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DIABETIC CLINICS IN DODDABALLAPUR ROAD BAMNGALORE Low-density lipoproteins Sixty to seventy per cent of total cholesterol is transported as LDL, and total cholesterol measurements usually reflect LDL levels. In both males and females, coronary heart disease risk is proportional to LDL and total cholesterol. As seen above, LDL supplies cholesterol to peripheral tissues. High concentrations of LDL in the serum accelerate atheroma by interacting with damaged endothelium. Oxidation of LDL accelerates this process. A total cholesterol of 5.5 mmol/L, or LDL of 3.5 mmol/L, is usually considered the upper limit of normal but even these levels seem to be responsible for an increased population risk of atheroma. Populations with lower average levels than these have less coronary disease. Lower levels are beneficial for patients with established coronary disease or multiple risk factors. It is not yet clear whether the lowering of total cholesterol to less than 4.0 (LDL 2.0) provides further benefit or whether a target level is indeed the correct approach. Trials of more aggressive cholesterol lowering are underway.14 Although a reduced HDL level (< 1) is associated with increased risk, there is no evidence as yet that raising HDL has beneficial effects. An elevation of triglyceride levels (> 1.7) is also considered a marker of increased risk, but there is no evidence to what level they should be reduced. Exogenous
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 DIABETOLOGISTS IN HSR LAY OUT 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.
THE BEST DIABETOLOGISTS IN HSR LAY OUT 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.
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.
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