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"The Heart in Type 2 Diabetes Mellitus - Hyperglycemia: A Target for Treatment in Acute Coronary Syndromes"Dr. Richard W. Nesto (biography)
English - 2005-01-21 - 71 minutes
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 | (48 slides) |
 | (26 slides) |
Summary :
Despite the recent improvements in cardiac care resulting in reduced risk of early mortality from acute MI (1), diabetes still confers an increased risk of poor outcome after MI although appropriate use of medications has been shown to reduce nonfatal events (2). In this presentation Dr. Nesto describes structural and metabolic abnormalities occurring in the diabetic heart, and implications for treatment.
Cohort studies show that patients with diabetes are more likely to develop congestive heart failure (CHF) compared to those without diabetes (3), and diabetes itself has emerged as an independent risk factor for mortality and MI in patients with unstable coronary artery disease (CAD) even after adjusting for the extent of CAD (4).
Different factors promote dysfunction in the diabetic heart. Dr. Nesto discusses the effects of advanced glycation end-products leading to diastolic stiffness of the ventricle, and the effects of epicardial fat deposition, in diabetes. The impact of gender and insulin resistance on cardiac structure was investigated in the Framingham Heart Study and it was found that left ventricular (LV) mass increased with worsening glucose intolerance with a more striking effect seen in women, and insulin resistance was associated with increased LV mass in women but not men (5). Insulin resistance also impacts myocardial metabolism (6).
Studies such as from Kaiser-Permanente show an increased risk of CHF morbidity and mortality with worsening glycemic control in patients with diabetes (7), and recent data show comparable long-term post-MI mortality in patients having an admission blood glucose level above or equal to 200mg/dL compared to those with known diabetes (8).
Dr. Nesto concludes his presentation by discussing the usefulness of some metabolic modulators as pharmacotherapy for AMI: recent studies on the use of glucose-insulin-potassium infusion; potentially cardioprotective effects of insulin (9,10) and TZDs (11,12).
Copyright © 2005 E-MedHosting.com Inc.
Learning objectives :
After viewing this presentation the participant will be able to discuss:
- Structural and metabolic changes in the heart associated with diabetes and insulin resistance;
- The effect of glycemic control on the risk of heart failure in diabetes;
- The importance of admission blood glucose level in predicting long-term survival post-MI;
- The usefulness of some metabolic modulators as pharmacotherapy for AMI.
Bibliographic references :
1. Eugene Braunwald, M.D. Cardiovascular Medicine at the Turn of the Millennium: Triumphs, Concerns, and OpportunitiesNEJM. 1997;337:1360-1369.
2. Hitinder S. Gurm MD, A. Michael Lincoff MD, David Lee MD, W. H. Wilson Tang MD, Gang Jia MS, Joan E. Booth RN, Robert M. Califf MD, E. M. Ohman MD, Frans Van de Werf MD, PhD, Paul W. Armstrong MD, Victor Guetta MD, Robert Wilcox MD and Eric J. Topol MD. Outcome of acute ST-segment elevation myocardial infarction in diabetics treated with fibrinolytic or combination reduced fibrinolytic therapy and platelet glycoprotein IIb/IIIa inhibitionJournal of the American College of Cardiology. Volume 43, Issue 4 , 18 February 2004, Pages 542-548.
3. Gregory A. Nichols, PHD, Christina M. Gullion, PHD, Carol E. Koro, PHD, Sara A. Ephross, PHD and Jonathan B. Brown, PHD, MPP. The Incidence of Congestive Heart Failure in Type 2 Diabetes: An update.Diabetes Care 27:1879-1884, 2004.
4. Anna Norhammar, Klas Malmberg, Erik Diderholm, Bo Lagerqvist, Bertil Lindahl, Lars Rydén and Lars Wallentin. Diabetes mellitus: the major risk factor in unstable coronary artery disease even after consideration of the extent of coronary artery disease and benefits of revascularizationJACC. 18 February 2004, Volume 43, Issue 4 Pages 585-591.
5. Martin K. Rutter, MB, ChB; Helen Parise, ScD; Emelia J. Benjamin, MD, ScM; Daniel Levy, MD; Martin G. Larson, ScD; James B. Meigs, MD, MPH; Richard W. Nesto, MD; Peter W.F. Wilson, MD; Ramachandran S. Vasan, MD Impact of Glucose Intolerance and Insulin Resistance on Cardiac Structure and Function: Sex-Related Differences in the Framingham Heart Study Circulation. 2003;107:448.
6. Oliver MF, Opie LH.Effects of glucose and fatty acids on myocardial ischaemia and arrhythmias.Lancet. 1994 Jan 15;343(8890):155-158.
7. Carlos Iribarren, MD, MPH, PhD; Andrew J. Karter, PhD; Alan S. Go, MD; Assiamira Ferrara, MD, PhD; Jennifer Y. Liu, MPH; Stephen Sidney, MD, MPH; Joseph V. Selby, MD, MPH. Glycemic Control and Heart Failure Among Adult Patients With Diabetes Circulation. 2001;103:2668.
8. Ischa Stranders, MD; Michaela Diamant, MD, PhD; Rogier E. van Gelder, MD; Hugo J. Spruijt, MSEE; Jos W. R. Twisk, PhD; Robert J. Heine, MD, PhD, FRCP; Frans C. Visser, MD, PhD. Admission Blood Glucose Level as Risk Indicator of Death After Myocardial Infarction in Patients With and Without Diabetes Mellitus Arch Intern Med. 2004;164:982-988.
9. Insulin therapy as an adjunct toreperfusion after acute coronary ischemia: A proposed direct myocardial cell survival effect independent of metabolic modulation JACC. 16 April 2003, Volume 41, Issue 8 Pages 1404-1407.
10. Dandona P, Aljada A, Mohanty P. "The anti-inflammatory and potential anti-atherogenic effect of insulin: a new paradigm." Diabetologia. 2002 Jun;45(6):924-30.
11. Tian-li Yue, PhD; Jun Chen, MS; Weike Bao, MD; Padma K. Narayanan, PhD; Antoine Bril, PhD; Wen Jiang, MD; Paul G. Lysko, PhD; Juan-Li Gu, MD; Rogely Boyce, PhD; Dawn M. Zimmerman, MS; Timothy K. Hart, PhD; Robin E. Buckingham, PhD; Eliot H. Ohlstein, PhD In Vivo Myocardial Protection From Ischemia/Reperfusion Injury by the Peroxisome Proliferator–Activated Receptor-(gamma) Agonist Rosiglitazone Circulation. 2001;104:2588.
12. Tetsuya Shiomi, MD; Hiroyuki Tsutsui, MD; Shunji Hayashidani, MD; Nobuhiro Suematsu, MD; Masaki Ikeuchi, MD; Jing Wen, MD; Minako Ishibashi, MD; Toru Kubota, MD; Kensuke Egashira, MD; Akira Takeshita, MD Pioglitazone, a Peroxisome Proliferator–Activated Receptor-(gamma) Agonist, Attenuates Left Ventricular Remodeling and Failure After Experimental Myocardial Infarction Circulation. 2002;106:3126.
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