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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
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.
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.
The median cardiovascular risk ( ) 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 ( ). 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) ( ) and the proportion without control of your systolic blood pressure (p 0.028) are significantly higher ( ).
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).
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.
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 ( ) 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.
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