What is cardiovascular endocrinology?
Cardiovascular endocrinology and metabolism publish peer-reviewed research on vascular disease, endocrinology, diabetes, and metabolism. Special emphasis will be placed on studies that illuminate the interplay between these disciplines and enhance effective collaboration between cardiologists, endocrinologists, and diabetologists.
The journal serves as a unique resource for the clinical and research communities specializing in cardiology, endocrinology, diabetes, and metabolism. High-quality, cutting-edge reviews, guest editorials, and expert commentary keep original articles relevant in the context of the basic and clinical research interface.
Hormones processed by the endocrine system play an important role in many parts of the cardiovascular system. Some hormone-lapsing properties accelerate high cholesterol and increase circulatory stress. After some time, these problems can be counted as a major risk factor for heart attack and stroke. Research on ways to detect hormones with the heart and veins is known as cardiovascular endocrinology.
Cardiovascular endocrinology disease patients should be evaluated for typical or distinctive cardiac symptoms as predicted by history or for patients with abnormal resting EKG for additional heart disease.
Patients with a normal and achievable resting electrocardiogram should be assigned a stress ECG stress test, but given the wide availability and greater specificity of the ECG stress test when combined with the imaging method, the stress test Exercise ECG should be used primarily to assess exercise response and function as an indicator of general prognosis.
For CAD diagnosis, radionuclide SPECT myocardial perfusion imaging and stress echocardiography have a sensitivity (approximately 90%) and specificity (approximately 50%) similar to coronary artery stenosis (greater than 70% defined as stenosis in one vessel) And you can use the modality according to absolute and relative anti-patient indications and the experience of the local operator.
Exercise should be the preferred stress method in all types of tests because the patient’s response to exercise has prognostic value. Poor diagnostic indicators include the inability to exercise beyond 5 METS, decrease in systolic blood pressure with exercise, development of exercise-induced angina, and chronotropic dysfunction (inability to adequately increase heart rate in response to exercise). If the patient cannot exercise, pharmacological stress should be used.
Diagnosis of cardiovascular endocrinology disease
Asymptomatic patients: CT angiography (CCTA), 2017 ADA standards for patients with diabetes who have asymptomatic CAD and rates of silent ischemia compared to the general population, with routine testing for CAD, either by exercise or drug stress testing or with new methods such as coronary artery calcium score (CACS) or coronary. Not recommended in asymptomatic patients under CARE (Level A recommendation).
This recommendation is mainly based on the results of randomized trials evaluating the role of myocardial perfusion imaging (MPI) in the detection of ischemia in asymptomatic diabetics (DIAD). The main results of this trial are:
- Silent ischemia was found in only 22% of patients. Most patients have mild perfusion abnormalities that are not suitable for reuse, And perfusion defects cannot be easily detected by a simple risk factor analysis.
- Although the prevalence of myocardial ischemia has not increased over time, many perfusion disorders have resolved with current appropriate medical treatment.
- Although a high-risk screening group was identified with MPI, the screening results did not change favorably.
Based on these results, and because aggressive medical treatment in diabetes (CC equivalent) is already warranted, the use of screening tests to identify patients with evidence of CAD may alter the clinical management of diabetic patients. asymptomatic and unlikely to effectively affect your overall prognosis.
Laboratory tests and key images
Laboratory evaluation: The American Diabetes Association (ADA) recommends the following laboratory tests:
The fasting lipid panel, including HDL, LDL, triglycerides, and total cholesterol levels, should be assessed at the time of diagnosis, at the initial medical evaluation, and at least once every 5 years. The lipid panel should also be obtained immediately before starting statin therapy. After a patient has taken statins, individual LDL cholesterol testing may be considered (eg, to monitor adherence and efficacy).
Hemoglobin a1c: The ratio of serum creatinine and urinary albumin/creatinine if the urine dipstick is negative for proteinuria.
- Liver function tests.
- Thyroid function tests.
Disease management and treatment
Treatment of cardiovascular disease risk factors in a diabetic patient Common conditions that coexist with diabetes, such as hypertension and dyslipidemia, are more likely to increase the risk of cardiovascular disease in this patient population, and treatment that aggressively addresses these comorbidities in diabetic patients should follow an approach globally.
Blood pressure: Blood pressure is a common comorbidity of diabetes and contributes to an increased risk of both microvascular and macrovascular disease. The control of blood pressure (BP) in diabetic patients should follow the recommendations of the ADA. Blood pressure (BP) should be less than the target of 140/90 mm Hg (level A recommendation).
Low systolic and diastolic blood pressure targets, such as 130/80 mmHg, may be appropriate for those at risk for cardiovascular disease if they can be achieved without unnecessary treatment burden (level C recommendation).
Diabetic patients with BP greater than 140/90 mm Hg should begin drug therapy in conjunction with lifestyle changes, preferably with a regimen that has been shown to reduce cardiovascular events, such as ACE inhibitor, angiotensin II receptor blocker (BRA), thiazide. The diuretic or dihydropyridine is similar to the calcium channel blocker and should contain multiple pharmacological agents (level A recommendation; trial evidence: Advance, ACCOMPLISH, HOT, ACCORD) if necessary to obtain target blood pressure.
For patients with blood pressure> 120/80 mmHg, lifestyle intervention may include weight loss if they are overweight or retarded; Dietary Approaches to Stopping Blood Pressure (DASH) – Diet-style approach, such as reducing sodium and increasing potassium intake; Control of alcohol intake; And more physical activity (level B recommended).
Dyslipidemia: The higher prevalence of lipid abnormalities in diabetic patients contributes to the increase in cardiovascular disease observed in these patients. Is lifestyle change an important part of lipid management in diabetic patients and reducing the intake of saturated fat, trans fat, and cholesterol and increase in diet? -3 Intake of fatty acids, viscous fiber, and plant stanols/sterols, as well as weight loss and increased physical activity (Level A recommendation).
Statin therapy: All diabetic patients with overt atherosclerotic cardiovascular disease (ASCVD) or older than 40 years should be treated with statins for additional risk factors for ASCVD regardless of baseline lipid levels. The severity of early statin therapy should be based on age, not on ASCVD or LDL levels, but the underlying risk determined by risk factors for ASCVD.
- For patients of all ages with diabetes and atherosclerotic cardiovascular disease, high-intensity statin therapy should be included in lifestyle therapy (level A recommendation).
- For patients with diabetes over 40 years of age with additional factors of atherosclerotic cardiovascular disease, consider the use of moderate or high-intensity statins and lifestyle therapy (level C recommendation).
- For patients with diabetes ages 40 to 75 without additional atherosclerotic cardiovascular disease factors, use moderate-intensity statins and lifestyle therapy (level A recommendation).
- For patients with diabetes ages 40 to 75 with additional factors of atherosclerotic cardiovascular disease, use high-intensity statins and lifestyle therapy (level B recommendation).
- For patients with diabetes older than 75 years without additional atherosclerotic cardiovascular disease factors, consider using moderate-intensity statin therapy and lifestyle therapy (level B recommendation).
- For patients with diabetes older than 75 years with additional factors of atherosclerotic cardiovascular disease, consider using moderate or high-intensity statin therapy and lifestyle therapy (level B recommendation).
The severity of statin therapy should be adjusted based on the patient’s response to the patient’s medications (eg, side effects, tolerance, LDL cholesterol levels) (level E is recommended). At present, there are no reliable data on whether treatment with low HDL levels and high triglycerides can lead to a further reduction in CVD risk when targeting LDL statin therapy. Furthermore, combination therapy increases the risk of transaminitis, myositis, and rhabdomyolysis. Therefore, treatment with low HDL or elevated triglycerides is not recommended at this time.
Combination therapy (statin/fibrate) improves the outcome of atherosclerotic cardiovascular disease and is generally not recommended (level A recommendation). However, men with triglyceride levels> 204 mg / dL (2.3 mmol / L) and HDL cholesterol levels <34 mg / dL (0.9 mmol / L) (recommended level B) are considered to be treated with statins and fenofibrates.
Combination therapy (statin/niacin) has not been shown to provide additional cardiovascular benefit than statin therapy alone and increases the risk of stroke and is generally not recommended (level A recommendation). Agetimib has been shown to provide additional cardiovascular benefit in addition to moderate-intensity statin therapy compared to moderate-intensity statin therapy only in patients with recent acute coronary syndrome and LDL cholesterol> 50 mg / dL (1.3 mmol / L). It is also considered in these patients (level A recommendation) and patients with diabetes and a history of intolerance to high-intensity statin therapy (level E recommendation).
Patients with severe hypertriglyceridemia (fasting triglyceride levels> 500 mg/dl or 5.7 mmol / l) may require medical treatment with fibrates, niacin, or fish oil to reduce the risk of pancreatitis (level C recommended).
Treatment for cardiovascular endocrinology disease in diabetic patients
Acute myocardial infarction (AMI) in diabetic patients
The presence or absence of diabetes should not affect the decision-making process regarding coronary perfusion in patients with AMI. In particular, in diabetic patients with ST-segment elevation myocardial infarction (STEMI), an immediate resuscitation strategy should be followed, preferably percutaneous coronary intervention (PCI) or thrombolytic therapy if PCI is not available promptly. However, diabetic patients do better with PCI compared to fibrinolysis.
- Antiplatelet therapy
- Antiplatelet therapy in the context of AMI
- All patients with myocardial infarction should receive aspirin indefinitely, with or without diabetes.
- In the context of PCI for NSTEMI or STEMI, a P2Y12 inhibitor such as clopidogrel, ticagrelor, or prasugrel should be administered in addition to aspirin, with a duration of P2Y12 inhibitory administration depending on the type of stent.
- In patients with persistent, medically treated NSTEMI, the P2Y12 inhibitor, such as clopidogrel or ticagrelor, but not Prasugrel, should be administered with aspirin for at least 1 year.
- In patients with diabetes and pre-myocardial infarction (1 to 3 years of age), the addition of ticagrelor to aspirin significantly reduces the risk of recurrent ischemic events, including death from heart and coronary disease.