A.S.L. 14 Chioggia

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A.S.L. 14 Chioggia. 1° Conferenza Regionale sul Diabete Mellito. Dr. Angelo Boscolo Bariga. Verona !2-13 dicembre 2008. L’impatto del prediabete. - PowerPoint PPT Presentation

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  • A.S.L. 14 ChioggiaVerona!2-13 dicembre 2008Limpatto del prediabete 1 Conferenza Regionale sul Diabete MellitoDr. Angelo Boscolo Bariga

  • Il diabete un insieme di disordini caratterizzati da valori glicemici elevati che causano complicazioni renali,oculari e nervose uniche e aumentano il rischio di patologia cardiovascolare.

  • Prediabete e microangiopatia

  • Retinopatia Prevalenza nell IGTdiabete6-12 mesi7.6%Hamman RF 65th annual meeting of ADA 200512.5%

  • Engelgau MM diabetes care 20: 785-791 1997Retinopatia Soglia glicemica per la retinopatiaA digiuno108-130 mg/dl 2h dopo carico orale155 - 215 mg/dl

  • Microalbuminuria Non diabeticiIGT4% 16%Metcalf PA diabetes 16 1485-1493 1993

  • Herman WH diabetes care 15: 1045-1051, 1998Neuropatia Prevalenza della polineuropatia simmetrica in soggetti egizianiNormali 4% 10% 13.6% IGT Diabete neo diagnosticato

  • 30-50%Singleton et al diabetes care 24: 1448-1453, 2001Neuropatia Prevalenza dell IGT in soggetti con neuropatia sensoriale dolorosa idiopatica

  • Prediabete e macroangiopatia

  • NFG IFG% Cardiogenic shockFasting BG mmol/lNo Shock ShockP=0.011P=0.003Impaired fasting glucose and cardiogenic shock in patients withacute myocardial infarctionZeller M et al, European Heart Journal 25:308-312,200499 pt with acute MI38% DM, 15%IFG, 47% NFGAnche la condizione di IFG a maggior rischio di shock cardiogeno post-IMA

  • www.diabetesclinic.ca2-hour PPG, Not FPG, PredictedAll-cause MortalityAdjusted for age, centre, sex
  • www.diabetesclinic.caEpidemiological Evidence Linking High PPG* with CVD Risk & MortalityDECODE, 19991High PPG is associated with increased risk of death, independent of FPGPacific and Indian Ocean, 19992High PPG with normal FPG doubles the risk of mortalityFunagata Diabetes Study, 19993IGT, but not IFG, is a risk factor for CVDWhitehall, Paris, Helsinki Study 19984Men in upper 2.5% of PPG distribution had significantly higher CHD mortalityThe Rancho-Bernardo Study, 19985PPG more than doubles the risk of fatal CVD and heart disease in older adultsDiabetes Intervention Study, 19966PPG (1-hr post-breakfast), but not FPG, is associated with CHD

    1DECODE Study Group. Lancet 1999;354:617. 2Shaw JE et al. Diabetologia 1999;42:1050.3Tominaga M et al. Diabetes Care 1999;22:920. 4Balkau B et al. Diabetes Care 1998;21:360.5Barrett-Connor E et al. Diabetes Care 1998;21:1236. 6Hanefeld M et al. Diabetologia 1996;39:1577. *2-hour PPG after 75g OGTT, except where indicated

    www.diabetesclinic.ca

  • Mod. da Tominaga M, et al. Diabetes Care 1999; 22: 920-924. La ridotta tolleranza ai carboidrati un fattore di rischio cardiovascolare: The Funagata Diabetes StudyNGTIGTDiabete01234567anni0,9400,9500,9600,9700,9800,9901,000Mortalit cardiovascolareMortalit per tutte le cause0,8800,9000,9200,9400,9600,9801,00001234567anni****************

  • Prevalence of Hyperglycemia in 181 Cardiac Patients Without Known Diabetes Norhammar A. Lancet. 2002;359:2140-2144.

  • Anche per la glicemia , come per il colesterolo si pu dire:Lower is better?

  • Rischio relativo cardiovascolare in rapporto allo status di diabeteFrank B. Hush et al. Diabetes Care N. 13 set. 2002

  • Rischio relativo cardiovascolare in base al tempo precedente la diagnosi di diabeteFrank B. Hush et al. Diabetes Care N. 13 set. 2002

  • Earlier is better ?

  • Grazie per lattenzione

    *Recognizing that overall glycemic control, A1C is comprised of both PPG and FPG, DECODE tried to determine the relationship between fasting plasma glucose (American Diabetes Association) versus 2-hour plasma glucose and the risk of cardiovascular disease and mortality.

    As PPG levels increased, moving up along the z-axis, the hazard ratio increased dramaticallyThe increase in risk was not as great as you increased FPG, shown across the x-axis DECODE clearly demonstrated that CV mortality was more closely associated with two-hour PPG than with FPG.

    n= 25,364 people in 13 European population- or occupational-based studies. 1,275 of these people had a previous diagnosis of diabetes. 18,048 men, 7316 women aged 30+; Mean follow-up: 7.3 yrs

    2-hr PPG was associated with a 73% increased risk of all-cause mortality independently of fasting glucose levels (DECODE, 1999). A two-hour glucose level of 11.1 mmol/L more than doubled the risk of deathThus, the DECODE study clearly demonstrated that CV mortality was more closely associated with two-hour glucose than with fasting glucose levels.

    DECODE study group. Glucose tolerance and mortality: comparison of WHO and American Diabetes Association diagnostic criteria. Lancet 1999;354:617621. Graph from Table 3, p. 619.*This slide summarizes a number of studies showing that elevated PPG* (2-hr PPG after 75g OGTT except where indicated)is a significant risk factor in the development of macrovascular diabetic complications

    The recent DECODE study indicated that using FPG concentrations alone, without 2-hr PPG to screen for diabetes, would not identify individuals at increased risk of death associated with hyperglycemia. Similarly the Pacific and Indian Ocean study determined that isolated 2 hour post-challenge hyperglycemia at least doubles the risk of mortality and that this is not detected using FPG alone. In the Funagata diabetes study, the new US category of impaired fasting glucose (IFG) (fasting plasma glucose of between 6.1-6.9 mmol/L) was found not to be a risk factor for cardiovascular disease (CVD) but impaired glucose tolerance, (plasma glucose concentration of 7.8-11 mmol/L 2 hours after a 75 g glucose dose) was. In the Whitehall, Paris, Helsinki study, men in the upper 20% and 2.5% of the 2-hour post meal glucose distribution were found to have a higher risk of all-cause mortality or cardiovascular associated mortality, respectively. The failure of fasting glucose alone to identify older adults at high risk for CVD was highlighted in the Rancho-Bernardo study, while in older women, 2-hour post meal hyperglycemia 11.1 mmol/L and FPG < 7 mmol/L doubled the risk of fatal CVD. In the Diabetes intervention study, 1-hr PPG (post-breakfast) was associated with increased risk of coronary heart disease and mortality.

    NOTE: Possible criticism of these studies is that they did not all include diagnosed type 2 diabetes patients

    *Norhammar data demonstrates that 2/3rds of patients admitted to the hospital for an AMI are either hyperglycemic or have undiagnosed DM. Importantly, this does not appear to be stress hyperglycemia in most cases since there is very little change in the pravalence of these disorders when test are repeated 3 months after discharge

    AbstractBACKGROUND: Glycometabolic state at hospital admission is an important risk marker for long-term mortality in patients with acute myocardial infarction, whether or not they have known diabetes mellitus. Our aim was to ascertain the prevalence of impaired glucose metabolism in patients without diagnosed diabetes but with myocardial infarction, and to assess whether such abnormalities can be identified in the early course of a myocardial infarction. METHODS: We did a prospective study, in which we enrolled 181 consecutive patients admitted to the coronary care units of two hospitals in Sweden with acute myocardial infarction, no diagnosis of diabetes, and a blood glucose concentration of less than 11.1 mmol/L. We recorded glucose concentrations during the hospital stay, and did standardised oral glucose tolerance tests with 75 g of glucose at discharge and again 3 months later. FINDINGS: The mean age of our cohort was 63.5 years (SD 9) and the mean blood glucose concentration at admission was 6.5 mmol/L (1.4). The mean 2-h postload blood glucose concentration was 9.2 mmol/L (2.9) at hospital discharge, and 9.0 mmol/L (3.0) 3 months later. 58 of 164 (35%, 95% CI 28-43) and 58 of 144 (40%, 32-48) individuals had impaired glucose tolerance at discharge and after 3 months, respectively, and 51 of 164 (31%, 24-38) and 36 of 144 (25%, 18-32) had previously undiagnosed diabetes mellitus. Independent predictors of abnormal glucose tolerance at 3 months were concentrations of HbA(1c) at admission (p=0.024) and fasting blood glucose concentrations on day 4 (p=0.044). INTERPRETATION: Previously undiagnosed diabetes and impaired glucose tolerance are common in patients with an acute myocardial infarction. These abnormalities can be detected early in the postinfarction period. Our results suggest that fasting and postchallenge hyperglycaemia in the early phase of an acute myocardial infarction could be used as early markers of high-risk individuals.

    *Frank B. Hush et al. Diadetes Care N. 13 set. 2002