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Risk of heart disease
The risk of developing coronary heart disease, which is the
kind of heart disease that is commonest in western society,
the kind that diabetes is particularly prone to. The risk is
roughly double in diabetics against the general population
without diabetes. Certainly a large proportion of diabetics
will present some form of arteriosclerosis, either in their
heart in the form of angina, heart attack or congestive heart
failure. In the circulation to the brain leading to stroke or
in the circulation to the periphery leading to abnormalities
of blood flow to the legs, the development of aneurisms in the
abdomen, abnormalities of the blood flow to the kidneys. That
is a common disease, arteriosclerosis, whether it occurs in
the heart, the cerebral or head circulation or elsewhere in
the body, it is all the same disease. While factors other than
diabetes will contribute to its development it is systemic in
nature and may occur in any of those in diabetics. Roughly
twice as prone as to the general population who have other
risk factors. In other words, diabetes is the most potent
factor for the development of arteriosclerosis that we know
of. More potent than isolated elevation of cholesterol, more
potent than high blood pressure, more potent than cigarette
smoking and more potent than family history. They are a more
difficult group to treat in general because their rate of
progression of their arteriosclerosis is higher on average and
because the amount of arteriosclerosis at any given time, what
we call the burden of arteriosclerosis, tends to be higher at
any point in their treatment. And as a consequence, although
they do very well in angiographies, they have a higher
likelihood of re-narrowing the sites of angioplasty, and they
have a higher likelihood of having their bypass grasp fail
than non-diabetic patients and requires a second bypass
operation higher incidences in diabetics for second bypass
operations. To put it in perspective, one of the ways that we
categorize patients with coronary disease is by the number of
blocked vessels that are involved. If just one of the three
vessels is involved, we call it single vessel disease. If it
is two, we call it a double and if it is three then we call it
triple vessel disease. The prognoses, the outlook for patients
with single vessel disease is much more favorable, for
instance, than the outlook, prognoses for patients with triple
vessel disease. If one examines the prognoses in diabetics
versus non-diabetics, the potency in the effects of diabetics
can be seen. Diabetics with single vessel disease fair as
poorly as non- diabetics with triple vessel disease in their
risk of heart attack, stroke, and death as a consequence with
their arteriosclerosis. Well, there is hope for diabetics. I
think the outlook is vastly better than it was even a decade
ago and there are many reasons to this. First of all, our
conventional therapies like bypass surgery and angioplasty,
although it is not good in diabetics are still very effective
therapies in diabetics and can offer a great deal of symptom
relief and in the case of bypass surgery, prolongation of life
and prevention of heart attack. The last five years has seen a
heightened awareness of the importance of very tight diabetic
control, tight glycemic control. Not only to prevent
complications in the small blood vessels, such as in the
kidneys, but also to prevent the development of
arteriosclerosis. And we now know with reasonable certainty
that tight diabetic control delays the progression of
arteriosclerosis and prevents heart attack as a consequence of
that progression in diabetic patients. And then the third
breakthrough really, is the recognition of the synergistic
benefits of controlling cholesterol with potent cholesterol
lowering medications and controlling blood pressure with blood
pressure medications. And finally, the administering drugs
such as the ACE inhibitors, which contribute directly to
restoring vascular health in diabetic patients. I want to
relate a story of a patient that Dr. Elliott and I looked
after just six weeks ago in the coronary care unit. The
delightful Slavic gentleman, who presented with his first
heart attack and at the same time his first diagnoses of
diabetes. Like many type 2 diabetes patients he probably has
his diabetes unrecognized for five or ten years. He was
seventy pounds overweight, he was drinking too much vodka, he
was smoking, he was eating a diet high in fast foods and
saturated and pre-prepared foods and he had an epiphany. I saw
him in the office yesterday and he has lost twenty pounds, he
is eating a healthy diet and he has completely quit smoking
and quit drinking and is undergoing a rapid titration of his
diabetes medication under Dr. Elliott’s care. I think that
those kinds of whole self-changes in lifestyles are the sorts
of things that we are talking about here. Weight loss, control
of high blood pressure, control of lipids, control of diabetes
and elimination of the bad actors, excessive alcohol intake,
and cigarette smoking in any degree. It is a very optimist
outlook for a patient like that.
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Blood Vessel damage
in the eye
Years ago, a lot of patients used to loose eyesight from
diabetes. It still happens but it happens a great deal less
than it used to. And the primary reason that it does not
happen as much is because we are able to save a lot of
patient’s eyesight by using laser treatment. Diabetes affects
the blood circulation throughout the body and it affects the
small blood vessels everywhere and the eye is no exception.
The eye is very much like the camera with lenses upfront and
film in the back. The film that lines the back of the eye and
takes pictures that we see is called the retina and in the
retina there are tiny little blood vessels, arteries and veins
that bring the blood to and from the back of the eye. In
diabetes, the blood circulation is not as good as it ought to
be and those blood vessels can close off and what can happen
is new blood vessels can grow. They can cause bleeding and
scarring and blood vessels can leak fluid into the center of
vision, which is called the macula. The two problems that we
see in diabetic eye disease, in diabetic retinopathy, are new
blood vessels growing and bleeding and the blood vessels
leaking fluid into the center. Both of those problems can be
treated with laser, which can often cut vision lost in half.
But we find that if we catch patients early, while they still
have pretty good vision, the laser treatment is much more
effective. So we really need to screen patients in advance
before they have trouble with their eyesight on a routine
basis usually once a year. And if they are doing well, we will
see them back the next year. If they have problems, then we
can do some tests to see whether laser treatment will be help
in holding on to vision. What we have learned in large studies
of patients with diabetes is that we can cut vision lost in
half with the laser treatment. Some of the people who take
really good care of themselves can have wonderful sight for
their whole lives and other people who are not as careful
often lose eyesight in a pretty serious way
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