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Conventional Treatment Results
In-Patients with Type 2 Diabetes
and Macrovascular Complications.

Clua Espuny, J.L.; Aguayo, Benito M.;
Dalmau Llorca, R.; Celma, Benito E.
for the East Tortosa Primary Care Study Group.

Institut Català de la Salut, Generalitat de Catalunya, Tortosa, Spain

RESUMEN

SUMMARY
Context: Type 2 diabetes is a prominent risk that predisposes to artery disease. When early and the appropriate intervention is instituted, the incidence of morbidity and mortality can be reduced. Likewise, there is evidence that in many situations guidelines are not applied.
Objectives: 1/ to stratify the risk cardiovascular; 2/ to know that interventions are associated to major change to the profile of minor cardiovascular risk; and 3/ if we achieved the risk factor targets predicated by the guidelines.
Methods and patients: Is a study descriptive and multicenter in the period 1995-2000. Were recruited 347 patients with type 2 diabetes, 35-70 years, followed by general practitioners. The sample was systematized and stratified by health districts and representative of the general diabetic population. All patients were evaluated for macrovascular artery disease and multivariate analysis were performed among the variables of metabolic control, and in relation to consumption of reagent strips, outpatients visits, derivations to specialist of reference and complementary test according to recommendations of the European NIDDM Policy Group; and stratified your cardiovascular risk using the Framingham study chart to ten years.
Results: The median cardiovascular risk (fig. 1) was 10% (CI 8,01-9,41), higher among men (p 0.0000), those who are deficient metabolic control (p 0.005), and those with differential blood pressure > 63 mmHg (p 0.000). The dyslipemia (22,7%), the body mass index > 30 Kg/m2 (46,6%), and the smoking (13,6%) are the risk factors with more failure to achieve targets. In the 63 patients with macrovascular complications, median age (p 0.0000), the median cardiovascular risk (p 0.0000) and the proportion without control of your systolic blood pressure (p 0.028) are higher.
Conclusions: The evidence support that the treatment need to be more aggressive in the reduction of blood pressure and hyperglycemia for improve the risk of cardiovascular complications.

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CONTEXT
   Type 2 diabetes is a prominent risk factor increasing the mortality from artery disease two to fours times higher than non-diabetic patients and the 70-80% of your mortality is caused for macrovascular complications (1). When the risk factors that predispose to artery disease are recognized early and the appropriate intervention is instituted, the incidence of morbidity and mortality can be reduced. Interest in preventing the consequences of vascular disease before the onset of symptoms is intense because the disease frequently presents suddenly and its prevalence is extraordinarily high in the diabetic patients. The actual data reflex that the benefits are proportionally to magnitude of change in the risk factors (2-5) with effectivity cost more favorable in the aged patients (6-8). Likewise, there is abundant evidence that in many situations guidelines are not applied. Defining and assessing the evidence de our results is of interest to health care providers, patients and the public.

OBJECTIVES: THEY ARE
   1/ To know, stratify and compare the risk of development and success cardiovascular in the patients of type 2 diabetes with macrovascular complications (MC) and the group without diagnostic of vascular disease.
   2/ To know that interventions are associated to major change to the profile of cardiovascular risk.
   3/ If we achieved the risk factor targets predicated by the guidelines.

METHODS AND PATIENTS
   The study was part of an observational, descriptive and multicenter study of analysis self-monitoring capillary blood glucose in 597 type 2 diabetes patients, covering the period 1995-2000. Baseline characteristics of the study group were representative of the general diabetic population in the seven health districts in the territorial ambit of Tortosa Primary Care.

    Were recruited 347 patients with a history of type 2 diabetes, 35-70 years of age, followed by general practitioners. The sample was systematized and stratified by health districts in order to obtain data through a pre-designed data collection form. All patients were evaluated for history of macrovascular artery disease: peripheral vascular, cerebrovascular and cardiovascular disease; and monitored the variables of your metabolic control(9), differential blood pressure; demographic characteristics; and consumption of reagent strips, outpatients visits, derivations to specialist of reference and complementary test according to recommendations of the European NIDDM Policy Group (9); and stratified your cardiovascular disease risk using the Framingham study risk reduction chart to ten years (10,11).

    Multivariate analysis was performed among all variables. For all statistical analysis a p value of less than 0.05 were or the 95 percent confidence interval were considered appropriate. Only the variables with a p value of less than 0.05 were entered in the multivariate model. All calculations were performed with SPSS software. Differences in proportions were evaluated by the chi-square test.

RESULTS
    The median cardiovascular risk (fig. 1) was 10% (CI 8,01-9,41), significantly higher among men (p 0.0000), those who are deficient metabolic control (p 0.005), and those with differential blood pressure > 63 mmHg (p 0.000). In more differential blood pressure, more cardiovascular risk associated (fig. 2). The dyslipemia (22,7%), the bodies mass indexes >30 Kg/m2 (46,6%) and the smoking (13,6%) are the risk factors with more failure to achieve targets. In the 63 patients with macrovascular complications, the median age (p 0.0000), the median cardiovascular risk (p 0.0000) (fig. 3) and the proportion without control of your systolic blood pressure (p 0.028) are significantly higher (table 1).




DISCUSSION
   The results of the trial has sparked additional discussion about of the necessity of treating intensively patients with type 2 diabetes with vascular disease, major cardiovascular risk and advanced age. The study shows that controlling blood glucose and the blood pressure control reduces the risk of complications in all patients. The opportunities of the primary care physicians for chronic preventive therapies are clinical indicators over time of the quality care.

    Although the use of the equations of Framingham to be obligated to make with precaution, they are effective for orient the comprehensive care and your effectivity. With these points in mind, note the significant high cardiovascular risk in-patients with macrovascular complications. Like in other Mediterranean populations (12), our patients are a high prevalence of deficient glycemic control, dyslipidemia, hypertension and obesity. This is attributable to aims more exigent in the management of type 2 diabetes, and to integral quantification of the cardiovascular risk, no only the glycemic level. Some of the targets currently set are ideal, but are not achievable in many patients.

    Like in other studies (13,14), the cardiovascular risk is major in men and resembling the prevalence of macrovascular complications and the percentage of patients in high cardiovascular risk (15). The age and the level of systolic blood pressure at another time (16) were identifies how the better predictors of cardiovascular success in long term. This major cardiovascular risk also is conditioned for the major age moreover of a possible different management of blood glucose and blood pressure controls (17-20), or for the presence of other risk factors (21). Also a level of differential blood pressure major of 62 mmHg is associated to major risk of cardiovascular complications (22).

   The principal conclusion of our study is to evidence the convenience of improve the standards of care in the blood-glucose control and the blood pressure management, specially the systolic level, in the type 2 diabetes with macrovascular complications for reduce the additional effects of them in the major age, and individualize a treatment plan without consider the age a restriction for achieve targets. For many reasons, diabetes is a difficult disease for primary care physicians to manage. To make this task easier, barriers to care must first be identifies and then overcome. High quality care for people with diabetes has been shown to make a difference: reduce 20-45% of risk associated to morbidity and mortality, improve the quality of life, and reduce the costs associated to deterioration in the personal levels of functioning (23-27).

CONCLUSIONS
   No evidence was found supporting that the treatment reduce the risk of cardiovascular in types 2 diabetes patients with macrovascular disease vs. these without. The evidence support that the treatment needs to be is more aggressive in the reduction of blood pressure specially and hyperglycemia for improves the risk of cardiovascular complications.


Resultados del tratamiento convencional en pacientes con diabetes tipo 2 y complicaciones macrovasculares.

RESUMEN
Introducción: La intervención precoz y adecuada puede reducir la incidencia de morbimortalidad por arteriopatía en la diabetes tipo 2. También existe evidencia de que en algunas situaciones no son aplicadas las recomendaciones de las guías clínicas.
Objetivos: 1/ Estratificar el riesgo cardiovascular; 2/ conocer qué intervenciones pueden mejorar el perfil de riesgo cardiovascular; 3/ si se lograron los objetivos recomendados en las guías clínicas.
Métodos y pacientes: Estudio descriptivo y multicéntrico realizado entre 1995-2000 con una muestra de 347 diabéticos tipo 2, de 35-70 años, estratificada por áreas básicas de salud y representativa de la población diabética general. Todos los pacientes fueron evaluados para detectar la presencia o antecedentes de complicaciones macrovasculares y se construyó un modelo de regresión múltiple con las variables de control metabólico, consumo de tiras reactivas, visitas ambulatorias, derivaciones a especialistas de referencia y pruebas complementarias según las recomendaciones del European NIDDM Policy Group; además, se estratificó por percentiles su riesgo cardiovascular usando las tablas del estudio Framingham.
Resultados: El riesgo cardiovascular medio (fig. 1) fue 10% (IC 8,01-9,41), más alto entre hombres ( p 0.0000), en aquellos con control metabólico deficiente (p 0.005), y aquellos con una presión diferencial >63 mmHg (p 0.000. La dislipemia (22,7%), el índice de masa corporal >30 Kg/m2 (46,6%), y el consumo de tabaco (13,6%) fueron los factores de riesgo más frecuentemente asociados al fallo del tratamiento. En los 63 pacientes con complicaciones macrovasculares, la edad media (p 0.0000), el riesgo cardiovascular medio (p 0.0000) y la proporción de pacientes sin control de su tensión arterial sistólica (p 0.028) fueron más altos.
Conclusiones: La evidencia apoya que es necesario un tratamiento más agresivo para reducir la tensión arterial y la glicemia para mejorar el riesgo de complicaciones cardiovasculares.


REFERENCES

1. Laakso M; Lehto S. Epidemiology of risk factors for cardiovascular disease in diabetes and impaired glucose tolerance. Atherosclerosis 1998;137:S65-73.

2. O'Connor PJ; Spann SJ; Woolf SH: Care of adults with type 2 diabetes mellitus. A review of the evidence. J Fam Pract 1998; 47:S13-22

3. Savage PJ: Treatment of diabetes mellitus to reduce its chronic cardiovascular complications. Curr Opin Cardiol 1998; 13:131-8

4. UK Prospective Diabetes Study Group: Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes. UKPDS BMJ 1998; 317:703-713

5. World Health Organization European Collaborative Trial of Multifactorial Prevention of Coronary Disease. Lancet 1986;1:869-72.

6. Jackson R: Which elderly patients should be considered for antihypertensive treatment? An evidence-based approach. J Hum Hypertens 1998; 12:607-13.

7. Havranek EP; Primary Prevention of CHD: nine ways to reduce risk. American Academy of Family Physicians 1999; 15:1466-78.

8. MacMahon S; Rodgers A: The effects of blood pressure reduction in older patients: an overview of five randomized controlled trials in elderly hypertensives. Clin Exp Hypertens 1993;15:967-78.

9. GedapS. Guía para el tratamiento de la diabetes tipo 2 en la Atención Primaria. Ediciones Harcourt Madrid 1999.

10. Hernández A; Córdoba R: Medición del riesgo cardiovascular en atención primaria. Aten Primaria 1999; 23:376-83.

11. Gordon T; Kannel WB: Multiple risk functions for predicting coronary heart disease. The concept, accuracy, and application. Am Heart J 1982;103:1031-39.

12. Bruno G; Cavallo P; Bargero G; Borra M, D'Errico N; Pagano G: Glycaemic control and cardiovascular risk factors in type 2 diabetes: a population-based study. Diabet Med 1998;15:304-7.

13. Lloyd DM; Larson MG; Levy D: Lifetime risk of developing coronary heart disease. Lancet 1999;353:89-92.

14. Jousilahti P; Vartiainen E; Tuomilehto J; Puska P: Sex, age, cardiovascular risk factors, and coronary heart disease: a prospective follow-up study of 14786 middle-aged men and women in Finland. Circulation 1999; 99:1165-72.

15. Sanchez de Toro JM; Navarro A; Hernandez T; Martínez MT; Lopez M; Ferrer A: Distribución por deciles del riesgo de mortalidad por cardiopatía isquémica en la población masculina registrada en un centro de salud. Aten Primaria 1998;22:375-78.

16. Menotti A; Giampaoli S: A single factor measurement predicts 35-year mortality from cardiovascular disease. G Ital Cardiol 1998; 28:1354-62.

17. Martell N; Fernandez P; Luque M: Estudio ESFIGMO. Hipertensión 1998;15:351-56.

18. Assmann G; Sculte H; Cullen P: New and classical factors. The Munster heart study (PROCAM). Eur J Med Res 1997;2:237-42.

19. Staessen JA; Fagard R; Thijs L; Celis H; Arabidze GG; Birkenhager WH: Randomised double-blind comparation of placebo and active treatment for older patients with isolated systolic hypertension. Lancet 1997;350:757-64.

20. Passa P: Reducing the cardiovascular consequences of diabetes mellitus. Diabet Med 1998;4:S69-72.

21. Blonde L, Dey J, Testa M, Guthrie R. Defining and measuring quality of diabetes care. Primary care 1999;26(4):841-55.

22. M de la Figuera von Wichmann; Fernández R: Presión diferencial y riesgo cardiovascular. Hipertensión 1998; 15:371-75. Vidt DG; Pohl MA: Aggressive blood pressure lowering is safe, but benefit is still hard to prove. Cleve Clin J Med 1999; 66:105-11.

23. Ribera Casado; JM: La atención sanitaria del anciano: ¿utilización eficiente de recursos o discriminación?. Humana 1997;1:30-41.

24. Muggeo M. Accelerated complications in type 2 diabetes mellitus: the need for greater awareness and earlier detection. Diabet Med 1998; 15:S60-2.

25. Wannamethee SG; Shaper AG; Walker M; Ebrahim S: Lifestyle and 15-year survival free of heart attack, stroke, and diabetes in middle-aged british men. Arch Intern Med 1998; 158:2433-40.

26. Daviglus ML; Liu K; Greenland P; Dyer AR; Garside DB; Manheim L; et al: Benefit of a favorable cardiovascular risk-factor profile in middle age with respect to Medicare costs. N Eng J Med 1998; 339:1122-29.

27. Cohen JD: Cardiovascular disease: tomorrow is the reason for today's therapeutics. Geriatrics 1999; 54:57-63.

 

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2nd Virtual Congress of Cardiology

Dr. Florencio Garófalo
Steering Committee
President
Dr. Raúl Bretal
Scientific Committee
President
Dr. Armando Pacher
Technical Committee - CETIFAC
President
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fgaro@satlink.com
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