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Cardiovascular complications in diabetic patients, especially type 2, can be classified as microvascular (renal, ophthalmologic and neurologic) and macrovascular (coronary, cerebrovascular and peripheral vascular). Type 1 and 2 diabetic patients have increased cardiovascular risk, especially for coronary artery disease. This has been well established through high-quality studies, as have interventions to ameliorate the major risk factors. The main risk factors for increased incidence of coronary artery disease in diabetic patients include hyperlipidemia, hypertension, smoking, microalbuminuria and hyperglycemia. The therapeutic approach to the type 2 diabetic patient should include--if there is no individual contraindication--diet control, physical exercise, smoking cessation and, particularly, pharmacologic interventions with antiplatelets (mainly aspirin and clopidogrel) and/or anticoagulants (warfarin), angiotensin-converting enzyme inhibitors, angiotensin II receptor antagonists, beta-blockers and anti-dyslipidemics (mainly statins), as well as oral antidiabetics (or insulin). In this paper we present and discuss the results of lowering cardiovascular risk in these patients, which should lead to a marked decrease in the incidence of coronary artery, cerebrovascular and peripheral vascular disease, with consequent improvement in prognosis.
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PMID:Coronary heart disease in diabetes mellitus: risk factors and epidemiology. 1564 Dec 98

Hyperlipidaemia is a pivotal risk factor for the development of atherosclerotic disease. A large number of studies have demonstrated that the treatment of abnormalities in lipoprotein levels reduces the risk for myocardial infarction, peripheral vascular disease, carotid artery disease, stroke, and cardiovascular mortality. Despite the development of multiple drug classes to treat dyslipidaemias and the promulgation of clearly defined guidelines for the management of lipid disorders, dyslipidaemia tends to be undertreated in the majority of patients at risk for cardiovascular disease. A part of the reluctance to treat different lipoprotein fractions to goal levels is attributable to physician- and patient-related concerns over the increasing toxicity of available therapies, as their dosages are increased. The risks of hepatotoxicity, myalgia, and rhabdomyolysis are fairly well characterised in patients receiving statins, fibrates and niacin. Another issue affecting treatment success rates is the fact that many patients with complex dyslipidaemias are inadequately responsive to single-agent therapy. As the epidemics of obesity, metabolic syndrome and diabetes mellitus continue to worsen, physicians will encounter severe, mixed dyslipidaemias more frequently. Many of these patients will require combinations of drugs to address the various metabolic derangements causing changes in multiple lipoprotein fractions. Although the need for combination therapy is well-established in the management of disorders, such as hypertension and diabetes, it is less often used for the treatment of dyslipidaemias. The development of safe, cost-effective, and efficacious combination dyslipidaemic therapy is an important goal in cardiovascular medicine. Simvastatin plus ezetimibe has recently been combined as a fixed dose therapy, which offers clinicians the opportunity to simultaneously inhibit two key pathways in cholesterol metabolism: hepatic cholesterol biosynthesis and the absorption of cholesterol at the level of the proximal jejunum. This dual mechanism of inhibition substantially increases the capacity to decrease serum levels of atherogenic low-density lipoproteins and increase high-density lipoprotein, compared with that observed when either drug is used alone. This combination increases the likelihood of therapeutic success in patients with dyslipidaemia.
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PMID:Simvastatin plus ezetimibe: combination therapy for the management of dyslipidaemia. 1570 90

The diabetic population is at high risk for development of cardiovascular disease (CVD), cerebrovascular disease, and peripheral vascular disease. Approximately 80% of these patients die from a thrombotic cause, with CVD complications being involved in 75% of those. The mechanisms involved in the development of coronary artery disease (CAD) in the diabetic population are multifactorial, including hyperglycemia, hyperlipidemia, hypertension, and insulin resistance, ultimately leading to endothelial dysfunction and accelerated atherogenesis. Thus, diabetes has become a CAD risk equivalent. Early and aggressive intervention in treating risk factors may reduce the risk of developing diabetes and may prevent CVD in patients with established diabetes.
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PMID:The proinflammatory and hypercoagulable state of diabetes mellitus. 1597 31

Peripheral vascular disease (PVD) is very prevalent in the United States and is part of a global vascular problem. PVD patients have a heightened inflammatory state and are at high risk of death from acute cardiovascular problems rather than from progression of PVD. Modifiable risk factors for PVD include smoking, hypertension, diabetes, hyperlipidemia, elevated high sensitivity C-reactive protein, obesity, and the metabolic syndrome. Symptomatic treatment of claudication includes smoking cessation, exercise, cilostazol, statins, and revascularization with percutaneous or surgical therapy. Antithrombotic therapy with aspirin or clopidogrel is important to reduce cardiovascular events but does not affect symptoms of claudication. Patients with rest limb ischemia or ulceration should be revascularized to minimize the chance of limb loss. Percutaneous revascularization is not without significant complications, however, and future research needs to focus on inflammation, thrombosis, and restenosis in the PVD patient. Finally, new devices that tackle difficult lesions, drug-eluting stents, and pharmacologic agents that reduce global atherosclerosis are on the horizon and are likely to become critical components in the management of the PVD patient.
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PMID:Evidence-based management of peripheral vascular disease. 1610 78

A disturbingly high prevalence of single or bilateral lower extremity amputations in our program prompted us to conduct a study to identify the prevalence of risk factors that predispose patients on hemodialysis (HD) to foot problems. The study consisted of a one-time assessment of subjects' risk for and actual prevalence of amputation. The sample consisted of 232 subjects--56% male, 44% female. Ages ranged from 21-91 years, mean age 65.1 and median age 69 years. The most common comorbidities were hypertension (75%), coronary artery disease (50%), diabetes (42.2%), hyperlipidemia (34.9%), and peripheral vascular disease (27.2%), which are all established risk factors for peripheral arterial occlusive disease. Twenty-one percent of subjects were current smokers; 28% were former smokers. Nearly 13.4% of subjects had undergone amputations ranging from single toes to bilateral above knee amputations. Only 31% of subjects had both bilateral palpable pedal pulses present. Neuropathy, as evidenced by the inability to feel the application of monofilaments to 10 sites on each foot or the presence of symptoms, was present in 74.6% of subjects. Only 2.6% of subjects demonstrated comprehensive self-care behaviors (SCBs). With respect to subjects' ability for self-care, 75% of subjects had adequate vision, 60% adequate dexterity, and 55% adequate flexibility to perform self-care. Study findings confirmed impressions that patients are at considerable risk for foot complications. Implications for nursing practice include regular foot assessment, education for self-care, and referral to specialists when required.
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PMID:Prevalence of risk factors predisposing to foot problems in patients on hemodialysis. 1618 Jul 79

The incidence of diabetes mellitus (DM) is increased in adult organ transplant recipients. As many as 30% to 45% of solid organ adult transplant patients have DM before transplantation or develop posttransplant diabetes mellitus (PTDM). Risk factors for PTDM include family history, ethnic or genetic background, insulin resistance, and diabetogenic effects of immunosuppressive medications. Posttransplant hyperglycemia may result in increased platelet aggregation, increased wound infections, dehydration, and loss of lean body mass. More significantly, long-term complications of DM such as coronary artery disease and peripheral vascular disease may be exacerbated with the use of immunosuppressive medications whose known side effects include hyperglycemia, hyperlipidemia, and hypertension; these effects may lead to premature transplant graft dysfunction. Treatment goals for PTDM reflect those of the American Diabetes Association guidelines; long-term management is linked with early, patient-centered education and optimizing minimally diabetogenic immunosuppressive medication regimens. A multidisciplinary team including the patient, family/support people, transplant surgeon, transplant physician, transplant nurse coordinator, transplant social worker, pharmacist, dietitian, and diabetes educator is crucial to long-term management of PTDM.
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PMID:Posttransplant diabetes mellitus: cause, impact, and treatment options. 1621 4

Peripheral vascular disease is a manifestation of systemic atherosclerosis that leads to significant narrowing of arteries distal to the arch of the aorta. The most common symptom of peripheral vascular disease is intermittent claudication. At other times, peripheral vascular disease leads to acute or critical limb ischemia. Intermittent claudication manifests as pain in the muscles of the legs with exercise; it is experienced by 2 percent of persons older than 65 years. Physical findings include abnormal pedal pulses, femoral artery bruit, delayed venous filling time, cool skin, and abnormal skin color. Most patients present with subtle findings and lack classic symptoms, which makes the diagnosis difficult. The standard office-based test to determine the presence of peripheral vascular disease is calculation of the ankle-brachial index. Magnetic resonance arteriography, duplex scanning, and hemodynamic localization are noninvasive methods for lesion localization and may be helpful when symptoms or findings do not correlate with the ankle-brachial index. Contrast arteriography is used for definitive localization before intervention. Treatment is divided into lifestyle, medical, and surgical therapies. Lifestyle therapies focus on exercise, smoking cessation, and dietary modification. Medical therapy is directed at reducing platelet aggregation. In addition, patients with contributing disorders such as hypertension, diabetes, and hyperlipidemia need to have these conditions managed as aggressively as possible. Surgical therapies include stents, arterectomies, angioplasty, and bypass surgery.
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PMID:Peripheral vascular disease: diagnosis and treatment. 1726 70

Patients with peripheral vascular disease are less likely to receive optimal medical management than patients with coronary artery disease. However, early medical treatment is critical because it is profoundly beneficial and the benefits are maximized. Even in patients with advanced disease requiring invasive intervention, medical management has been proven to improve outcome, prolong the success of the intervention, improve functional capacity, and prolong life. The vascular surgeon should be knowledgeable enough to initiate basic medical therapy and to define for their patients the goals that need to be met to optimize their medical management. The vascular surgeon should be instrumental in assuring that the peripheral vascular patient receives medical therapy of the same standard as the patient with coronary disease. The major modifiable risk factors in the vascular patient are: smoking, high blood pressure, hyperlipidemia, physical inactivity, obesity, and diabetes. In addition, the use of beta blockers for patients with coronary disease and antiplatelet therapy as well as angiotensin-converting enzyme (ACE) inhibitors are recommended for all patients with peripheral vascular disease. Statins have favorable effects on multiple interrelated aspects of vascular biology important in atherosclerosis. In particular they have beneficial effects on inflammation, plaque stabilization, endothelial dysfunction, and thrombosis. Statins have also been shown to be beneficial in acute vascular events. Angiotensin-converting enzyme inhibitors have been shown to reduce cardiovascular morbidity and mortality in patients with peripheral arterial disease regardless of the presence or absence of hypertension. A number of the pleiotropic effects of statins are shared by ACE inhibitors. In summary, patients with known vascular disease should be treated aggressively with a combination of a HMG CoA reductase inhibitor, an angiotensin-converting enzyme inhibitor, an antiplatelet agent and a beta blocker if there is a history of coronary disease. They should also receive tight control of their blood pressure and blood sugar. Smokers should be encouraged to stop smoking and should be provided with pharmaceutical and emotional support by their physicians. All of these patients should have their body mass index as close to normal as possible and be on a therapeutic lifestyle diet. Regular aerobic exercise is also indicated. Patients with symptomatic claudication should be considered for cilostazol. Patients with multiple risk factors for vascular disease, but who do not have documented disease should also be on statin therapy. As more studies define the linear relationship between lower LDL-C levels and lowered risk of vascular events, indicating that the lower the LDL-C level, the lower the risk, experts are advocating more aggressive lipid-lowering therapy. In patients with peripheral arterial disease, some experts now advocate lowering the goal of LDL therapy to 70 mg/dL.
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PMID:Optimal medical management of peripheral arterial disease. 1727 51

It is becoming increasingly clear that suboptimal blood glucose control results in adverse effects on large blood vessels, thereby accelerating atherosclerosis and cardiovascular disease, manifested as myocardial infarction, stroke, and peripheral vascular disease. Cardiovascular disease is accelerated by both type 1 and type 2 diabetes. In type 1 diabetes, hyperglycemia generally occurs in the absence of elevated blood lipid levels, whereas type 2 diabetes is frequently associated with dyslipidemia. In this review article, we discuss hyperglycemia versus hyperlipidemia as culprits in diabetes-accelerated atherosclerosis and cardiovascular disease, with emphasis on studies in mouse models and isolated vascular cells. Recent studies on LDL receptor-deficient mice that are hyperglycemic, but exhibit no marked dyslipidemia compared with nondiabetic controls, show that diabetes in the absence of diabetes-induced hyperlipidemia is associated with an accelerated formation of atherosclerotic lesions, similar to what is seen in fat-fed nondiabetic mice. These effects of diabetes are masked in severely dyslipidemic mice, suggesting that the effects of glucose and lipids on lesion initiation might be mediated by similar mechanisms. Recent evidence from isolated endothelial cells demonstrates that glucose and lipids can induce endothelial dysfunction through similar intracellular mechanisms. Analogous effects of glucose and lipids are also seen in macrophages. Furthermore, glucose exerts many of its cellular effects through lipid mediators. We propose that diabetes without associated dyslipidemia accelerates atherosclerosis by mechanisms that can also be activated by hyperlipidemia.
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PMID:Do glucose and lipids exert independent effects on atherosclerotic lesion initiation or progression to advanced plaques? 1752 72

A retrospective analysis was conducted of 79 consecutive patients who underwent enhanced external counterpulsation (EECP) at West Virginia University Hospitals during the period of November 1998 to September 2005 to determine its efficacy and safety in treating angina. A chart review and/or phone survey was performed to analyze pertinent clinical data (sublingual nitroglycerin use and angina class) pre and post EECP. A total of 60 (76%) patients who were referred for EECP successfully finished the 35 treatments. Seventy-five percent of the patient population improved at least one angina class after a full course of treatment. Therapy was discontinued due to adverse effects in 12 (15%) patients. Statistically significant improvements in angina class and reduction in anti-angina medications were observed in every co-morbid subgroup analyzed, including patients with peripheral vascular disease, diabetes, hyperlipidemia, hypertension, smoking, Post-MI, and LVEF < 40% (P < .05, Wilcoxon Signed-Rank test). Overall, EECP was effective in improving angina as reflected in a substantial reduction in antiangina medications in 59 (75%) patients.
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PMID:An analysis of the efficacy and safety of enhanced external counterpulsation at West Virginia University Hospitals. 1784 68


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