estimates

Prevalence

estimates for

for Diabetes

Diabetes and

and Borderline

Borderline

Diabetes Diabetes across across California California racial racial and and ethnic ethnic groups groups (California (California
Diabetes
Diabetes across
across California
California racial
racial and
and ethnic
ethnic groups
groups
(California
(California Health
Health interview
interview Survey
Survey 2009)
2009)
Borderline
Diabetes
Diabetes
Increasing prevalence of diabetes in urban China 健康危害 健康危害——糖尿病患病率持续增长 糖尿病患病率持续增长 Prevalence % Ministry of Health of
Increasing prevalence of diabetes in urban China
健康危害
健康危害——糖尿病患病率持续增长
糖尿病患病率持续增长
Prevalence
%
Ministry of Health of the People’s Republic of China
  • 2008 2008 Diabetes

Diabetes Cases

Cases inin China

China Exceeds

Exceeds

  • 2008 2008 and

and 2016

2016 Projected

Projected Levels

Levels

2008 Diabetes Cases in in China Exceeds 2008 2008 and and 2016 2016 Projected Projected Levels

Sources: Liu et al 2002, Pan et al, US CDC

Changes inin Overweight/Obesity

Changes

  • 2002 2002 inin Adults

Adults inin China

China (Wang

Overweight/Obesity Prevalence

(Wang etet al.,

al., 2007)

2007)

Prevalence 1992-

1992-

Increases Increases inin Overweight/Obesity Overweight/Obesity Prevalence Prevalence inin China China byby Urban/Rural Urban/Rural and and Income
Increases
Increases inin Overweight/Obesity
Overweight/Obesity
Prevalence
Prevalence inin China
China byby Urban/Rural
Urban/Rural and
and
Income
Income Status
Status (Du
(Du etet al.
al. 2002)
2002)

Metabolic

Metabolic Syndrome:

Syndrome: Clustering

Metabolic Risk

Risk

Clustering ofof

Interconnected Metabolic

Interconnected

Factors

Factors

Obesity
Obesity

Insulin

Resistance

+ Hyperglycemia

Hypertension

Atherogenic

Dyslipidemia

2009 IDF/IAS/NHLBI/AHA/WHF Joint Scientific

Statement on Diagnosis of Metabolic Syndrome

(Alberti et al. Circulation 2009) (>=3 criteria required for

diagnosis)
diagnosis)
Alberti et al. Circulation 2009

Alberti et al. Circulation 2009

Intra-abdominal (Visceral)

Intra-abdominal

The dangerous

The

dangerous inner

inner fat!

(Visceral) Fat

fat!

Fat

Front

Visceral AT Subcutaneous AT
Visceral AT
Subcutaneous AT

Back

Abdominal Adiposity

Abdominal

Adiposity IsIs Associated

Associated

With Increased

With

Increased Risk

Risk of

of Diabetes

Diabetes

P value for trend <0.001 Relative Risk of Diabetes
P value for trend <0.001
Relative Risk of Diabetes

Waist Circumference (in)

Carey VJ, et al. Am J Epidemiol. 1997;145:614-619

Metabolic Metabolic Syndrome Syndrome and and Diabetes Diabetes inin Relation Relation toto CHD, CHD, CVD, CVD,
Metabolic
Metabolic Syndrome
Syndrome and
and Diabetes
Diabetes inin
Relation
Relation toto CHD,
CHD, CVD,
CVD, and
and Total
Total Mortality:
Mortality:
(Risk-factor Adjusted Cox Regression) NHANES II
U.S.
U.S. Men
Men and
and Women
Women Ages
Ages 30-74
30-74
Follow-up (n=6255)
***
***
***
***
***
***
***
***
*
**
***
***

Malik and Wong, et al., Circulation 2004.

* p<.05, ** p<.01, **** p<.0001 compared to none

Metabolic Syndrome

Risk: Meta-Analysis:

Risk:

Meta-Analysis:

inin etet 8383 al. al.

JACC

Metabolic

Syndrome and

and CVD

CVD

951,083 951,083 Mottillo Mottillo pts pts

JACC 2010

2010

studies

studies

Little Little variation variation inin risk risk between between definitions definitions

Relative

Relative risk:

risk:

2.35

2.35 (2.20-2.73)

(2.20-2.73) for

for CVD

CVD events

events

2.40

2.40 (1.87-3.08)

(1.87-3.08) for

for CVD

CVD mortality

mortality

1.58 (1.39-1.78)

1.58

(1.39-1.78) for

for all-cause

all-cause mortality

mortality

1.99 (1.61-2.46)

1.99

(1.61-2.46) for

for myocardial

myocardial infarction

infarction

2.27 (1.80-2.85)

2.27

(1.80-2.85) for

for stroke

stroke

Those with

Those

with metabolic

metabolic syndrome,

syndrome, without

without diabetes,

diabetes,

maintained high

maintained

high CVD

CVD risk

risk (RR=1.75,

(RR=1.75, 95%

95%

CI=1.19-2.58)

CI=1.19-2.58)

Metabolic

Metabolic Syndrome

(by NCEP

(by

Syndrome Trends

Trends

NCEP Definition)

City Diabetes

Definition) inin Mexico:

Mexico:

Diabetes Study

Study

Mexico City

Mexico

Metabolic Metabolic Syndrome (by NCEP (by Syndrome Trends Trends NCEP Definition) City Diabetes Definition) in in

Lorenzo C, Haffner SM et al., Diabetes Care 2005

Prevalence ofof MetS

Prevalence

MetS inin Middle

Middle

Eastern Populations

Eastern

Populations

of of MetS Prevalence in in Middle Eastern Populations Eastern Populations Sliem HA et al.

Sliem HA et al. Indian J Endocrinol Metab 2012; 16:

Significant Prevalence

Middle

Middle East:

East: BMI

Significant

Prevalence ofof Obesity

BMI >=30

>=30

Obesity inin

Oman Oman 30.8% 30.8%

Qatar Qatar 40.8% 40.8%

Gaza/West Gaza/West Bank Bank 41.5% 41.5%

Egypt Egypt 30.2%

30.2% of

of men

men and

and 70.9%

70.9% of

of women

women

based onon IDF

based

IDF European

European cutpoints

cutpoints (80cm

(80cm

women and

women

and 9494 cmcm men),

men), but

but 31.7%

31.7% of

of men

men and

and

50.8% of

50.8%

of women

women based

based onon new

new Egyptian

Egyptian waist

waist

circumference

circumference cutpoints

cutpoints (97.5

(97.5 cmcm men

men and

and 92.3

92.3

cmcm women)

women)

Metabolic

Metabolic syndrome

syndrome present

present inin 26%

26% of

of obese

obese

children inin Lebanon

children

Lebanon

Sliem HA et al. Indian J Endocrinol Metab

Lifestyle

Lifestyle Issues

Obesity

Obesity and

Issues Contribute

Contribute toto

and MetS

MetS inin Saudi

Saudi Arabia

Arabia

Lifestyle Lifestyle Issues Obesity Obesity and Contribute to to MetS in in Saudi Arabia
Lifestyle Lifestyle Issues Obesity Obesity and Contribute to to MetS in in Saudi Arabia

Recent Diabetes

Recent

Diabetes and

and

Metabolic

Metabolic Syndrome

Syndrome

Benin Benin 3%3%

Prevalence inin Africa

Prevalence

Mauritania Mauritania 6%6%

Africa

Cameroon

Cameroon 6%6%

Congo

Congo 7%7%

Zimbabwe

Zimbabwe 10%

10%

Democratic

Democratic Republic

Republic of

of Congo

Congo 14.5%

14.5%

Nigeria

Nigeria 2%;

2%; Metabolic

Metabolic syndrome

syndrome

(hypertensive (hypertensive Nigerians) Nigerians) 34% 34% (ATP (ATP III), III), 35% 35%

(WHO), (WHO), 43% 43% (IDF) (IDF)

Prevalence ofof Metabolic

Prevalence

Metabolic

Syndrome inin Africa

Syndrome

Africa

depends greatly

greatly onon the

Prevalence

Prevalence depends

the population

population setting;

setting;

increase attributed

increase

attributed toto the

the Western

Western lifestyle

lifestyle from

from reduced

reduced

physical activity

physical

activity and

and substitution

substitution of

of the

the traditional

traditional

African

African diet

diet (rich

(rich inin fruits

fruits and

and vegetables)

vegetables) toto energy-

energy-

laden foods

laden

foods

More

More common

common inin females,

females, with

with increasing

increasing age,

age, and

and

urban setting;

urban

setting; some

some exceptions

exceptions such

such asas lower

lower

prevalence

prevalence among

among women

women inin Jos

Jos plateau

plateau of

of Nigeria

Nigeria who

who

are more

are

more active

active whereas

whereas inin Sokota

Sokota region

region the

the religious

religious

practice of

practice

of women

women inin Purdah

Purdah makes

makes them

them sedentary.

sedentary.

Purdah Purdah isis the the traditional traditional Islamic Islamic practice practice that that confines confines women
Purdah
Purdah isis the
the traditional
traditional Islamic
Islamic practice
practice that
that confines
confines
women
women toto the
the home
home oror compound
compound and
and soso limits
limits their
their
participation
participation inin society.
society. Women
Women living
living inin purdah
purdah are
are not
not
allowed
allowed toto come
come out
out ofof their
their homesteads.
homesteads.

Prevalence ofof Metabolic

Prevalence

South Asians

South

Metabolic Syndrome

(Pandit etet al.,

al., 2012)

2012)

Syndrome inin

Asians (Pandit

Several

Several large

large surveys

surveys of

of large

large citys

citys inin different

different

parts of

parts

of India

India suggest

suggest about

about one-third

one-third of

of the

the urban

urban

population has

population

has MetS.

MetS.

Key risk

Key

risk factors

factors are

are highly

highly prevalent

prevalent inin Asian

Asian

Indians: 31%

Indians:

31% abdominal

abdominal obesity,

obesity, 46%

46%

hypertriglyceridemia, 66%

hypertriglyceridemia,

66% lowlow HDL,

HDL, 55%

55% HTN,

HTN, 27%

27%

elevated fasting

elevated

fasting glucose

glucose

Study

Study inin urban

urban Karachi,

Karachi, Pakistan

Pakistan showed

showed high

high

prevalence of

prevalence

of 35%

35% byby IDF

IDF and

and 49%

49% byby ATP

ATP III

III

obesity inin urban

obesity

urban Pakistan

Pakistan ranges

ranges from

from 46-68%,

46-68%,

hypertriglycerdemia 27-54%,

hypertriglycerdemia

27-54%, and

and 68-81%

68-81% lowlow HDL.

HDL.

Prevalence ofof MetS

Prevalence

MetS inin Asian

Asian

Indians,

Indians, Malays

Malays and

and Chinese

Chinese

of of MetS Prevalence in in Asian Indians, Indians, Malays Malays and and Chinese Chinese

From Pandit K et al., Indian J Endocrinol Metab

2012

Risk

Risk Factors

Factors Greater

Greater inin Asians

Asians

than inin Caucasians

than

Caucasians

(Williams,

(Williams, 1995)

1995)

Sedentary lifestyle

Sedentary

lifestyle

Truncal

Truncal obesity

obesity

Hyperinsulinemia

Hyperinsulinemia and

and insulin

insulin resistance

resistance

Diabetes

Diabetes mellitus

mellitus

Elevated

Elevated triglycerides

triglycerides

Low HDL-C

Low

HDL-C

Type 22 Diabetes

Type

  • 7- 7-Year

Year Incidence

Diabetes and

Incidence of

of

and CHD

CHD

Fatal/Nonfatal Fatal/Nonfatal MI MI (East (East West West Study) Study) P<0.001 P<0.001 45.0% 20.2% 18.8% 3.5%
Fatal/Nonfatal
Fatal/Nonfatal MI
MI
(East
(East West
West Study)
Study)
P<0.001
P<0.001
45.0%
20.2%
18.8%
3.5%
7-Year Incidence Rate of
MI

No

Diabetes

Diabetes

CHD=coronary heart disease; MI=myocardial infarction; DM=diabetes mellitus

Haffner SM et al. N Engl J Med. 1998;339:229-234.

Is DM really a CHD Risk Equivalent?

Meta-Analysis of 38,578

subjects (Bulugahapitiya et al. Diabetic Med 2008)

Is DM really a CHD Risk Equivalent? Meta-Analysis of 38,578 subjects (Bulugahapitiya et al. Diabetic Med
Global Global Risk Risk Assessment Assessment inin DM: DM: 10-year 10-year Total Total CVD CVD Risk
Global
Global Risk
Risk Assessment
Assessment inin DM:
DM:
10-year
10-year Total
Total CVD
CVD Risk
Risk byby Gender
Gender
(Wong
(Wong NDND etet al.,
al., Diab
Diab Vas
Vas Dis
Dis Res
Res 2012)
2012)

Annual CHD

Annual

CHD Event

Event Rates

Rates (in(in %)

Subjects with

al., Diabetes

%) byby Calcium

DM, MetS,

Calcium Score

Score Events

Events byby

CAC Categories

CAC

(Malik

(Malik and

Categories inin Subjects

and Wong

Wong etet al.,

with DM,

MetS, oror Neither

2011)

Neither Disease

Disease

Diabetes Care

Care 2011)

Coronary Heart Disease

Coronary Artery Calcium Score

ACCF/AHA

ACCF/AHA 2010

2010 Guideline:

Guideline:

CAC Scoring

CAC

Scoring for

for CVCV risk

risk

assessment inin asymptomatic

assessment

asymptomatic adults

adults aged

aged 4040 and

and over

over with

with

diabetes (Class

diabetes

(Class IIa-B)

IIa-B)

Summary of

Summary

ABC's for

ABC's

of Care:

Care:

for Providers

Providers

A

A1c Target

Aspirin Daily

B

Blood Pressure Control

C

Cholesterol Management

Cigarette Smoking Cessation

D

Diabetes and Pre-Diabetes

Management

E

Exercise

F

Food Choices

Control of DM Risk Factors in a Large Multipayer

Outpatient Population in Northern California

(n=15,826)

(Holland et al., J Diab Complic 2013)

Individual control of HbA1c, BP, and LDL

ranged from 42-78% in Asians

Composite control of HbA1c, BP, and LDL

ranged from 21-27% in Asians

Diabetes Mellitus:

Diabetes

Mellitus:

Effect Effect of of Aspirin Aspirin p<0.002 p=NS p < 0.001 p=.04 p<0.05 p=NS p=NS n=
Effect
Effect of
of Aspirin
Aspirin
p<0.002
p=NS
p < 0.001
p=.04
p<0.05
p=NS
p=NS
n=
533
3711
4502
2368
1031
1276
2539
Endpoint
7yr MCE
183 vs 133
5 yr MI
4 yr MCE
20 vs 22
7 yr MI
# Events
117 vs 116
1 yr MCE
26 vs 11
86 vs 68
5 yr CV Death
4 yr MCE
283 vs 241
502 vs 415
NS=Not Significan
1. Steering Committee of the Physicians'
4. Harpaz D et al.
Am J Med
Health Study Research Group. NEJM
1998;105:494

1989;321:129-35

  • 2. ETDRS Investigators. JAMA 1992;268:1292

  • 3. Antiplatelet Trialists' Collaboration. BMJ

3.

4.

Sacco M et al. Diabetes Care

2003;26:3264

Belch J et al. BMJ 2008; 337:a1840

Variation in Aspirin Use by Ethnicity: MESA

Study (Sanchez DR, Am J Cardiol 2011)

1)Regular use of aspirin (>=3X per week) examined in

6,452 White, Black, Hispanic, and Chinese patients

without CVD.

2)In 2002, prevalence of aspirin use in those at

increased (6-<10%) risk was greatest in whites (41%)

followed by Blacks (27%), Hispanics (24%), or

Chinese (15%) (p<0.001).

3)Among high risk subjects (>=10%), corresponding

prevalences were 53%, 43%, 38%, and 28%.

4)Important racial/ethnic disparities exist for unclear

reasons.

Recommendations:

Recommendations:

Antiplatelet

Antiplatelet Agents

Agents (1)

(1)

Consider

Consider aspirin

aspirin therapy

therapy (75–162

(75–162 mg/day)

mg/day) (C)

(C)

AsAs aa primary

primary prevention

prevention strategy

strategy inin those

those with

with type

type 11 or

or type

type 22 diabetes

diabetes at

at

increased cardiovascular

increased

cardiovascular risk

risk (10-year

(10-year risk

risk >10%)

>10%)

Includes

Includes most

most men

men >50

>50 years

years of

of age

age or

or women

women >60

>60 years

years of

of age

age who

who have

have

at least

at

least one

one additional

additional major

major risk

risk factor

factor

Family

Family history

history of

of CVD

CVD

Hypertension

Hypertension

Smoking

Smoking

Dyslipidemia

Dyslipidemia

Albuminuria

Albuminuria

Recommendations: Recommendations: Antiplatelet Antiplatelet Agents Agents (1) (1) • Consider Consider aspirin aspirin therapy therapy (75–162

ADA. VI. Prevention, Management of Complications. Diabetes Care 2013;36(suppl

1):S32-S33.

Recommendations:

Recommendations:

Antiplatelet

Antiplatelet Agents

Agents (2)

(2)

Aspirin

Aspirin should

should not

not bebe recommended

recommended for

for CVD

CVD prevention

prevention for

for

adults with

adults

with diabetes

diabetes at

at lowlow CVD

CVD risk,

risk, since

since potential

potential

adverse effects

adverse

effects from

from bleeding

bleeding likely

likely offset

offset potential

potential benefits

benefits

(C)

(C)

10-year CVD

10-year

CVD risk

risk <5%:

<5%: men

men <50

<50 and

and women

women <60

<60 years

years of

of age

age with

with

nono major

major additional

additional CVD

CVD risk

risk factors

factors

InIn patients

patients inin these

these age

age groups

groups with

with multiple

multiple other

other risk

risk

factors (10-year

factors

(10-year risk

risk

5510%),

10%), clinical

clinical judgment

judgment isis required

required (E)

(E)

Recommendations: Recommendations: Antiplatelet Antiplatelet Agents Agents (2) (2) • Aspirin should not be be recommended for

ADA. VI. Prevention, Management of Complications. Diabetes Care 2013;36(suppl

1):S33.

Recommendations:

Recommendations:

Antiplatelet

Antiplatelet Agents

Agents (3)

(3)

Use aspirin

Use

aspirin therapy

therapy (75–162

(75–162 mg/day)

mg/day)

Secondary

Secondary prevention

prevention strategy

strategy inin those

those with

with diabetes

diabetes with

with aa

history of

history

of CVD

CVD (A)

(A)

For patients

For

patients with

with CVD

CVD and

and documented

documented aspirin

aspirin allergy

allergy

Clopidogrel

Clopidogrel (75

(75 mg/day)

mg/day) should

should bebe used

used (B)

(B)

Combination

Combination therapy

therapy with

with aspirin

aspirin (75–162

(75–162 mg/day)

mg/day) and

and clopidogrel

clopidogrel

(75 mg/day)

(75

mg/day)

Reasonable

Reasonable for

for upup toto aa year

year after

after anan acute

acute coronary

coronary syndrome

syndrome

(B)

(B)

Recommendations: Recommendations: Antiplatelet Antiplatelet Agents Agents (3) (3) • • Use aspirin Use aspirin therapy therapy

ADA. VI. Prevention, Management of Complications. Diabetes Care 2013;36(suppl

1):S33-S34.

CV death, MI, or stroke (%)

mortality (%)

All-cause

Diabetes Mellitus

Diabetes

Mellitus (Type

(Type II):

II):

Effect ofof Intensive

Effect

Intensive Glycemic

Glycemic Control

Control

Action to Control Cardiovascular Risk in Diabetes (ACCORD) Trial

10,251 diabetic patients randomized to intensive glucose lowering (HbA 1C <6%) or standard glucose lowering (HbA 1C 7.0-7.9%) for 3.5 years

P=0.16

9

6

3

0

CV death, MI, or stroke (%) mortality (%) All-cause Diabetes Mellitus Diabetes Mellitus (Type (Type II):

7.2

6.9

Standard

Intensive

Therapy

Glucose

Lowering

9

6

3

0

P=0.04
P=0.04
P=0.04 4.0 5.0
4.0 5.0
4.0
5.0
P=0.04 4.0 5.0

Standard

Intensive

Therapy

Glucose

Lowering

Intensive glucose lowering does not reduce adverse CV events and increases all- cause mortality

CV=Cardiovascular, HbA 1C =Glycated hemoglobin, MI=Myocardial infarction

ACCORD Study Group. NEJM 2008;358;2545-59

American Diabetes

American

Diabetes Association

Association

  • 2012 2012 Standards

Standards ofof Medical

Medical Care:

Care:

HbA1c Goals

HbA1c

Goals