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What
treatment options are available?
Treatment of CHD in people with diabetes is very similar
to that in those without. There are three stages to the treatment
of CHD, depending on how advanced the disease is.
1. Lifestyle changes
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High-carbohydrate, low-fat diet. |
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Stop smoking. |
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Increase physical activity. |
2. Pharmacologic
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Antithrombotics. |
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ß-blockers. |
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Lipid-lowering agents. |
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ACE inhibitors. |
3. Revascularisation procedures
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Percutaneous transluminal coronary angioplasty (PTCA). |
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Percutaneous coronary artery stenting. |
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Coronary artery bypass grafting (CABG). |
Although these are all separate therapies they can be used
concomitantly. However, the introduction of each therapy is
usually made stepwise if previous therapies fail to provide
continued symptom control.
The first sign of CHD is raised cholesterol levels. A recent
report from the National Cholesterol Education Program (NCEP)
stated that diabetes counts as a CHD risk equivalent.
[Adult Treatment
Panel III, 2001]
When assessing a person's risk status there are three categories
that modify LDL-cholesterol goals, and people with CHD risk
equivalents carry the highest risk of CHD. People with diabetes
are included in this group, whose risk of coronary events
is equal to that of those with established CHD. They, therefore,
also have the lowest LDL-cholesterol goal, <100 mg/dl (<2.6
mmol/l).
[Adult Treatment
Panel III, 2001]
The NCEP report provided guidelines on when to initiate primary
and secondary intervention in patients with CHD risk equivalents.
Primary intervention involves therapeutic lifestyle changes,
while secondary intervention involves lipid-lowering drugs.
The LDL-cholesterol levels at which each should be considered
are outlined below in Table 1. [Adult
Treatment Panel III, 2001]
| |
LDL-C goal
|
LDL-C level at which to initiate therapeutic lifestyle
changes
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LDL-C level at which to consider drug therapy
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CHD risk equivalents
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≥ 130
(≥ 3.4)
|
Table 1.
LDL-cholesterol goals and cutpoints in mg/dl (mmol/l) for
therapeutic lifestyle changes and drug therapy in people with
diabetes.
[Adult
Treatment Panel III, 2001]
However, some patients present with advanced CHD, or in
others, primary and secondary intervention may not be effective.
These patients require revascularisation procedures, such
as those listed above. This can range from a patient with
unstable angina, who may elect for revascularisation, to someone
suffering from a myocardial infarction, who requires rapid
reperfusion of the myocardium. The intervention used will
depend on many different factors including the presentation,
and extent of disease and angiographic evidence. This will
be discussed further in the next section.
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Why is the
emphasis on mechanical reperfusion in patients with diabetes?
The mortality of people with diabetes is reduced
with the introduction of thrombolytic agents. In one study,
although the rate of successful reperfusion was not significantly
different in patients with diabetes compared to those without,
the 30-day mortality rate was still much higher in people with
diabetes. Although thrombolysis is sometimes still used in emergency
situations, these findings prompted some investigators to question
whether strategies with mechanical reperfusion might improve
the fate of patients with diabetes. [Mak
et al, 1996]
Because of the high rates of mortality associated with thrombolysis,
many studies have recently examined the relationship between
the intervention used in people with diabetes and mortality
rates. In particular, coronary artery stenting has attracted
a lot of attention as it is percutaneous but has lower rates
of restenosis than other percutaneous techniques. This is
of great importance when treating people with diabetes as
they have a much higher risk of restenosis than people without.
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