Abstract
Objective:
To identify the pattern of glycemic, lipid and
blood pressure control among a cohort of diabetic patients referred to Queen
Alia Heart Institute for further evaluation of coronary artery disease.
Methods:
This is a descriptive study conducted at Queen Alia Heart Institute
between 1/12/2004
and 1/9/2005. All
newly referred diabetic patients (N=112) to Monday official referral clinic at
the centre during this period were enrolled. A specially designed record form
was completed including demographics, risk factors for coronary artery disease,
medications, diabetes care giver name and the type of culprit cardiovascular
event. Blood pressure was measured, and fasting lipid panel, blood sugar, and
HbA1c were drawn.
Results: Only about one fourth of the study population
had optimal glycemic and blood pressure control. Optimal body mass index was present in only 13.9% of patients
(lower in females 7.5%). Smoking was prevalent in our study population (41.1%).
Optimal low density lipoprotein, high density lipoprotein and triglyceride
levels were obtained only in 33%, 22% and 34% of patients, respectively. Usage of recommended medications for secondary
prevention was relatively low: aspirin
(52.7%), angiotensin converting enzyme inhibitors, angiotensin receptor blockers
(55.4%), beta blockers (59.8%) and HMG-coA
reductase inhibitors (statins) (79.5%). Over
half of the patients (51%) could not name their diabetes care-giver.
Conclusion: Diabetic patients referred to Queen Alia Heart
Institute for further evaluation of coronary artery disease have poor glycemic,
blood pressure and lipid control prior to their referral. More emphasis on
these issues at the level of primary as well as secondary health care levels is
imperative to delay the progression of atherosclerosis and reduce adverse cardiovascular
events in these patients.
Key words: Coronary artery disease, Diabetic patients, Glycemic
control
JRMS
March 2010; 17(1): 21-27
Introduction
Diabetes mellitus (DM) affected approximately 171
million patients worldwide in 2000 (2.8% of the population). The large majority
of these patients are type 2 diabetics (90-95%). By the year 2030, the diabetic
population is expected to reach 366 million (4.4%). The projected increase is
attributed to demographic changes as well as the increasing rate of obesity.(1-3)
The adult treatment panel of the National Cholesterol
Education Program (NCEP) considered type 2 diabetes
as a coronary artery disease (CAD) risk equivalent.(4,5) Both
accelerated atherosclerosis and the increased adverse outcomes after coronary
intervention have been attributed to various physiological mechanisms related
to diabetes.(6-8) A
growing body of evidence has demonstrated an association between tight glycemic
controls on macrovascular endpoints, although the effect was unclear in the United Kingdom
Prospective Diabetes Study.(9-13)
Moreover, recent studies have demonstrated that aggressive treatment of DM may
improve the clinical outcome after PCI.(14,15) In fact, the reduction of the increased
cardiovascular risk in diabetic population requires a multifactorial approach in
addition to glycemic control. There is substantial amount of evidence in the
literature demonstrating the beneficial effects of tight control of multiple
risk factors in them. These modifiable factors include: blood pressure, dyslipidemia, anti-platelet
therapy, obesity and smoking status.(16)
The objective of this study was to identify the pattern of glycemic, lipid
and blood pressure (BP) control among a cohort of diabetic patients referred to
Queen Alia Heart Institute (QAHI) for further evaluation of their CAD.
This study represents an essential step in evaluating and promoting the proficiency
of diabetic patient care among primary and secondary care physicians in Jordan.
Methods
This is an observational study conducted in Monday
referral cardiology clinic at QAHI –Amman
/Jordan. The study enrolled 112 consecutive diabetic patients (59 males, 53
females) referred for further evaluation of CAD who were seen d between
1/12/2004 and 1/9/2005 and evaluated by one consultant (OA) and three
cardiology specialists covering the mentioned clinic. Diabetic patients were identified as patients
undergoing treatment with diet, insulin or oral hypoglycemic medications. Exclusion
criteria include only patients who could not offer complete information and
those with uncertain diagnosis for DM.
Data collected included risk factors for CAD and
clinical characteristics (age, gender, history of hypertension, dyslipidemia,
smoking, family history of CAD and type of clinical presentation, previous
history of stroke or transient ischemic attack). Patients were also asked
whether they knew the name of their diabetes care-giver. The prior use of statins, β blockers, ACEI
and/or ARB, and aspirin were also
evaluated.
During clinical examination, measurement of blood
pressure (BP) was performed using a standard cuff technique using mercury
sphygmomanometer to the nearest 5mmHg for all subjects. Weight and height were
measured with ordinary scales to the nearest kilogram and centimeter, without
footwear and in standing position. Body mass index (BMI) was then
calculated using this formula (BMI= weight in Kg/height
in m2. Finally, blood was withdrawn for all patients regarding HBA1C
and fasting blood sugar (FBS) to assess glycemic control and for lipid panel to
assess control of dyslipidemia. The
following parameters were used to define optimal treatment in these patients
according to recent guidelines.(17,18)
- Optimal glycemic control: HBA1C≤7%.
- Optimal lipid control: LDL-C≤100
mg/dl, TG ≤ 150mg/dl, and HDL-C≥40
mg/dl (50mg/dl in women).
- Blood pressure ≤130/80mmHg in diabetic patients (≤120/80 after MI).
- Prophylactic daily therapy with aspirin for diabetic patients with CAD.
- BMI≤25 Kg/m2.
- Current non-smoking status.
Continuous variables were expressed as mean values ±
SD and discrete variables as absolute values and percentages.
Results
The percentages of those who achieve optimal as well
as suboptimal goals for various studied factors are shown in Fig. 1.
Demographic data (Table I) reveal the high frequency of many traditional risk
factors among our study population: hypertension (63.4%), smoking (41.1%),
overweight (36.6%) and obesity (50%). Positive family history for CAD was
present in one third of patients while previous history of stroke and TIAs was
infrequent (6.3%). Fifty seven patients (51%) were unaware of their diabetes
care-giver’s name.
The overall mean BMI
was 30.2 ± 5.6 Kg/m2 (29.1± 5.1 in males, 30.4 ± 6.1 in females).
Optimal BMI ≤ 25 were obtained
only in 13.4% of patients (18.6% in males, 7.5% in females), as demonstrated in
Table II.
Only about a quarter of the study population had optimal
glycemic control prior to presentation as clearly shown in Tables III and IV.
Fig. 1. The percentage of patients
who achieved optimal or suboptimal treatment goals
Table I. Risk factors and clinical
characteristics of our study population.
|
Item
|
Male
|
Female
|
Total
|
|
Total No. of patients
|
59
|
53
|
112 (100%)
|
|
Age (yrs)
|
59 ± 7.9
|
62 ± 9.1
|
60 ± 8.7
|
|
BMI (Kg/m2)
|
29 ± 5.1
|
30.4 ± 6.1
|
30.2 ± 5.6
|
|
Current smoking
|
38 (64.4%)
|
8 (15.1%)
|
46 (41.1%)
|
|
Family history of CAD
|
20 (33.9%)
|
16 (30.2%)
|
36 (32.1%)
|
|
Hypertension
|
34 (57.6%)
|
37 (69.8%)
|
71 (63.4%)
|
|
Previous stroke
|
5 (8.5%)
|
2 (3.8%)
|
7 (6.3%)
|
|
Angina
|
20 (33.9%)
|
25 (47.2%)
|
45 (40.2%)
|
|
Unstable angina
|
15 (25.4%)
|
10 (18.9%)
|
25 (22.3%)
|
|
Post-MI
|
15 (25.4%)
|
7 (13.2%)
|
22 (19.6%)
|
|
Other presentation
|
9 (15.3%)
|
11 (20.7%)
|
20 (17.9%)
|
|
Treatment with diet alone
|
3 (5%)
|
4 (7.5%)
|
7 (62.5%)
|
|
Insulin
|
14 (23.7%)
|
10 (18.9%)
|
24 (21.4%)
|
|
Oral agents
|
36 (61.0%)
|
29 (54.7%)
|
65 (58.0%)
|
|
Insulin and oral agents
|
6 (10.2%)
|
10 (18.9%)
|
16 (14.3%)
|
Very
bad control (A1C > 9.5%) was observed in around a third of the study population.
Table V shows that only 24.1% of patients had optimal
B/P control (less in females). The overall mean SBP
was 149 ± 24.8 mmHg and DBP 87 ± 11.3 mmHg. The mean values in previously known
hypertensive patients were 153 ± 25.5 mmHg for SBP
and 88.2 ± 12.7 mmHg for DBP ( males: 148.6 ± 29.2/ 86.1 ± 11.7, females :
157.0 ± 21.4 / 90.1 ± 12.7). Among the 24 patients who denied having
hypertension, 10 patients (40.2%) were hypertensive (BP ≥ 160/90) during
clinical examination.
Optimal LDL,
HDL and triglyceride levels were noted
in 37 patients (33%), 25 patients (22.3%) and 38 patients (33.9%) respectively.
See Tables IV, IIV, IIIV.
Many medications shown to decrease the total and cardiac
mortality in such a subset of patients were under-prescribed. Aspirin, ACE inhibitors, β blockers and statins were not
administered in 52.7%, 55.4%, 59.8% and 79.5% of patients, respectively (See Table
IX).
Discussion
Only around a quarter of the study population had
optimal glycemic control prior to presentation. Similar bad control was seen in
previously reported trials.(19-21)
A growing body of evidence has shown recently an
association between tight glycemic control and macrovascular endpoints.(9-13)
Table II. Values of body mass indices of our study population
|
Value
Kg/m2
|
< 25 Optimal (%)
|
25.1-29.9
Overweight
(%)
|
> 30
Obese (%)
|
Total (%)
|
|
Male
|
11(18.6)
|
25(42.4)
|
23 (39)
|
59 (100)
|
|
Female
|
4 (7.5)
|
16 (30.2)
|
33 (62.3)
|
53 (100)
|
|
Total
|
15 (13.4)
|
41 (36.6)
|
56 (50)
|
112 (100)
|
Table III. Level of hyperglycemic
control according to values of HBA1C
|
HbA1C
|
< 7%
Optimal Control (%)
|
>
7%-<8.5%
Good (%)
|
>8.5-<9.5%
Fair (%)
|
> 9.5
Uncontrolled (%)
|
Total(%)
|
|
Male
|
10 (16.9)
|
15 (25.4)
|
16 (27.1)
|
18 (30.5)
|
59 (52.7)
|
|
Female
|
11 (20.8)
|
15 (28.3)
|
10 (18.9)
|
17 (32.1)
|
35 (47.3)
|
|
Total
|
21 (18.8)
|
30 (26.8)
|
26 (23.2)
|
35 (31.3)
|
112 (100)
|
Table IV. Level of hyperglycemic
control according to values of fasting blood sugar
|
Total (%)
|
> 155 (%)
|
126-155 (%)
|
<126 (%)
|
FBS Mg/dl
|
|
59 (100)
|
33 (55.9)
|
15 (25.4)
|
11 (18.7)
|
Male
|
|
53 (100)
|
29 (54.7)
|
10 (18.9)
|
14 (26.4)
|
Female
|
|
112 (100)
|
62 (55.4)
|
25 (22.3)
|
25 (22.3)
|
Total |
Khaw and his colleagues(10) demonstrated that a 1%
increase in HbA1C was associated with 38% increase in cardiovascular mortality.
During 10 years of post United Kingdom Prospective Diabetes Study follow-up,
Holman and his colleagues(12) observed emergent risk
reductions for MI and death from any cause despite modest differences in
glycated hemoglobin. Moreover, recent studies showed that aggressive treatment
of diabetes to achieve HBA1C levels ≤ 7% has a significant role in reducing the
risk of restenosis and rates of target vessel revascularization and may improve
the clinical outcome after PCI.(14,15)
Demographic data clearly demonstrated the high
frequency of smoking habit among our male population (41.1% who were current
smokers). Multiple large prospective trials have demonstrated a two-fold
increase in the relative risk for all-cause mortality in the smoking versus
non-smoking diabetic population.(22-23)
Optimal BMI was found in only in 13.4% of patients.
This low percentage is an extremely important issue, as numerous studies have
demonstrated increased mortality rates in individuals with a BMI ≥ 30
Kg/m2.(19, 24,25)
To alter what is otherwise a fairly dismal prognosis,
out-patient education programs should be used as an integral part of
patient-care in DM, aiming at encouraging lifestyle modification (cessation of
smoking, weight reduction and promotion of physical activity), in addition to
coordination of nutritional therapy with dieticians.
Systemic hypertension was very frequent in our study
population (63.4%), far exceeding the previously reported prevalence rates of 39-42%.(26-28) The current antihypertensive treatment targets are
< 130/80 mmHg in diabetic patients and < 120/80 after myocardial
infarction.(29-32)
From the 24 patients who denied having
prior history of hypertension, 10 patients (40.2%) were found hypertensive (BP
≥ 160/90) during clinical examination. Only 24.1% of patients had optimal B/P
control (less in females). Current guidelines recommend the use of ACE inhibitors or ARB's
as first line therapy in hypertension treatment in diabetic patients.(17,18,33)
Unfortunately, more than half of the patients were neither on these medications
nor on β blockers upon referral.
Poor BP control demonstrated among our hypertensive
diabetic patients is similar to previously reported international and regional
studies.(19-21,34,35) Although we did not look for the
non-compliance rate which is the greatest obstacle to good BP in hypertensives(36)
our findings strongly suggest that referring physicians are underutilizing
appropriate medical therapies and therefore we recommend the implementation of
management guidelines in order to achieve the required objective.
There
is compelling evidence from literature that suggests that statins confer
cardiovascular risk reduction to both high and low-risk diabetic patients.(37)
The HPS (Heart Protection Study) demonstrated that cholesterol-lowering therapy
was beneficial for people with DM even if they did not already have a history
of CAD or high cholesterol concentrations.(38) Both the STEMI
and the NSTEMI/UA ACC/AHA guidelines consider statin drugs class I
recommendation regardless of baseline
Table V. Distribution of patients
according to blood pressure readings
|
B/P Range
|
< 130/80 (%)
|
130-160 /80-90 (%)
|
> 160/> 90
|
> 160/< 90
|
<160/>90
|
Total
|
|
Male
|
17 (28.8)
|
32 (54.2)
|
7 (11.9)
|
2 (3.4)
|
2 (1.7)
|
59
|
|
Female
|
10 (18.9)
|
23 (43.4)
|
13 (24.5)
|
3 (5.7)
|
4 (7.5)
|
53
|
|
Total
|
27 (24.1)
|
55 (49.1)
|
20 (17.8)
|
5 (4.5)
|
5 (4.5)
|
112
|
Table VI. Low density lipoprotein
levels in our study population
|
LDL level mg/dl
|
<
100 (%)
|
100-129
(%)
|
>130 (%)
|
Total (%)
|
|
Male
|
21 (35.6)
|
18 (30.5)
|
20 (33.9)
|
59 (100)
|
|
Female
|
16 (30.2)
|
10 (18.9)
|
27 (50.9)
|
53 (100)
|
|
Total
|
37 (33)
|
28 (25)
|
47 (42)
|
112 (100)
|
Table VII. High density lipoprotein levels
in our study population
|
LDL level mg/dl
|
> 40 males & > 50
females (%)
|
> 40 males & > 50
females (%)
|
Total (%)
|
|
Male
|
10 (16.9)
|
49 (83.1)
|
59 (100)
|
|
Female
|
15 (28.2)
|
38 (71.7)
|
35 (100)
|
|
Total
|
25 (22.3)
|
87 (77.7)
|
112 (100)
|
Table VIII. Triglyceride levels
|
TG level mg/dl
|
<150 (%)
|
> 150 (%)
|
Total
|
|
Male
|
22 (37.3)
|
37 (62.7)
|
59 (100)
|
|
Female
|
16 (30.2)
|
37 (69.8)
|
35 (100)
|
|
Total
|
38 (33.9)
|
74 (66.1)
|
112 (100)
|
Table IX. Underpresciption of medications
|
Item
|
Yes (%)
|
No (%)
|
|
ACEI intake
|
50 (44.6)
|
62 (55.4)
|
|
B-Blockers
|
45 (40.2)
|
67 (59.8)
|
|
Statins
|
23 (20.5)
|
89 (79.5)
|
|
Aspirin intake
|
53 (47.3)
|
59 (52.7)
|
LDL Cholesterol. LDL targets of less than 70 mg/dl are also
considered reasonable.(39-41) Unfortunately, despite the
effectiveness of statins in altering cardiovascular mortality, several prior
studies have documented low treatments rates in patients with established CAD.(19,
42-44)
In
our study statins were prescribed only to about one fifth of our patient
population. Only about one third of patients achieved the target LDL values (<100 mg/dl), a finding that is in other similar
studies.(21,37,45,46) Moreover, only 22 % and 34% of patients
met the existing guidelines for HDL
levels and TG levels respectively.
Contemporary guidelines recommend prophylactic therapy
with aspirin for diabetic patients with CAD(6, 17,18)
unfortunately, fewer than half of the patients with CAD in this study were
treated with aspirin suggesting, again, deficiencies in applying the
appropriate guidelines by referring physicians.
Our data suggest that both glycemic control as well as
numerous modifiable cardiovascular risk factors in diabetic patients referred
to our centre are not adequately treated according to current guidelines and
may highlight deficiencies in cardiovascular risk factor modification in the
diabetic population as a whole. The low level of control reported is a clear
signal that current paradigms of care delivery are inadequate.
Despite being a single centre observational study, we
feel that our findings are broadly applicable because our institution has a
very broad patient base. In this study, the patient
sample was drawn from out-patients of a tertiary care centre in a metropolitan
city of the country, where it may be expected that patients have access to
higher standards of care than the rest of the country, but many of the patients
were living outside the city and had attended
The
relatively small sample size is a limitation to generalize our results to the
community, but nevertheless we feel that important information is gathered from
this subset, which is fairly typical regarding the type of patients we come
across.
To promote patient-care in diabetic patients,
combining strategies to combat more effectively cardiovascular disease is
extremely essential.
We should encourage out-patient education programs that
aim at increasing patient knowledge about the disease, motivating the patient
to comply with complex treatment scheme, encouraging lifestyle modification and
better coordination with dieticians.
From physician standpoint, we should urge primary as
well as secondary care physicians to read and follow the guidelines that are
generally published after a body of evidence is present in the literature.
Lastly, the deficiencies in diabetic patient's care can be controlled by
introducing a checklist (flow sheet) or electronic medical records as reminders
to referring physicians.
Conclusion
Our efforts to face the current epidemic of DM and its
cardiovascular consequences must include improved compliance to lifestyle
measures and drug therapy through patient and community counselling as well as
sensibilization of the medical profession to the importance of primary and
secondary CAD prevention through appropriate long-term prescription of
evidence-based therapies.
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