Macrovascular complications

Key points

  • Macrovascular complications essentially equates to cardiovascular disease due to atherosclerosis
  • There are 3 main macrovascular complications:
    • Ischaemic Heart Disease (IHD)
    • Stroke
    • Peripheral Arterial Disease (PAD)
  • Cardiovascular disease is the main contributor to morbidity and mortality in diabetes
  • Linked section: Atherosclerotic disease

Definitions: The three types of cardiovascular disease
  • Although atherosclerosis affects all vessels, three main areas are affected:
    •  See separate
  1. CardiacIschaemic heart disease
    1. Angina
    2. Acute coronary syndromes

NB angina/ACS Often present silently due to autonomic neuropathy

  1. BrainCerebrovascular accidents (CVAs). This includes both:
    1. TIAs
    2. Stroke
  1. LegsPeripheral Arterial Disease
    • Claudications
    • Arterial foot ulcers
Pathophysiology
  • Atherosclerosis is accelerated in diabetes
    • Diabetes leads to inflammation around the body through oxidative stress and endothelial dysfunction
    • This inflammation leads to atheroma formation
  • NB atheroma formation particularly affects T2DM patients as it is chiefly driven by the same risk factors that cause insulin resistance
Epidemiology
  • Diabetes is the second biggest risk factor for atherosclerotic vascular disease (after smoking)
    • 3x higher risk of CVD in diabetics vs the normal population
    • 50% of diabetic patients have signs of CVD disease at diagnosis of diabetes
      • Therefore the process occurs early in the disease
    • CVD is the cause of death in 75% of diabetic patients
  • NB atherosclerosis shares risk factors with DMII e.g. HTN, smoking.

 


Preventing macrovascular complications

Preventing macrovascular complications is important to implement at the point where diabetes is diagnosed.

There are 3 main aspects which are:

  1. Managing glycaemic control tightly as it is such a big risk factor

 

  1. Monitoring – Regular screening for CVD is part of diabetes check-ups
    • Check peripheral pulses – for PAD
    • Cardiac auscultation
    • Monitor other risk factors for CVD development in all diabetics
      • BMI
      • Lipid profile – Cholesterol <4
      • BP – aim for <140/90
      • Smoking cessation
  2.  Medication
    1. Statins are given to all diabetics >40or any patients with QRISK >10%
      • Commonly atorvastatin 20mg/40mg
    2. Anticoagulation
      • Aspirin 75mg in patients who have already had a MI
      • Give clopidogrel in those with a stroke
      • Not used as 1º prevention unlike statins
    3. Antihypertensives
      • ACEIs are preferred
      • ARBs are second line
      • Other anti-hypertensives are less used for various reasons
        • B-Blockers mask hypos symptoms
        • Thiazides cause hyperglycaemia and increase polyuria
        • CCBs increase risk of CCF