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Year 2 - endocrinology > Macrovascular complications > Flashcards

Macrovascular complications Flashcards

1
Q

Who gets macrovascular disease?

A

Occurs in people with and without diabetes. Only thing varying is the extent to which it occurs and how early.

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2
Q

What is macrovascular disease? (examples)

A

Macrovascular Disease is a systemic disease and is commonly present in multiple arterial beds.

  • Early widespread atherosclerosis
  • Ischaemic heart disease (e.g. myocardial infarction)
  • Cerebrovascular disease (e.g. stroke)
  • Renal artery stenosis (causes hypertension and renal failure)
  • Peripheral vascular disease
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3
Q

What is the sequence of endothelial dysfunction?

A
  • initial lesion (macrophages and foam cells)
  • fatty streak (intracellular lipid accumulates)
  • intermediate lesions (+extracellular lipid)
  • atheroma (core of extracellular lipid)
  • fibroatheroma (fibrotic/calcific layers)
  • complicated lesions which can thrombose/haemorrhage
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4
Q

What factors are associated with arterial damage?

A
  • hyperglycemia
  • hypertension
  • low HDL
  • High waist circumference
  • Insulin resistance
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5
Q

What are the initial stages of arterial damage associated with?

A

insulin resistance, lipid accumulation and blood pressure

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6
Q

What is smooth muscle hypertrophy in vessels associated with?
In which cases is thrombosis most likely to occur?

A

Insulin resistance, and is a feature of atheroma. Lesions then develop collagen, and can go on to thrombose on top of the lesion, and block the vessel. Thrombosis is more likely to occur in insulin resistant patients.

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7
Q

What is the relationship between hyperglycaemia and life expectancy?

A
  • Hyperglycaemia is associated with significantly reduced life expectancy
  • Diabetics are expected to die earlier when age of diagnosis is earlier
  • This is related to the length for which someone has had diabetes
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8
Q

Relationship between insulin resistance and MI/life expectancy

A

If insulin levels are low (the patient is insulin sensitive), they are likely to live longer. Subjects with insulin resistance have a significantly increased chance of heart attack (age and sex adjusted).

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9
Q

Is diabetes a progressive disease?

A

YES

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10
Q

What is the difference between microvascular and macrovascular disease in terms of morbidity and mortality?

A

Microvascular disease causes morbidity; macrovascular disease causes morbidity and mortality.

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11
Q

In diabetic patients, how many die from MI, how many have strokes and malignancy?

A
  • 60% from myocardial infarction
  • 25% for stroke (but they are having strokes younger than the general population)
  • Malignancy is reduced as they aren’t living long enough to develop cancer
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12
Q

Why is ischaemic heart disease treated strictly in diabetics?

A

People with diabetes have the same risk of MI and death as those people who have previously had an MI

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13
Q

What is the effect of ethnicity on diabetes?

A
  • In White Caucasians, the coronary heart disease risk was predicted well by Framingham data
  • In South Asians, the Framingham data underestimated risk
    Framingham risk score
  • South Asians have a worse mortality for coronary heart disease than white Caucasians.
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14
Q

Ischaemic heart disease in diabetics

A
  • The major cause of morbidity and mortality in diabetes

- The mechanisms are similar with and without diabetes (but in diabetes, it occurs earlier on)

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15
Q

Cerebrovascular disease in diabetes

A
  • Occurs earlier than without diabetes (younger rather than elderly)
  • More widespread – has the risk factors of high blood pressure and cholesterol
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16
Q

Peripheral vascular disease in diabetes

A
  • Contributes to diabetic foot problems with neuropathy

- Neuropathy alone can cause diabetic foot problems, but peripheral vascular disease worsens this

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17
Q

Renal artery stenosis in diabetes

A
  • May contribute to high blood pressure (hypertension) and renal failure
  • It can permanently damage renal function
18
Q

How does hyperglycaemia treatment affect risk of cardiovascular disease?

A

Small effect on risk of cardiovascular disease.

  • If you treat glucose intensively, you do slightly reduce coronary artery disease risk
  • Intensive glucose control does improve coronary heart disease risk but it does not change mortality much.
  • Management of glucose alone does not address vascular risk
19
Q

What are some modifiable and non-modifiable factors contributing to diabetes?

A

Non-modifiable factors (age, sex, birth weight, FH and genetic makeup)

Modifiable factors (dyslipidaemia, high blood pressure, smoking, diabetes)

20
Q

What factors must be addressed to reduce macrovascular disease and death?

A

All aspects of diabetes. Prevention of macrovascular disease requires aggressive management of multiple risk factors. Insulin resistance before hyperglycaemia itself contributes

21
Q

What is the role of statins in diabetes?

A

Giving a statin early on in diabetes has a very significant reduction in the risk of a heart attack or stroke. Practically all people >50 with diabetes should be treated with a statin.

22
Q

Why are diabetics given antihypertensives?

A
  • To control their blood pressure

- This produces a significant reduction in the risk of having a heart attack, and risk of diabetic retinopathy

23
Q

What is multi-factorial risk reduction?

A

Subjects can be intensively treated in terms of weight, exercise, BP, lipids and glucose - many factors

24
Q

What are the treatment goals in type 2 diabetes?

A
  1. Blood glucose lowering therapy –via metformin, sulphonylurea, insulin, etc.
  2. Blood pressure management – if damage is to kidneys, eyes or cerebrovascular damage, lower considerably (<130/80mmHg) but other targets and lower less (<140/80mmHg)
    Constant monitoring
  3. Management of blood lipids –review CV risk annually
25
Q

What is canakinumab?

A
  • It is a monoclonal antibody that targets interleukin-1-beta
  • Reduces inflammation, without affecting lipids
  • Treatments results in reduced HbA1c, and lower risk of recurrent cardiovascular events
  • However, this agent causes a risk of infection (interference with antibodies)
26
Q

Which complications in diabetes lead to foot disease?

A

Neuropathy (sensory, motor and autonomic) – affects all types of nerves

Peripheral vascular disease

27
Q

What is the risk of amputation in diabetics compared to the general population?

What is the % of bed occupancy due to diabetics is foot related?

A

The risk of amputation is 60x bigger in patients with diabetes

50% of the patients with diabetes admitted is due to foot disease

28
Q

What is the pathway to foot ulceration?

A
  1. Sensory neuropathy
  2. Motor neuropathy – the balance of short and long extensors and flexors are required for weight balance
  3. Limited joint mobility
  4. Autonomic neuropathy
  5. Peripheral vascular disease
  6. Trauma - repeated minor/discrete episode
  7. Reduced resistance to infection (athlete’s foot)
  8. Other diabetic complications e.g. retinopathy – patients hurt their feet when walking
29
Q

Which foot infection are diabetics more likely to develop?

A

Athelete’s foot

30
Q

What is angiopathy and why may diabetics develop it?

A

Some diabetic patients may develop angiopathy – this involves extensive atheroma blocking arteries, and preventing blood from reaching the feet properly. Peripheral vascular disease (if present) can contribute to many problems in diabetic individuals).

31
Q

What is a neuropathic foot?

A

Numb, warm, dry, palpable foot pulses, ulcers at points of high-pressure loading.

32
Q

What is the ischaemic foot?

A

Cold, pulseless, ulcers at the foot margins

33
Q

What is the neuro-ischaemic foot?

A

Numb, cold, dry, pulseless, ulcers at points of high-pressure loading and at foot margins.

34
Q

How should the foot of a diabetic person be assessed?

A
  1. Look at the appearance – look for deformity and callus
  2. How does the foot feel – temperature, dryness
  3. Feel for foot pulses – dorsalis pedis pulse, posterior tibial pulse
  4. Signs of neuropathy – vibration sensation, temperature, ankle jerk reflex, fine touch sensation
35
Q

How should diabetic foot be managed?

A

Treat:

  1. Hyperglycaemia – if glucose is high, infection risk is high
  2. Hypertension – stop further damage to blood vessels
  3. Dyslipidaemia
  4. Stop smoking – more likely to lead to foot problems
  5. Education
36
Q

What is the preventative management for diabetic foot?

A
  1. Control diabetes
  2. Inspect feet daily
  3. Have feet measured when buying shoes
  4. Buy shoes with laces and square toe box
  5. Inspect inside of shoes for foreign objects
  6. Cut nails straight across
  7. Care with heat
  8. Never walk barefoot
37
Q

To treat diabetic foot, which team members are needed?

A

Diabetologist, diabetes nurse, chiropodist, podiatrist, orthotist, orthopaedic and vascular surgeons

38
Q

How is foot ulceration managed?

A
  • Relief of pressure
  • Bed rest (but there is a risk of DVT, heel ulceration)
  • Redistribution of pressure/total contact cast
  • Antibiotics, possibly long term (e.g. for osteomyelitis)
  • Debridement (dead tissue and callous tissue has to go)
  • Revascularization (angioplasty, arterial bypass surgery)
  • Amputation
39
Q

What is Charcot’s foot?

A

Condition causing weakening of the bones in the foot in people who have neuropathy - can cause breakages. It is inflammation of bones.

40
Q

How is Charcot’s foot investigated?

What must it be differentiated from?

A

MRI – we can see ulceration and infection

From osteomyelitis (bone infection)

Year 2 - endocrinology (18 decks)

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