Audit of cardiovascular risk assessment in type 2 diabetic patients referred for insulin therapy: a cardiological perspective

Abstract

We present an audit of cardiovascular risk, and drug prescription of 250 type 2 diabetic patients referred from primary care to a District General Hospital for prescription of 250 type 2 diabetic patients referred from primary care to a District General Hospital for management of insulin therapy. Prescription patterns were compared to current UK guidelines for primary and secondary prevention and evidence-based practice. The audit uncovered substantial under-recognition of the high vascular risk of this type 2 diabetic population with respect to the use of antiplatelet therapy, statins and angiotensin blockers. Type 2 diabetic patients requiring insulin therapy have a particularly high cardiovascular risk and we believe they should be considered for antiplatelet, statin and angiotensin blocking therapy on initiation of insulin treatment even if they have no previous history of overt vascular events.

Keywords

angiotensin blockers statins antiplatelet cardiovascular audit.

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References

Campbell IW , Purcell H. The silent sextet. Br J Diabetes Vasc Dis 2000; 1:3-6.

O'Driscoll G. , Green D. , Maiorana A. et al. Improvement in endothelial function by angiotensin-converting enzyme inhibition in non-insulindependent diabetes mellitus. J Am Coll Cardiol 1999;33:1506-11. 3. Festa A. , D'Agostino R., Jr Howard G. et al. Chronic subclinical inflammation as part of the insulin resistance syndrome: the Insulin Resistance Atherosclerosis Study (IRAS). Circulation 2000;102:42-7.

Takagi T. , Yoshida K. , Akasaka T. et al. Hyperinsulinemia during oral glucose tolerance test is associated with increased neointimal tissue proliferation after coronary stent implantation in nondiabetic patients: a serial intravascular ultrasound study. J Am Coll Cardiol 2000;36:731-8. Metabolism 2003;52(8 suppl 1):6-12.

Otel I. , Ledru F. , Danchin N. Ischemic heart disease in type 2 diabetes. Metabolism 2003;52(8 suppl 1):6:12.

Rumberger JA , Sheedy PF , Breen JF et al. Electron beam computed tomographic coronary calcium score cutpoints and severity of associated angiographic lumen stenosis. J Am Coll Cardiol 1997;29:1542-8.

Korpilahti K. , Syvanne M. , Engblom E. et al. Components of the insulin resistance syndrome are associated with progression of atherosclerosis in non-grafted arteries 5 years after coronary artery bypass surgery. Eur Heart J 1998;19:711-19.

Arad Y. , Newstein D. , Cadet F. et al. Association of multiple risk factors and insulin resistance with increased prevalence of asymptomatic coronary artery disease by an electron-beam computed tomographic study. Arterioscler Thromb Vasc Biol 2001;21:2051-8.

Haffner SM , Lehto S. , Ronnemaa T. et al. Mortality from coronary heart disease in subjects with type 2 diabetes and in nondiabetic subjects with and without prior myocardial infarction . N Engl J Med 1998;339:229-34.

Grover SA , Coupal L. , Zowall H. et al. Cost-effectiveness of treating hyperlipidemia in the presence of diabetes: who should be treated? Circulation 2000;102:722-7.

10.

Joint British recommendations on prevention of coronary heart disease in clinical practice. British Cardiac Society, British Hyperlipidaemia Association, British Hypertension Society, endorsed by the British Diabetic Association. Heart 1998;80(suppl 2):S1-29.

11.

Scottish Intercollegiate Guidelines Network (SIGN). Management of diabetes. (SIGN Guideline 55). Edinburgh: SIGN 2001 (available on www.sign.ac.uk).

12.

National Institute for Clinical Excellence. Management of type 2 diabetes. Management of blood glucose . NICE No.128, National Institute for Clinical Excellence , London, September 2002.

13.

Effects of ramipril on cardiovascular and microvascular outcomes in people with diabetes mellitus: results of the HOPE study and MICRO-HOPE substudy. Heart Outcomes Prevention Evaluation Study Investigators. Lancet 2000;355:253-9.

14.

Isomaa B. , Almgren P. , Tuomi T. et al. Cardiovascular morbidity and mortality associated with the metabolic syndrome. Diabetes Care 2001;24: 683-9.

15.

Patel V. , Panja S. , Venkataraman A. The HOPE and MICRO-HOPE Substudy: effects of ramipril on cardiovascular and microvascular outcomes in people with diabetes mellitus. Br J Diabetes Vasc Dis 2001;1: 44-51.

16.

McKee SP , Leslie SJ , LeMaitre JP et al. Management of chronic heart failure due to systolic left ventricular dysfunction by cardiologist and non-cardiologist physicians. Eur J Heart Fail 2003;5:549-55.

17.

Fagot-Campagna A. , Gary TL , Benjamin SM

Cardiovascular risk in diabetes: a story of missed opportunities?

Diabetes Care 2001;24:2015-16.

18.

Collins R. , Armitage J. , Parish S. et al. MRC/BHF Heart Protection Study of cholesterol-lowering with simvastatin in 5963 people with diabetes: a randomised placebo-controlled trial. Lancet 2003;361:2005-16.