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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 6  |  Issue : 2  |  Page : 39-44

Appraising risk of development of cardiovascular disease in patients with type 2 diabetes mellitus


1 Department of Pharmacy Practice, Al-Ameen College of Pharmacy, Bengaluru, Karnataka, India
2 Department of General Medicine, St. Philomena's Hospital, Bengaluru, Karnataka, India
3 Department of Pharmacy, Nelson Mandela University, Port Elizabeth, Grahamstown, South Africa
4 Department of Pharmacy Practice, Rhodes University, Grahamstown, South Africa

Date of Web Publication19-Jun-2018

Correspondence Address:
Shadan Modaresahmadi
No. 4, Mother Theresa Road, Near Life Style, Vivek Nagar Post, St. Philomena's Hospital, Bengaluru, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/heartindia.heartindia_7_18

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  Abstract 


Background: Research shows a strong relationship between type 2 diabetes mellitus (T2DM) and cardiovascular diseases (CVD). Most commonly, diabetic participants experience increased morbidity and mortality due to CVD complications. This study aims to determine the proportion of CVD prevalence and to evaluate the risk factors for developing CVD among T2DM participants and to evaluate the CVD risk factor for the next 10 years using Joint British Societies recommendations on the the Prevention of Cardiovascular Disease (JBS3) scale.
Materials and Methods: In this hospital-based observational study, data including serum creatinine, blood urea, high-density lipoprotein (HDL), low-density lipoprotein (LDL), very LDL, echocardiography, and ECHO readings were collected from a random sample of 106 participants, both diabetic and nondiabetic. The risk of developing CVD in participants with DM in the next 10 years was evaluated using the JBS3 risk calculator through analysis of collected data.
Results: Among 106 participants, there were 72 participants with DM, and the majority of these participants had comorbidities, including hypertension and other CVDs. According to the data collected from DM participants, it was observed that 77.77% had elevated serum creatinine value, 27.77% had elevated blood urea level, 61.11% had abnormal HDL value, 65.27% had elevated LDL value, and 26.38% had elevated VLDL value. Total triglycerides level was also observed to be high in 54.16% of the DM participants. Moreover, the results indicated that CVD was present in 77.78% of type 2 diabetic patients, which was comparatively higher than in nondiabetic participants of whom 32.35% had CVD.
Conclusion: Based on the data collected and results obtained from the JBS3 risk calculator, it was found that the participants with DM were at higher risk of developing CVD.

Keywords: Cardiovascular disease, low-density lipoproteins, type 2 diabetes mellitus, very low-density lipoproteins


How to cite this article:
Modaresahmadi S, R Hiremath SR, Vithya T, Prasad S, Bobbins A, Srinivas S. Appraising risk of development of cardiovascular disease in patients with type 2 diabetes mellitus. Heart India 2018;6:39-44

How to cite this URL:
Modaresahmadi S, R Hiremath SR, Vithya T, Prasad S, Bobbins A, Srinivas S. Appraising risk of development of cardiovascular disease in patients with type 2 diabetes mellitus. Heart India [serial online] 2018 [cited 2018 Nov 21];6:39-44. Available from: http://www.heartindia.net/text.asp?2018/6/2/39/234664




  Introduction Top


Noncommunicable diseases (NCDs) are currently the world's greatest public health challenge, with cardiovascular diseases (CVD), cancers, chronic respiratory diseases, and diabetes resulting in 63% deaths globally.[1] Diabetes in adults (20–79 years) is estimated to increase to 439 million (7.7%) by 2013, with an estimated 20% increase in developing countries alone, largely accredited to population growth, increased life expectancy, fluctuation in aging populations and urbanization, and associated lifestyle changes. In the long-term, diabetes may lead to complications that result in premature death; most commonly involving heart attacks, kidney failure, stroke, limb amputation, nerve damage, and vision loss.[2]

India has a triple burden of disease, with the rapid rise in NCDs threatening sustainable development of the health system and economy as a whole. In 2010, NCDs resulted in approximately 235 million disability-adjusted life years (DALYs), with the increased diabetes burden having resulted in an estimated 8 million DALYs in 2010.[3] In 2012, 63 million Indians were living with diabetes mellitus (DM), with an estimated 33% of adults estimated to be undiagnosed by the International Diabetes Federation in 2012. The alarmingly high rate of DM in India has resulted in the country being named the “diabetes capital of the world” and will have an estimated 87.0 million adults with DM in 2030.[4],[5]

Most commonly, diabetic participants experience a death due to CVD complications, more than any other related cause, such as ketoacidosis or hypoglycemia.[5] CVD and DM develop earlier in South Asians with complications arising more frequently compared to those of European descent.[6],[7] The reason for a higher CVD risk for those of South Asian descent is unclear; however, it is thought that it may be due to a higher prevalence of insulin resistance and adherence risk factors prevalent in the population.[6],[8] Other factors previously mentioned, such as urban lifestyle (inadequate diet and lack of physical activity), further drives this link between insulin resistance and consequent CVS in South Asian populations. There is a noted low amount of research focused on South Asian communities with regard to the diabetes and CVS link, thus knowledge gaps are prevalent and are a barrier to successful health promotion interventions regarding the diabetes and CVD association.[9] Thus, the inequality in the availability of health promotion and education, together with the unequal access to healthcare and effective management of diabetes and CVD also drive the prevalence of the diabetes and CVD link, exacerbated by contextual cultural or traditional health beliefs an relative socioeconomic status.[10] The increase in diabetes in India and other developing countries threatens strides made to combat the high prevalence of CVD in low- and middle-income (LMIC) countries.[4]

The purpose of the study was to assess the risk of development of CVD among DM participants in the next 10 years using the Joint British Societies recommendations on the Prevention of Cardiovascular Disease (JBS3) CVD risk calculator (JBS3), and to identify associated risk factors in the development of CVD in these participants. CVD and associated outcomes are often determined by assessing a combination of risk factors often co-existing in participants, with prevention of CVD requiring the integrated approach targeting different organ systems and related conditions. An estimation of CVD risk is desirable; however, previous strategies were based on quantification of a 10-year risk (considered short-term risk) with pharmacological treatments being employed if this risk surpasses a threshold value. This “risk-based” approach is employed to direct treatment to those of highest absolute benefit; however, concerns have since arisen, as there is a “continuum” of CVD risk and most CVD events are actually reported in those with an intermediate CVD risk (20% of 10 years risk). Thus, the new JBS3 risk calculator has been intended to evaluate individuals in the population that are at low short-term risk, but high lifetime risk, with novel metrics being used to quantify heart age and CVD event-free survival displayed together with the 10-year risk. Long-term consequences of the lifestyle of an individual are evaluated, thus CVD risk factors and the lowering of these can be modified earlier on where necessary by the use of appropriate drug therapies. In addition, this risk estimation helps facilitate dialogue between health professional and patient to ensure that risk factors can be minimized earlier on in participants life through the evaluation of CVD risk more long term.[11]


  Materials and Methods Top


This observational-based study was conducted from June to November 2016, with data being collected during the first 4 months of the study to appropriately estimate the prevalence of CVD among DM participants at Tertiary Care Hospital, Bengaluru. The study was approved by the Institutional Ethical Review Board committee, and the study was explained to participants in their own language, with their written informed consent being obtained before participation in the study.

The analysis of lipid profile tests was carried out for participants with medical histories of DM and CVD. The details regarding medical and medication histories were collected from the case sheets and bedside interviews of participants. The data were analyzed statistically to assess the risk factors of CVD among type 2 DM (T2DM) subjects, using the JBS3 risk calculator to estimate both 10-year risk and lifetime risk of CVD in all individuals, except those with existing CVD. There is a relationship between cholesterol levels and CVD risk with the absolute benefit of cholesterol reduction being related to the baseline CVD risk. Thus, CVD risk can be determined by values of nonfasting blood samples to measure total cholesterol and high-density lipoprotein (HDL) level, both in participants with and without CVD. The JBS3 risk calculator allows the entry of these values to calculate the CVD risk in participants.[11]

Statistical analysis

Normally distributed variables were reported using mean ± standard deviation and categorical variables were reported using numbers and percentages. Continuous variables, which were normally distributed, were compared between categories using an Independent t-test and the Mann–Whitney U-test used for the comparison. The association between the categorical variables was examined using the Chi-square test or Fisher's exact test as appropriate. All the analyses were done using SPSS version 24 (IBM Corporation, Armonk, New York, United States of America).


  Results Top


A total number of 106 participants were included in this study, out of which 54 were male and 52 were female. [Table 1] shows the demographic details, risk factors, and clinical features of the study population. From [Table 1], it can also be understood that the study population had both diabetic males and diabetic females. Risk factors such as hypertension and body mass index (BMI) (>25 kg/m 2) were prevalent in individuals of the diabetic population. Similarly, HbA1c (>6.5), elevated blood urea, and elevated serum creatinine were significantly higher in the diabetic population compared to the non-DM population. [Table 1] also represents the abnormal electrocardiogram and abnormal ECHO in CVD participants. The overall age group of participants ranged from 22 to 89 years old. [Figure 1] shows that majority of the participants were between the age range of 51–60 years in both the DM and non-DM Group.
Table 1: Demographic details, risk factors, and clinical feature of the study population (n=106)

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Figure 1: Distribution of patients with respect to age

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Serum creatinine, total triglyceride and low-density lipoproteins (LDL) values were significantly elevated in participants with DM (P< 0.001) and in CVD participants; however, HDL values were decreased in DM participants, although not proven as statistically significant (P = 0.100), and in participants with CVD (P = 0.489) when compared to non-DM participants [Table 2]. Very LDLs value was significantly elevated in participants with DM (P = 0.037) compared to non-DM participants, but not significantly proved (P = 0.0587) among CVD participants [Table 2]. [Table 3] shows the presence of CVD among DM participants, which was high and significantly proven (P< 0.001) when compared to non-DM participants. The JBS3 risk calculation score was carried out among all non-CVD participants to assess their risk ratio to develop CVD for the next 10 years. It was observed that the risk ratio was higher for the DM participants when compared with non-DM participants [Figure 2].
Table 2: Distribution of patients with respect to elevated biochemistry values among diabetes mellitus, nondiabetes mellitus, and cardiovascular diseases

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Table 3: Distribution of patients with respect to the presence of cardiovascular disease

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Figure 2: Distribution of patients based on 10-year cardiovascular diseases risk category

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  Discussion Top


It was observed that 77.78% of DM participants had CVD; and with respect to the JBS3 risk calculation score, it was found that the risk ratio was high for the DM participants when compared with non-DM participants. Similarly, in other study carried out by Tungdim et al.[5] based on gender-specific CVD risk scores, approximately one-third of the participants recruited for the study will have cardiovascular complications in the next 10 years, with 38.3% being high risk, 37% moderate risk, and 24.7% low risk. Participants with diabetes are at 2-fold to 4-fold risk of developing CVD, such as coronary artery disease (CAD), as diabetes and insulin resistance increase this risk, but also hypertension, obesity, physical inactivity, and age (the risk factors for diabetes) are also risk factors of the development of CVD.[12],[13] This is also coherent with the results of the Chennai Urban Population Study, whereby 11% of respondents in LMIC groups in Chennai, South India, had CAD, 1.2% had a myocardial infarction, 1.5% with ST-segment changes, 7% with T-wave abnormalities, and 1.3% with Q-wave abnormalities. The study not only indicated 10 times the prevalence rate of diabetes in urban areas since 1970 but also that diabetic respondents had 21.4% CAD (compared to 9.1% with no diabetes or glucose intolerance).[14],[15]

The study reports a higher prevalence of DM in female participants. Currently, in India studies surrounding gender distribution of DM is inconclusive, as some studies from the North, including that by Misra et al.[16] report a prevalence in women and others from the South including Ramachandran et al.[17] report a prevalence of men, while some find no prevalence, such as that by Tripathy et al.[18] However, the rate of diabetes in women could be widely unreported in India due to traditional gender roles, socioeconomic position of women, decision-making abilities of women in families, and control of resources of the individual. Fifty-five percent of early diagnoses of T2DM are males.[19] Analyses have shown that diabetes contributes for a more intensive cardiovascular risk profile, with women having higher levels of blood pressure and lipids than men.[20],[21] The prevalence of treatment bias is evident in many contexts in both developing and developed countries, with men with diabetes or diagnosed with CVD more likely to receive statin, aspirin, or antihypertensive over women with DM.[22],[23]

In this study, it was observed that hypertension is more predominant in the diabetic population by 72.22%. The prevalence of hypertension and diabetes varies between the urban and rural population, due to urbanized living contributing to the epidemiological transition that underpins the spread of NCDs, of which hypertension is a part.[24],[25],[26] There is an estimated 33% hypertension in urbanized populations and 25% rural population, with diabetes showing a similar trend with 12.9% urban Indians with diabetes and 6.5% in rural India.[26]

In 2008, the WHO stated that the mean BMI of people in India was around 21 kg/m 2.[27] However, in our study, 68.05% of diabetic population had a BMI more than 25 kg/m 2. Overwhelming evidence shows the link between obesity and DM and CVD, with the rapid urbanization and westernization of Indian communities resulting in more consumption of calorie dense, high sugar, processed foods, and paired with less physical activity of this increasingly sedentary lifestyle.[1],[4] Like many other LMICs, India has a double burden of malnutrition, with undernutrition and obesity being prevalent in communities in both adults and children. In 2014, the ICMR-INDIAB study estimated that obesity was found to be greatest in Chandigarh, the region with the highest income per capita, that is mostly urban with peri-urban surrounding areas, further emphasizing the link between obesity and urbanized living.[1],[4],[28]

The JBS3 risk calculator recommends the reduction of risk factors associated with the development of CVD, involving lifestyle modification to be introduced as early as possible and to be sustained to ensure the avoidance of CVD and other diabetic complications. The JBS3 calculator is valuable because of its ability to introduce interactive communication between patient and health professional, to ensure the “investment in health” concept, and health promotion that may influence health behaviors. To ensure the maximum benefit of the patient, this health promotion needs to take place to ensure that participants understand the link between their lifestyle and health, and particularly the importance in lifestyle modification in the prevention and control of diabetes and the prevention of future CVD events.[11]

Evidently, from the uncontrolled results of the HBA1C and lipid profiles (88.88% of DM participants had HbA1C values above 6.5%, and the majority of participants with CVD had elevated biochemistry values) participants are not empowered with appropriate health promotion and medicine-related information to adherently ensure the adequate maintenance of their chronic conditions. Monitoring and maintaining the participants' glucose and cholesterol levels could prevent the complications of DM and risk of future CVD events; and can largely be influenced by the active input of a health-care professional, such as a pharmacist, in ensuring that the disease condition is understood, that the patient knows how to test their blood or where to go to attain the means to do so and how to adequately use medicines to ensure the maintenance of chronic therapy.[11],[29]

In addition, strengthened health systems involving several comprehensive and integrated patient-centered care programs have shown that focusing on contextual counseling, facilitating self-care, and medication adherence of these participants would improve their quality of life of participants, ensuring that chronic illnesses can be easily managed. Multidisciplinary health-care teams consisting of interdisciplinary health professionals, including clinical pharmacists, could contribute toward optimized outcomes for participants who need chronic care, while contributing to a stronger health system, more favorable to ensuring the success of chronic care of participants.[30],[31] Furthermore, the use of an Expanded Chronic Care Model is pertinent in the LMIC context, to ensure that prevention efforts identify social determinants of health and optimize community participation in the attainment of better community health. The empowerment of the patient is crucial going forward, to ensure the adherence to chronic therapy and true commitment to meaningful lifestyle modification.[31]

Limitations of the study

There were less number of lipid profile tests prescribed for the participants.


  Conclusion Top


From the results obtained, it was clearly observed that DM participants are more likely to develop CVD compared to non-DM participants. This mirrors similar studies conducted within India, indicating the interdependence of NCDs on one another, and the heightened burden of disease that is caused by comorbidities. The readiness of the health system and the multidisciplinary health-care team needs to be optimized to involve patient-centered and health promotion interventions to curb the epidemic rise of diabetes and CVS in Indian communities.

Acknowledgment

The authors would like to acknowledge the co-operation of the participants, nurses, resident doctors, and the senior physicians of medicine Department of St. Philomena's Hospital, Bangalore for their valuable support and guidance.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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