Lecture Cardiovascular Disease Epidemiology

„Classical“ Risk Factors

WS 2014/15 Focus:

Diabetes – Metabolic Syndrome - Obesity

Lecturer: PD Dr. Barbara Thorand Helmholtz Zentrum München German Research Center for Environmental Health Institute of Epidemiology II e-mail: [email protected]

Diabetes Mellitus - Classification

Diabetes Mellitus (DM) •

• Definitions: DM – IGT – IFG - IR • Prevalence – Awareness – Regional Differences

ß-cell destruction, ususally leading to absolute insulin deficiency •

• Micro- and macrovascular complications

Type 2 diabetes (formerly: Non-Insulin Dependent Diabetes Mellitus (NIDDM)) high blood glucose in the context of insulin resistance and relative insulin deficiency

• Prevention and Treatment

Diabetes Mellitus - Diagnosis

Type 1 diabetes (formerly: Insulin Dependent Diabetes Mellitus (IDDM))

•

Other specific types (e.g. genetic defects of ß-cell function, drug or chemical-induced)

•

Gestational diabetes

Diagnosis of Derangements in Glucose Metabolism 2h-glucose

Fasting glucose

•

HbA1c: ≥6.5% Diabetes

•

≥ 200 mg/dl (11.1 mmol/l)

Fasting plasma glucose (FPG): ≥126 mg/dl / ≥7.0 mmol/L Diabetes

or •

≥ 140 mg/dl (7.8 mmol/l)

2h postload plasma glucose: ≥200 mg/dl / ≥11.1 mmol/L ≥ 126 mg/dl (7.0 mmol/l)

The WHO recommends the performance of an OGTT and the use of FPG and 2h PG in the absence of overt hyperglycemia. The ADA criteria encourage use of HbA1c, FPG and 2hPG in that order, mainly due to practical reasons.

WHO criteria 2006/2011 ADA criteria 2012: Diabetes Care 2012; 35: S1: S64-71

≥ 110 mg/dl (6.1 mmol/l)*

IGT Impaired glucose tolerance

IFG Impaired fasting glucose

*ADA 2003/2012 uses ≥ 100 mg/dl (5.6 mmol/l) as the cutpoint for IFG

WHO criteria: 1999/2006/2011

1

Prevalence of Derangements in Glucose Metabolism (KORA S4 Study – 1999-2001, age: 55-74 yrs)

Regional Differences in the Prevalence of Type 2 Diabetes in Germany

9.2 % (7.3-11.1)

KORA F4 2006-2008, age: 35-59 yrs 2.4 2.2 7.9 3.2 84.3

7.1 % (6.4-7.8)

10.8 % (9.5-12.1)

11.8 % (10.2-13.6)

5.7 % (4.8-6.6)

Diabetes prev. diag.

Diabetes newly diag.

IGT

IFG

NGT

Prevalence (95% CI), standardized to the German population on December 31, 2007

Age range: 45-74 yrs

Schipf et al., Diabetic Medicine 2012

S4: Rathmann et al., Diabetologia 2003 F4: Meisinger et al. Diabetic Medicine 2009

Macrovascular Consequences

MI Morbidity per 100,000 Inhabitants diabetic vs. non-diabetic Men

Women

25-74 J. 1490 vs. 364

25-74 J. 653 vs. 94

OR 3,7

OR 5,9

(95% KI 3,5-3,9)

(95% KI 5,5-6,4)

Alter

Quelle: Löwel et al: Diab Stoffw 1999; 8: 11-21

2

Probability of Death From CHD in Patients With & Without Type 2 Diabetes, With & Without Prior MI

Survival after an Acute MI Results from the MONICA/KORA MI Registry

100

Survival (%)

80

survived >28 days

60 died on day 2-28 died 33,000 Conventional treatment vs. intensive glycemic control (HbA1c 0.90 (M), > 0.85 (W) or BMI > 30 kg/m2

Waist Circumference > 102 cm (M), > 88 cm (W)

Abdominal Adiposity

↓

Triglyceridee

↑

Metabolic Syndrome Microalbuminuria

Triglycerides HDL-Cholesterol

Impaired Hemostasis

Coronary Heart Disease

Blood Pressure

≥ 150 mg/dl

≥ 150 mg/dl

< 35 mg/dl (M) < 39 mg/dl (W)

< 40 mg/dl (M) < 50 mg/dl (W)

≥ 140/90 mmHg

≥ 130/85 mmHg

Impaired Glucose Metabolism

IGT / IFG / Diabetes / Insulin Resistance

Fasting Glucose ≥ 110 mg/dl

Microalbuminuria

Albumin in Urine ≥ 20 g/min or Albumin/Creatinine: ≥ 30 mg/g

Typ 2 Diabetes Mellitus

Metabolic Syndrome (MS)

Metabolic Syndrome (MS)

NCEP ATP III update by AHA/NHLBI 2005 / IDF 2005

IDF, NHLBI, AHA, WHF, IAS, IASO 2009

Risk Factor

NCEP ATP III Update AHA/NHLBI 2005 MS if ≥ 3 Factors

IDF Abdominal Adiposity + ≥ 2 other Factors

Risk Factor

IDF, NHLBI, AHA, WHF, IAS, IASO 2009 MS if ≥ 3 Factors

Abdominal Adiposity

Waist Circumference > 102 cm (M), > 88 cm (W)

Waist Circumference > 94 cm (M), > 80 cm (W) (Europeans)

Abdominal Adiposity

Population- and Country Specific Cutpoints (more research necessary)

Triglycerides

≥150 mg/dl or Treatment*

≥150 mg/dl or Treatment*

Triglycerides

HDL-Cholesterol

< 40 mg/dl (M) < 50 mg/dl (W) or Treatment*

< 40 mg/dl (M) < 50 mg/dl (W) or Treatment*

≥150 mg/dl or Treatment*

HDL-Cholesterol

Blood Pressure

≥130/85 mmHg or Treatment

≥130/85 mmHg or Treatment

< 40 mg/dl (M) < 50 mg/dl (W) or Treatment*

Blood Pressure

Impaired Glucose Metabolism

Fasting Glucose ≥ 100 mg/dl

Fasting Glucose ≥ 100 mg/dl or diagnosed DM

≥130/85 mmHg or Treatment

* with fibrates or nicotinic acid

Impaired Glucose Metabolism

IDF Cutpoints for NonEuropeans / IDF oder AHA/NHLBI for Persons with European Ancestry

Fasting Glucose ≥ 100 mg/dl or Treatment

* with fibrates or nicotinic acid

Alberti KGMM, et al. Circulation. 2009;120:1640–1645.

6

Prevention

Vascular Injury in Type 2 Diabetes BLACK BOX Dyslipidemia Hypertension Hyperinsulinemia/ Insulin Resistance Impaired Hemostasis Hyperglycemia Advance Glycation End-products (AGE) Oxidative Stress AGE = advanced glycation end products Adapted from Bierman EL. Arterioscler Thromb 1992;12:647-656.

ESC Guidelines 2013, Eur Heart J 2013, 34: 3035-87

Pharmacological Treatment

Pharmacological Treatment Glycemic target: HbA1c