Correlation between diabetes and Coronary artery Disease

Bangun Said Santoso

030.12.047

Trisakti University

2013
preface

Thanks to Allah SWT, because due his grace I can finish my paper with the title "Correlation between

diabetes and Coronary artery Disease." On time and without any material issues.

This paper is made to suit the requirement of passing english 2 Trisakti university faculty of medicine,

Hopefully this article can be useful for readers, especially for other medical students at other universities.

Author definitely needs to be developed criticisms and suggestions to the author peper in the future to get

better.

In this case I would like to thank:

 Allah SWT, my friend

Abstract

Heart health should always be a concern, but for people with diabetes, it is extremely important.

Diabetes is a disorder in which your body doesn’t produce or process insulin correctly and is often

directly connected to Coronary artery disease. In fact, a person with diabetes has twice the chance of

developing heart disease as someone without this condition. In the world, there were so many people that

killed by heart disease. People with diabetes didn’t know what exactly cause of Coronary artery can

happen to them
 Introduction

The connection between diabetes and Coronary artery disease starts with high blood glucose

(sugar) levels. With time, the high glucose in the bloodstream damages the arteries, causing them to

become stiff and hard. Fatty material that builds up on the inside of these blood vessels can eventually

block blood flow to the heart or brain, leading to heart attack or stroke.

Individuals with insulin resistance or diabetes in combination with one or more of these risk

factors are more likely to fall victim to Coronary artery disease. However, by controlling these risk

factors, diabetes patients may avoid or delay the development of heart and blood vessel disease.
Diabetes mellitus

Definition

Disbetes is a group of metabolic diseases in which a person has high blood sugar, either because

the pancreas does not produce enough insulin, or because cells do not respond to the insulin that is

produced. This high blood sugar produces the classical symptoms of polyuria (frequent urination),

polydipsia (increased thirst) and polyphagia (increased hunger).

There are two main types of diabetes mellitus (DM).

 Type 1 DM results from the body's failure to produce insulin, and currently requires the person to

inject insulin or wear an insulin pump. This form was previously referred to as "insulin-dependent

diabetes mellitus" (IDDM) or "juvenile diabetes".

 Type 2 DM results from insulin resistance, a condition in which cells fail to use insulin properly,

sometimes combined with an absolute insulin deficiency. This form was previously referred to as

non insulin-dependent diabetes mellitus (NIDDM) or "adult-onset diabetes".

Diabetes militus type1

type 1 diabetes mellitus is characterized by loss of the insulin-producing beta cells of the islets of

Langerhans in the pancreas, leading to insulin deficiency. This type can be further classified as immune-

mediated or idiopathic. The majority of type 1 diabetes is of the immune-mediated nature, in which beta

cell loss is a T-cell-mediated autoimmune attack. There is no known preventive measure against type 1

diabetes, which causes approximately 10% of diabetes mellitus cases in North America and Europe. Most

affected people are otherwise healthy and of a healthy weight when onset occurs. Sensitivity and

responsiveness to insulin are usually normal, especially in the early stages.

 Type 1 diabetes can affect children or adults, but was traditionally termed "juvenile diabetes"

because a majority of these diabetes cases were in children.

"Brittle" diabetes, also known as unstable diabetes or labile diabetes, is a term that was

traditionally used to describe to dramatic and recurrent swings in glucose levels, often occurring for no

apparent reason in insulin-dependent diabetes. This term, however, has no biologic basis and should not

be used. There are many reasons for type 1 diabetes to be accompanied by irregular and unpredictable

hyperglycemias, frequently with ketosis, and sometimes serious hypoglycemias, including an impaired

counterregulatory response to hypoglycemia, occult infection, gastroparesis (which leads to erratic

absorption of dietary carbohydrates), and endocrinopathies (e.g., Addison's disease). These phenomena

are believed to occur no more frequently than in 1% to 2% of persons with type 1 diabetes.

Diabetes militus type2

Type 2 diabetes mellitus is characterized by insulin resistance, which may be combined with

relatively reduced insulin secretion. The defective responsiveness of body tissues to insulin is believed to

involve the insulin receptor. However, the specific defects are not known. Diabetes mellitus cases due to a

known defect are classified separately. Type 2 diabetes is the most common type.

In the early stage of type 2, the predominant abnormality is reduced insulin sensitivity. At this

stage, hyperglycemia can be reversed by a variety of measures and medications that improve insulin

sensitivity or reduce glucose production by the liver.

Symptoms

The classic symptoms of untreated diabetes are loss of weight, polyuria (frequent urination),

polydipsia (increased thirst) and polyphagia (increased hunger). Symptoms may develop rapidly (weeks
or months) in type 1 diabetes, while they usually develop much more slowly and may be subtle or absent

in type 2 diabetes.

Prolonged high blood glucose can cause glucose absorption in the lens of the eye, which leads to

changes in its shape, resulting in vision changes. Blurred vision is a common complaint leading to a

diabetes diagnosis. A number of skin rashes that can occur in diabetes are collectively known as diabetic

dermadromes.

Causes

 Genetic, Heredity plays an important part in determining who is likely to develop diabetes

 Autoimmune Destruction of Beta Cells, white blood cells called T cells attack and destroy beta
cells. The process begins well before diabetes symptoms appear and continues after diagnosis.
Often, type 1 diabetes is not diagnosed until most beta cells have already been destroyed. At this
point, a person needs daily insulin treatment to survive. Finding ways to modify or stop this
autoimmune process and preserve beta cell function is a major focus of current scientific
research.
Recent research suggests insulin itself may be a key trigger of the immune attack on beta cells.
The immune systems of people who are susceptible to developing type 1 diabetes respond to
insulin as if it were a foreign substance, or antigen. To combat antigens, the body makes proteins
called antibodies. Antibodies to insulin and other proteins produced by beta cells are found in
people with type 1 diabetes.

 Environmental
 Obesity
 Insulin Resistance, Insulin resistance is a common condition in people who are overweight or
obese, have excess abdominal fat, and are not physically active. Muscle, fat, and liver cells stop
responding properly to insulin, forcing the pancreas to compensate by producing extra insulin. As
long as beta cells are able to produce enough insulin, blood glucose levels stay in the normal
range. But when insulin production falters because of beta cell dysfunction, glucose levels rise,
leading to prediabetes or diabetes.

Treatment

The main goal of diabetes mellitus treatment is to try to normalize the activity of insulin and
blood glucose levels in an attempt to reduce vascular complications as well as therapeutic
neuropati.Tujuan on any type of diabetes is to achieve normal blood glucose levels.
Complication

 Acute
Hypoglikemia, Symptomatic hypoglycemia reaction is caused by the body lacks glucose,
dengantanda Symptoms: hunger, trembling, cold sweat, dizziness. If this condition is not
segeradiobati, patients may be comatose. Because coma in patients due to the lack of glucose in
the blood, then the commas called "hypoglycemic coma".

 Chronic

Diabetic retinopathy, which is damage to the eye such as cataracts and glaucoma or

increased pressure in the eyeball. Form of damage is the most common form of retinopathy that

can lead to blindness.

Diabetic nephropathy, the renal impairment caused by diabetic patients in a long time.

Prevention

The same lifestyle habits that can help treat diabetes disease can also help prevent it from

developing in the first place. Leading a healthy lifestyle can help keep your blood sugar. To improve your

health, you can:

 Stay physically active

 Control your blood sugar

 Eating healthy foods

Coronary artery disease

Definition

Coronary artery disease develops when your coronary arteries the major blood vessels that

supply your heart with blood, oxygen and nutrients become damaged or diseased. Cholesterol-

containing deposits (plaque) on your arteries are usually to blame for coronary artery disease.

When plaques build up, they narrow your coronary arteries, causing your heart to receive less blood.

Eventually, the decreased blood flow may cause chest pain (angina), shortness of breath, or other

coronary artery disease signs and symptoms. A complete blockage can cause a heart attack.

Because coronary artery disease often develops over decades, it can go virtually unnoticed until

you have a heart attack.

Epidemiology

Cerebro Vascular Disease encompasses not only CAD but also cerebrovascular disease,

peripheral arterial disease as well as other cardiac disorders, and is currently the leading cause of death in

the world, particularly amongst women. The World Health Organisation (WHO) estimates that such

diseases caused almost 32% of all deaths in women and 27% in men in 2004 (World Health Organisation

[WHO], 2008). CAD is the most common cause of CVD deaths (45% of all CVD deaths) accounting for

7.2 million deaths/year, or 12% of all deaths worldwide (Figure 2). In many developed countries, CAD is

the single leading cause of death. In the United Kingdom (UK) in 2008, CAD was responsible for about

one in five male deaths and one in eight female deaths; a total of 88,000 CAD deaths (15% of total

deaths) (British Heart Foundation [BHF], 2010). Similarly in the United States in 2005, CAD was

responsible for one of every five deaths, accounting for 445,687 deaths (18% of total deaths) (Lloyd-

Jones et al, 2009). In Australia in 2006, CAD accounted for 22,983 deaths (17% of all deaths) and once

more was the most common condition responsible for Australian deaths (Australian Institute of Health

and Welfare [AIHW], 2010).

Etiologi

Coronary artery disease is thought to begin with damage or injury to the inner layer of a

coronary artery. The damage may be caused by various factors, including:

 Smoking

 High blood pressure

 High cholesterol

 Diabetes

 Radiation therapy to the chest, as used for certain types of cancer

Pathology

Once the inner wall of an artery is damaged, fatty deposits (plaques) made of cholesterol and

other cellular waste products tend to accumulate at the site of injury in a process called atherosclerosis.

If the surface of these plaques breaks or ruptures, blood cells called platelets will clump at the site to try

to repair the artery. This clump can block the artery, leading to a heart attack

Diagnosis

The doctor will ask questions about your medical history, do a physical exam and order routine

blood tests. Doctor may suggest one or more diagnostic tests as well, including:

 Electrocardiogram (ECG). An electrocardiogram records electrical signals as they travel

through your heart. An ECG can often reveal evidence of a previous heart attack or one that's

in progress. In other cases, Holter monitoring may be recommended. With this type of ECG,
 you wear a portable monitor for 24 hours as you go about your normal activities. Certain

abnormalities may indicate inadequate blood flow to your heart.

 Echocardiogram. An echocardiogram uses sound waves to produce images of your heart.

During an echocardiogram, your doctor can determine whether all parts of the heart wall are

contributing normally to your heart's pumping activity. Parts that move weakly may have

been damaged during a heart attack or be receiving too little oxygen. This may indicate

coronary artery disease or various other conditions.

 Cardiac catheterization or angiogram. To view blood flow through your heart, your doctor

may inject a special dye into your arteries (intravenously). This is known as an angiogram.

The dye is injected into the arteries of the heart through a long, thin, flexible tube (catheter)

that is threaded through an artery, usually in the leg, to the arteries in the heart. This

procedure is called cardiac catheterization. The dye outlines narrow spots and blockages on

the X-ray images. If you have a blockage that requires treatment, a balloon can be pushed

through the catheter and inflated to improve the blood flow in your coronary arteries. A mesh

tube (stent) may then be used to keep the dilated artery open.

 CT scan. Computerized tomography (CT) technologies, such as electron beam computerized

tomography (EBCT) or a CT coronary angiogram, can help your doctor visualize your

arteries. EBCT, also called an ultrafast CT scan, can detect calcium within fatty deposits that

narrow coronary arteries. If a substantial amount of calcium is discovered, coronary artery

disease may be likely. A CT coronary angiogram, in which you receive a contrast dye

injected intravenously during a CT scan, also can generate images of your heart arteries.

 Magnetic resonance angiography (MRA). This procedure uses MRI technology, often

combined with an injected contrast dye, to check for areas of narrowing or blockages

although the details may not be as clear as those provided by coronary catheterization
Treatment

o Drugs

Various drugs can be used to treat coronary artery disease, including:

 Cholesterol-modifying medications. By decreasing the amount of cholesterol in the

blood, especially low-density lipoprotein (LDL, or the "bad") cholesterol, these

drugs decrease the primary material that deposits on the coronary arteries. Boosting

your high-density lipoprotein (HDL, or the "good") cholesterol may help, too. Your

doctor can choose from a range of medications, including statins, niacin, fibrates and

bile acid sequestrants.

 Aspirin. Your doctor may recommend taking a daily aspirin or other blood thinner.

This can reduce the tendency of your blood to clot, which may help prevent

obstruction of your coronary arteries. If you've had a heart attack, aspirin can help

prevent future attacks. There are some cases where aspirin isn't appropriate, such as

if you have a bleeding disorder or you're already taking another blood thinner, so ask

your doctor before starting to take aspirin.

 Beta blockers. These drugs slow your heart rate and decrease your blood pressure,

which decreases your heart's demand for oxygen. If you've had a heart attack, beta

blockers reduce the risk of future attacks.

 Nitroglycerin. Nitroglycerin tablets, sprays and patches can control chest pain by

opening up your coronary arteries and reducing your heart's demand for blood.

 Angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor

blockers (ARBs). These similar drugs decrease blood pressure and may help prevent

progression of coronary artery disease. If you've had a heart attack, ACE inhibitors

reduce the risk of future attacks.

  Calcium channel blockers. These medications relax the muscles that surround your

coronary arteries and cause the vessels to open, increasing blood flow to your heart.

They also control high blood pressure.

Procedures to restore and improve blood flow

Sometimes more aggressive treatment is needed. Here are a few options:

 Angioplasty and stent placement (percutaneous coronary revascularization). In

this procedure, your doctor inserts a long, thin tube (catheter) into the narrowed part

of your artery. A wire with a deflated balloon is passed through the catheter to the

narrowed area. The balloon is then inflated, compressing the deposits against your

artery walls. A stent is often left in the artery to help keep the artery open. Some

stents slowly release medication to help keep the artery open.

 Coronary artery bypass surgery. A surgeon creates a graft to bypass blocked

coronary arteries using a vessel from another part of your body. This allows blood to

flow around the blocked or narrowed coronary artery. Because this requires open-

heart surgery, it's most often reserved for cases of multiple narrowed coronary

arteries

Complications

 Chest pain (angina). When your coronary arteries narrow, your heart may not receive

enough blood when demand is greatest — particularly during physical activity. This can

cause chest pain (angina) or shortness of breath.

 Heart attack. If a cholesterol plaque ruptures and a blood clot forms, complete blockage of

your heart artery may trigger a heart attack. The lack of blood flow to your heart may

damage to your heart muscle. The amount of damage depends in part on how quickly you

receive treatment.
  Heart failure. If some areas of your heart are chronically deprived of oxygen and nutrients

because of reduced blood flow, or if your heart has been damaged by a heart attack, your

heart may become too weak to pump enough blood to meet your body's needs. This

condition is known as heart failure.

 Abnormal heart rhythm (arrhythmia). Inadequate blood supply to the heart or damage

to heart tissue can interfere with your heart's electrical impulses, causing abnormal heart

rhythms.

Prevention

The same lifestyle habits that can help treat coronary artery disease can also help prevent it from

developing in the first place. Leading a healthy lifestyle can help keep your arteries strong and clear of

plaques. To improve your heart health, you can:

 Quit smoking

 Control conditions such as high blood pressure, high cholesterol and diabetes

 Stay physically active

 Eat a low-fat, low-salt diet that's rich in fruits, vegetables and whole grains

 Maintain a healthy weight

Reduce and manage stres

Correlation between diabetes and Coronary artery Disease.

People with impaired glucose tolerance have a higher risk for CHD. Even in the presence of

normoglycemia, an increase in cardiovascular risk is observed as the glucose increases. It has been

proposed that glucose is a continuous cardiovascular risk factor, similar to hypercholesterolemia and

hypertension.

In the Whitehall Study, there was an increase of 1.5- to 2-fold in CHD mortality for people

with a 2-hour post-50-g glucose load of 5.4 mmol/L (~95th percentile), independent of age, smoking,

blood pressure, cholesterol, and occupation.

The Rancho Bernado Study of 3,458 men and women followed for an average of 14 years

showed a linear increase in ischemic heart disease mortality rates with increasing fasting blood glucose

(FBG) in men. The threshold effect of increased mortality with FBG in women was an FBG of >110

mg/dl.Based on the above, dysglycemia has been proposed as a cardiovascular risk factor. Gerstein

postulated that plasma glucose concentrations are associated with different risk at different

concentrations:

 in the diabetic range, glucose is associated with an increasing risk of macroangiopathies and

microangiopathies.

 in the impaired glucose tolerance range, glucose is associated with an increased risk for diabetes

and CVD.

 in the yet-to-be-defined "dysglycemia" glucose levels in the nor mal range, glucose is associated

with increased risk for CVD alone.

Recently, FBG was called an underestimated risk factor for cardiovascular death. An FBG >85 mg/dl had

a relative risk of cardiovascular death for men of 1.4 even after adjusting for age, smoking habits, serum

lipids, blood pressure, and physical fitness. A meta-regression analysis of published data from 20 studies
of 95,783 individuals followed for 12.4 years showed the progressive relationship between glucose levels

and cardiovascular risk extends below the diabetic threshold.

Conclusion

The DM-CHD connection is complex. Hyperglycemia in the diabetic range does not explain all

of it. The prevalence and incidence of CHD are increased in people with diabetes. Many, but not all,

studies show an increased risk for CHD with rising fasting and post-challenge plasma glucose, even in the

nondiabetic range. Dysglycemia appears to be a continuous cardiovascular risk factor.

It appears that diabetes, with hyperglycemia as its hallmark, is a major risk factor for

development of CHD and the adverse outcomes after MI. Intensive insulin therapy following MI in

diabetic patients reduces mortality.

Although adults with diabetes have a higher prevalence of cardiovascular risk factors, these

account for <50% of the excess mortality associated with diabetes. Clustering of cardiovascular risk

factors is more common in people with diabetes.

Although much new knowledge has been uncovered on the DM-CHD connection in the past

decade, more research to elucidate it is urgently needed. This is important, for it can affect significantly

the morbidity and mortality of diabetes.

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