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SAMIKSHA HEART AND DIABETIC CARE IN YELAHANKA NEW TOWN Dyslipidemia Average total serum cholesterol and low-density lipoprotein (LDL) cholesterol levels increase in men until approximately age 70 and then level off. In women, total serum cholesterol and LDL-cholesterol levels rise sharply after menopause and average 15–20 mg/dL higher than in men after age 60. Highdensity lipoprotein (HDL) cholesterol levels average about 10 mg/dL higher in women than in men throughout adult life. Although the strength of association of cholesterol levels with cardiovascular disease declines with age, in part due to the confounding effects of comorbid conditions and nutritional factors, low HDL-cholesterol levels and high total cholesterol to HDL-cholesterol ratios remain independent predictors of coronary events in older persons, including those over 80 years of age. In addition, observational studies and clinical trials indicate that statin therapy is associated with a reduction in cardiovascular events in moderate to high risk patients up to age 85.3 In the PROSPER trial, for example, which randomized 5804 patients 70-82 years of age to pravastatin or placebo, those receiving pravastatin experienced a 15% reduction in the primary outcome of coronary death, nonfatal myocardial infarction, or nonfatal or fatal stroke during a mean follow-up period of 3.2 years. Conversely, limited data are available on statin therapy in lower risk patients and in patients over 85 years of age. Treatment of these subgroups must therefore be individualized based on an overall assessment of potential benefits and risks.
BEST DIABETOLOGISTS IN HEBBALA BANGALORE Diabetes Type 1 and type 2 diabetes and impaired glucose tolerance (IGT) are associated with an increased risk of coronary disease, peripheral vascular disease and cerebrovascular disease.21 Diabetics have a two- to threefold risk of coronary disease at all ages and those with IGT have a 1.5-fold risk. Diabetes is a stronger risk factor for women (3.3 times) than for men (1.9 times). The excess risk for type 1 patients is largely confined to those with diabetic renal disease. All type 2 patients are at increased risk.22 Diabetes is thought to increase coronary heart disease because: n increased insulin levels result in increased hepatic synthesis of LDL and triglycerides, causing a mixed dyslipidaemia n insulin resistance, which is characteristic of type 2 diabetes, is associated with numerous other cardiovascular risk factors: dyslipidaemia, hypertension, endothelial dysfunction and microalbuminuria n hyperglycaemia itself may cause endothelial damage n glycosylated LDL may be more atherogenic than non-glycosylated LDL. Table 1.12 Glucose tolerance, current WHO definitions (venous plasma glucose) Fasting glucose 2-hour post-glucose load (mmol/L) Normal glucose regulation < 6.0 < 7.8 Impaired fasting glucose 6.1–6.9 < 7.8 Impaired glucose tolerance < 7.0 7.8–11.0 Diabetes > 7.0 > 11.1 16 PRACTICAL CARDIOLOGY Glycaemic control The UKPDS Trial has shown a very significant reduction in the microvascular complications of diabetes with improved glycaemic control but the improvement in macrovascular complications did not quite reach significance. Nevertheless, the UKPDS trialists estimate that each 1% reduction in HbA1c leads to a 14% reduction in cardiovascular risk. Diabetics tend to have more diffuse coronary disease. shows a diffusely diseased right coronary artery from a type 2 diabetic patient before and after coronary stenting . Coronary artery surgery involves a higher risk for diabetics, and graft disease and progression of native disease occur earlier in these patients. Nevertheless, diabetics probably have a better prognosis after surgical revascularisation than after angioplasty because of their higher risk of restenosis following angioplastY
THE BEST CARDIOLOGISTS IN GANGAMMA CIRCLE BANGALORE Thrombogenic factors Thrombosis is an important pathological process in coronary artery disease. Factors increasing the tendency to thrombosis include: n smoking n hypertriglyceridaemia n elevated fibrinogen (possibly) n oestrogen-containing contraceptive pills n polycythaemia n increased von Willebrand factor (a marker of endothelial dysfunction). The following factors are associated with reduced thrombotic tendency: n low-dose aspirin n other anti-platelet drugs (e.g. clopidogrel) n fish oils and mono-unsaturated fatty acids. Alcohol intake Alcohol intake has a complex relationship with coronary heart disease, with moderate intake being associated with decreased risk, and nil or heavy intake being associated with increased risk. Moderate intake is defined as 10–30 g per day for men; the optimal level for women is uncertain and alcohol may not have the same protective effect for women. Moderate alcohol intake is thought to be protective by: n increasing HDL levels n having anti-platelet activity n having an anti-oxidant effect—some components of alcoholic drinks, especially red wine and possibly beer. The evidence for the protective effect of alcohol is not strong and non-drinkers should never be urged to take up drinking. Hypertension and cerebrovascular disease increase in a linear fashion with alcohol intake, as do triglyceride levels. Therefore the beneficial effects of alcohol intake on coronary disease occur only at moderate intakes, and for those patients with hypertension, hypertriglyceridaemia or cerebrovascular disease, alcohol intake probably does not confer benefit.
''SAMIKSHA HEART AND DIABETIC CARE'' Smoking The Framingham study found an 18% increase in coronary events for males and a 31% increase for females for every 10 cigarettes smoked per day. There is more of an association between smoking and myocardial infarction than between smoking and stable angina. Smoking increases the risk of stroke, coronary heart disease and peripheral vascular disease through a number of mechanisms (Table 1.11). Smoking is a major factor in the increased risk of coronary heart disease for women using oestrogen-containing contraceptive pills Some effects of smoking 1 Increased atherogenesis, probably by toxic injury to endothelial cells 2 Hypoxia, resulting in intimal proliferation 3 Thrombogenesis 4 Reduction in HDL 5 Oxidation of lipids 6 Increase in fibrinogen levels Smoking cessation is associated with a rapid decline in death rates from coronary disease, probably because of smoking’s thrombogenic effects. Smoking seems less important as a risk factor in populations with low LDL levels Smoking cessation Many strategies are available to help patients to give up smoking. These should all begin with an explanation of the reasons smoking cessation is worthwhile. Some explanation of the mechanism of its deleterious effects may be helpful. Patients who have recently presented with possible cardiac symptoms may be amenable to advice of this nature. It is also especially important to give strong advice about smoking to patients with multiple existing coronary risk factors. The rapidity at which benefits begin to occur, and the risks and difficulties involved in further cardiac treatment (e.g. coronary surgery) for smokers, should be emphasised. The postoperative risk is considerably higher for smokers, particularly for serious chest infections. This risk falls quickly (within four weeks) once smoking is stopped. Nicotine replacement patches may be helpful and appear safe even for patients with ischaemic heart disease. The drug bupropion, which is a non-tricyclic antidepressant, is now available for patients who wish to stop smoking. This drug seems safe for patients with cardiac disease, at least for those without unstable symptoms. It does not cause conduction abnormalities or increase the risk of ventricular arrhythmias. Patients should be advised to continue smoking when they first start the drug but plan to stop on a particular day after about a week of treatment. The drug is usually continued for at least seven weeks. The starting dose is 150 mg daily and then 150 mg twice a day. It is important to discuss strategies for smoking cessation with the patient and to try to establish a treatment plan that suits the individual. Passive smoking Evidence of an increased cardiovascular risk from environmental smoke has been available for some years.20 Legislation is gradually reducing the risk for people in occupations associated with smoking (e.g. serving in bars and restaurants) but patients with existing ischaemic heart disease should be advised to avoid exposure.
Cardiologist in Rajanukunte, Bangalore • Factors that increase triglyceride levels 1 Obesity 2 Alcohol 3 Diabetes 4 Oestrogen (including HRT in 20% of users) 5 Diuretics 6 Beta-blockers Secondary causes: • Cushing’s syndrome • acromegaly • uraemia • acute hepatitis
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