Diabetes and Cardiovascular Risk A review Thomas Bodenheimer MD University of California, San...

Diabetes and Diabetes and Cardiovascular RiskCardiovascular Risk

A reviewA review

Thomas Bodenheimer MDThomas Bodenheimer MD

University of California, San Francisco University of California, San Francisco

Department of Family and Community MedicineDepartment of Family and Community Medicine

AgendaAgenda• Mild diabetes: Mild diabetes: Bertha GoodeBertha Goode

– PathophysiologyPathophysiology– DiagnosisDiagnosis– ManagementManagement– Chronic care modelChronic care model

• Poorly controlled diabetes, hyperlipidemia and Poorly controlled diabetes, hyperlipidemia and hypertension: hypertension: Dolores RojasDolores Rojas– Framingham risk scoreFramingham risk score– Management of lipidsManagement of lipids– Management of blood pressureManagement of blood pressure– Chronic care modelChronic care model

• Population management: Population management: your entire panel of people your entire panel of people with diabeteswith diabetes

• Metabolic syndrome: Metabolic syndrome: JulioJulio

Bertha GoodeBertha Goode

• Bertha Goode Is a 35 y.o. African-Bertha Goode Is a 35 y.o. African-American woman who comes to the American woman who comes to the clinic with weight loss, frequent clinic with weight loss, frequent urination, and thirst urination, and thirst

• The nurse practitioner, Nancy Rush, The nurse practitioner, Nancy Rush, suspects diabetes, does a random suspects diabetes, does a random glucose finger stick and finds a glucose finger stick and finds a blood sugar of 237blood sugar of 237

Bertha GoodeBertha Goode• Ms. Goode wants to know what Ms. Goode wants to know what

diabetes is diabetes is

• She says her father had diabetes and She says her father had diabetes and died of kidney failuredied of kidney failure

• She says she’s determine to “beat She says she’s determine to “beat that sugar thing”that sugar thing”

• Nancy Rush spends 45 minutes with Nancy Rush spends 45 minutes with her; now she is 1 1/2 hours behind in her; now she is 1 1/2 hours behind in seeing her morning patientsseeing her morning patients

Pathophysiology of type 2 Pathophysiology of type 2 diabetesdiabetes

• Nancy Rush explains that type 2 diabetes Nancy Rush explains that type 2 diabetes starts with insulin resistancestarts with insulin resistance

• Insulin is required for sugar in the blood to Insulin is required for sugar in the blood to go into the cells (brain, muscle, heart) go into the cells (brain, muscle, heart) where sugar is needed for energywhere sugar is needed for energy

• Insulin resistance means that the insulin Insulin resistance means that the insulin is less effective in moving sugar into the is less effective in moving sugar into the cellscells

Pathophysiology of type 2 diabetesPathophysiology of type 2 diabetes

• Insulin resistance: It takes more insulin to Insulin resistance: It takes more insulin to move sugar from the blood into the cellsmove sugar from the blood into the cells

• The beta cells of the pancreas have to The beta cells of the pancreas have to constantly secrete more insulinconstantly secrete more insulin

• If you measure insulin in the blood, people If you measure insulin in the blood, people with insulin resistance have higher insulin with insulin resistance have higher insulin levelslevels

• Bertha Goode wants to know if insulin Bertha Goode wants to know if insulin resistance is the same as diabetes resistance is the same as diabetes

Pathophysiology of type 2 diabetesPathophysiology of type 2 diabetes

• Nancy Rush explains that people with insulin resistance get Nancy Rush explains that people with insulin resistance get diabetes only if the beta-cells of the pancreas are unable to diabetes only if the beta-cells of the pancreas are unable to keep producing enough insulinkeep producing enough insulin

• In people with insulin resistance, the beta-cells are working In people with insulin resistance, the beta-cells are working harder year after year to produce the additional insulin harder year after year to produce the additional insulin needed to move the sugar into the cellsneeded to move the sugar into the cells

• In many people with insulin resistance, the beta-cells poop In many people with insulin resistance, the beta-cells poop out, are unable to produce enough insulin, and the person out, are unable to produce enough insulin, and the person develops diabetes develops diabetes

• Insulin resistance + insulin deficiency = type 2 diabetesInsulin resistance + insulin deficiency = type 2 diabetes

Insulin Resistance and Insulin Insulin Resistance and Insulin DeficiencyDeficiency

InsulinInsulinDeficiencyDeficiency

InsulinInsulinDeficiencyDeficiency

InsulinInsulinResistanceResistance

InsulinInsulinResistanceResistance

HyperglycemiaHyperglycemiaHyperglycemiaHyperglycemia

Natural History of Type 2 DiabetesNatural History of Type 2 DiabetesG

luco

se

Glu

cose

(m

g/d

L)

(mg/

dL

)R

elat

ive

func

tion

Rel

ativ

e fu

ncti

on

YearsYears

DiabetesDiabetesdiagnosisdiagnosis

-10-10 -5-5 00 55 1010 1515 2020 2525 3030

5050

100100

150150

200200

250250

300300

350350

Insulin ResistanceInsulin Resistance

Insulin ResponseInsulin Response

Fasting GlucoseFasting Glucose

Post Meal GlucosePost Meal Glucose

OnsetOnsetDiabetesDiabetesOnsetOnset

DiabetesDiabetes

Pre DiabetesPre Diabetes (IFG, IGT)(IFG, IGT)

Metabolic Syndrome Metabolic Syndrome 00

5050

100100

150150

200200

250250

-15-15

Progressive reduction in beta cell massProgressive reduction in beta cell mass

Kendall DM, Bergenstal RM Kendall DM, Bergenstal RM ©© 2004 International Diabetes Center, Minneapolis, MN All rights reserved. 2004 International Diabetes Center, Minneapolis, MN All rights reserved.

Type 2 Diabetes is a Progressive DiseaseType 2 Diabetes is a Progressive Disease

06

7

8

9

2 4 6 8 10Years

Med

ian

Hb

AM

edia

n H

bA

1c1c (

%)

(%

)

UKPDS 34, Lancet 1998.

Type 2 Diabetes as a “Syndrome”Type 2 Diabetes as a “Syndrome”

VascularVascularinflammationinflammation

VascularVascularinflammationinflammation

Thrombotic riskThrombotic riskThrombotic riskThrombotic risk Abnormal Abnormal vascular behaviorvascular behavior

Abnormal Abnormal vascular behaviorvascular behavior

HyperglycemiaHyperglycemiaIFG/IGT Type 2 diabetesIFG/IGT Type 2 diabetes

HyperglycemiaHyperglycemiaIFG/IGT Type 2 diabetesIFG/IGT Type 2 diabetes

DyslipidemiaDyslipidemiaLDL Trigs HDLLDL Trigs HDL

DyslipidemiaDyslipidemiaLDL Trigs HDLLDL Trigs HDL

Insulin ResistanceInsulin ResistanceCentral obesityCentral obesity

Insulin ResistanceInsulin ResistanceCentral obesityCentral obesity

HypertensionHypertensionMicroalbuminuriaMicroalbuminuria

HypertensionHypertensionMicroalbuminuriaMicroalbuminuria

Kendall DM and Harmel AP. Am J Manag Care Kendall DM and Harmel AP. Am J Manag Care 2002; 2002; 88:S635–S653.:S635–S653.

Criteria for Diagnosis of Type 2 Criteria for Diagnosis of Type 2 DiabetesDiabetes

Random blood sugar Random blood sugar >> 200 mg/dl 200 mg/dl OROR

Fasting blood sugar Fasting blood sugar >> 126 mg/dl 126 mg/dl OR OR

2 hr blood sugar after 75 gm oral glucose 2 hr blood sugar after 75 gm oral glucose >> 200 mg/dl 200 mg/dl

Testing should be repeated on a separate day Testing should be repeated on a separate day Fasting blood sugar is preferred testFasting blood sugar is preferred test

Categories of Fasting Blood SugarCategories of Fasting Blood Sugar

CategoryCategory FBS (mg/dl)FBS (mg/dl)

NormalNormal < 100< 100

Impaired (IFG)Impaired (IFG) 100 - 125100 - 125

DiabetesDiabetes 126 126

Blood sugar = blood glucose = plasma glucoseBlood sugar = blood glucose = plasma glucose

Initial managementInitial management• Patient education in the ADA 26 domains Patient education in the ADA 26 domains

of diabetes knowledge and skillsof diabetes knowledge and skills

• Set specific goals for starting achievable Set specific goals for starting achievable lifestyle changes for diet and exercise lifestyle changes for diet and exercise

• Bertha Goode says she will start by Bertha Goode says she will start by drinking no more sodas and drinking drinking no more sodas and drinking water instead. She says at the next visit water instead. She says at the next visit she will set an exercise goalshe will set an exercise goal

Initial management:Initial management:ADA: 26 domains of skills/knowledgeADA: 26 domains of skills/knowledge

• 1. All About Pre-Diabetes 1. All About Pre-Diabetes

• 2. Getting the Best Care for Your Diabetes 2. Getting the Best Care for Your Diabetes

• 3. Taking Care of Type 2 Diabetes 3. Taking Care of Type 2 Diabetes

• 4. All About Your Blood Glucose4. All About Your Blood Glucose

• 5. All About Insulin Resistance 5. All About Insulin Resistance

• 6. Protect Your Heart: Wise Food Choices 6. Protect Your Heart: Wise Food Choices

• 7. Protect Your Heart: Choose Fats Wisely 7. Protect Your Heart: Choose Fats Wisely

• 8. Protect Your Heart: Heart Healthy Foods 8. Protect Your Heart: Heart Healthy Foods

• 9. Protect your Heart: Check Food Labels 9. Protect your Heart: Check Food Labels

• 10. All About Carbohydrate Counting 10. All About Carbohydrate Counting

• 11. Protect Your Heart by Losing Weight 11. Protect Your Heart by Losing Weight

• 12. All About Physical Activity 12. All About Physical Activity

•13. Getting Started with Physical Activity13. Getting Started with Physical Activity

• 14. Learning How to Change Habits 14. Learning How to Change Habits

• 15. Recognizing and Handling Depression 15. Recognizing and Handling Depression

• 16. Treating High Blood Pressure 16. Treating High Blood Pressure

• 17. Treating High Cholesterol17. Treating High Cholesterol

• 18. Taking Care of Your Heart 18. Taking Care of Your Heart

• 19. Know Warning Signs of a Heart Attack 19. Know Warning Signs of a Heart Attack

• 20. Taking Aspirin to Protect Your Heart 20. Taking Aspirin to Protect Your Heart

• 21. All About Stroke 21. All About Stroke

• 22. All About Peripheral Arterial Disease 22. All About Peripheral Arterial Disease

• 23. Tests for Heart and Blood Vessel Disease 23. Tests for Heart and Blood Vessel Disease

• 24. Managing Your Medicines 24. Managing Your Medicines

• 25. Food and Activity Tracker 25. Food and Activity Tracker

• 26. Blood Glucose Log26. Blood Glucose LogUse Ask-Tell-AskUse Ask-Tell-Ask

Medication managementMedication management• Bertha Goode says she never wants to take Bertha Goode says she never wants to take

pills. Nancy Rush explains that if lifestyle pills. Nancy Rush explains that if lifestyle changes don’t work, she will recommend changes don’t work, she will recommend medications. medications.

• Most people start with metformin unless Most people start with metformin unless elevated creatinine or other contraindications. elevated creatinine or other contraindications. Start low dose because of GI side effectsStart low dose because of GI side effects

• Add other medications as neededAdd other medications as needed• Most people with type 2 diabetes, if they live Most people with type 2 diabetes, if they live

long enough, will eventually have serious beta long enough, will eventually have serious beta cell failure and will need insulincell failure and will need insulin

Matching Pharmacology to PathophysiologyMatching Pharmacology to Pathophysiology

Block absorption of glucose from food

Block absorption of glucose from food

HyperglycemiaHyperglycemiaIncrease

insulin from pancreas

Increase insulin from

pancreas

Reduceglucose

output from liver

Reduceglucose

output from liver

Reduce insulin resistance, thereby making it easier for

glucose to move from blood into cells

Reduce insulin resistance, thereby making it easier for

glucose to move from blood into cells

-Glucosidase Inhibitors

Acarbose (Precose)

MetforminGlitazones

(Actos, Avandia) Glitazones(Actos, Avandia)

Metformin

SulfonylureasGlyburide, Glipizide

ADA Treatment Guidelines: 2004 ADA Treatment Guidelines: 2004 goalsgoals

• Fasting blood sugar: Fasting blood sugar: 90-130 mg/dl90-130 mg/dl• HbA1C:HbA1C: <7%<7%• 2hr postprandial BG:2hr postprandial BG: <180<180• LDL cholesterol:LDL cholesterol: <100 (high risk < 70)<100 (high risk < 70)• Blood Pressure:Blood Pressure: <130/80<130/80• Individualize care: maintain an A1C level as close Individualize care: maintain an A1C level as close

to normal as is safely possible. As A1c goes down, to normal as is safely possible. As A1c goes down, risk of hypoglycemia goes uprisk of hypoglycemia goes up

www.diabetes.orgwww.diabetes.org

Hemoglobin A1cHemoglobin A1c• Ms. Goode wants to know what that Ms. Goode wants to know what that

“hemoglobin thing” is“hemoglobin thing” is• Blood sugar binds to the hemoglobin Blood sugar binds to the hemoglobin

molecule in the red blood cellmolecule in the red blood cell• You can measure the amount of sugar bound You can measure the amount of sugar bound

to hemoglobin with the lab test HbA1cto hemoglobin with the lab test HbA1c• Because the red blood cell lives an average Because the red blood cell lives an average

of 3-4 months, the HbA1c is an indication of of 3-4 months, the HbA1c is an indication of the average blood sugar over the past 3-4 the average blood sugar over the past 3-4 monthsmonths

Benefits of Lowering Benefits of Lowering Hemoglobin A1cHemoglobin A1c

00

44

88

1212

1616

66 77 88 99 1010 1111 1212Hemoglobin A1cHemoglobin A1c

Rel

ativ

e R

isk

Rel

ativ

e R

isk

of C

omp

lica

tion

sof

Com

pli

cati

ons

Adapted from: Skyler JS. J Clin Endo Metab 1996Adapted from: Skyler JS. J Clin Endo Metab 1996UKPDS 33: UKPDS 33: Lancet Lancet 1998; 352, 837-853.1998; 352, 837-853.DCCT Study GroupDCCT Study Group. N Engl J Med. N Engl J Med 329:977, 1993 329:977, 1993

120120 150150 180180 210210 240240 270270 300300Average GlucoseAverage Glucose

Lowering HbA1c: risk and benefitLowering HbA1c: risk and benefit

Rate of Severe Hypoglycemia

(per 100 patient-years)

DCCT. NEJM.1993;329:977-986DCCT. NEJM.1993;329:977-986

0

20

40

60

80

100

120

HbAHbA1c 1c (%)(%)

5.5 6.0 6.5 7.0 7.5 8.0 8.5 9.0 9.5 10 10.5

Relative Risk for

Progression of Retinopathy

0

20

Routine care guidelinesRoutine care guidelines• BP, weight, foot exam every visitBP, weight, foot exam every visit• HbA1c every 6 months if stable, every 3 months if not stableHbA1c every 6 months if stable, every 3 months if not stable• Lipid panel, urine microalbumin every yearLipid panel, urine microalbumin every year• Dilated eye exam every yearDilated eye exam every year• Dental exam/cleanining at least twice a yearDental exam/cleanining at least twice a year• Assess knowledge of diabetes, diet issues, physical activity, Assess knowledge of diabetes, diet issues, physical activity,

and set achievable goals at least once a yearand set achievable goals at least once a year• Aspirin 81mg/day or 325 mg every other if moderate/high riskAspirin 81mg/day or 325 mg every other if moderate/high risk• Smoking cessation advice every visit if neededSmoking cessation advice every visit if needed• Flu shot every year and pneumococcal immunization at least Flu shot every year and pneumococcal immunization at least

once in lifetime with repeat for higher-risk patientsonce in lifetime with repeat for higher-risk patientswww.diabetes.orgwww.diabetes.org

2004 Revisions to ADA Guidelines 2004 Revisions to ADA Guidelines

"Standards of Medical Care in Diabetes” www.diabetes.org

Glycemic control: A normal HbA1C <6% canGlycemic control: A normal HbA1C <6% can be be considered in individualconsidered in individual patientspatients

Lipid management: In people with diabetes overLipid management: In people with diabetes over the age the age of 40 with a totalof 40 with a total cholesterol >135 mg/dl,cholesterol >135 mg/dl, statin therapy to statin therapy to reduce LDL regardless of baselinereduce LDL regardless of baseline LDL levels may be LDL levels may be appropriate.appropriate.

Retinopathy: Consider less frequent examsRetinopathy: Consider less frequent exams in low-risk in low-risk patients on the advice ofpatients on the advice of an eye care professionalan eye care professional

(Diabetes Care, January, 2004)

Chronic Care Model Chronic Care Model components neededcomponents needed

• Patient self-managementPatient self-management• Clinical information system: reminders Clinical information system: reminders

for clinicians and for patientsfor clinicians and for patients• Delivery system redesign to create a teamDelivery system redesign to create a team• Decision support to make sure the Decision support to make sure the

caregivers know best practice guidelinescaregivers know best practice guidelines• Use community resourcesUse community resources• Health system organizationHealth system organization

Self-management:Self-management:Disease-specific informationDisease-specific information

• 1. All About Pre-Diabetes 1. All About Pre-Diabetes

• 2. Getting the Best Care for Your Diabetes 2. Getting the Best Care for Your Diabetes

• 3. Taking Care of Type 2 Diabetes 3. Taking Care of Type 2 Diabetes

• 4. All About Your Blood Glucose4. All About Your Blood Glucose

• 5. All About Insulin Resistance 5. All About Insulin Resistance

• 6. Protect Your Heart: Wise Food Choices 6. Protect Your Heart: Wise Food Choices

• 7. Protect Your Heart: Choose Fats Wisely 7. Protect Your Heart: Choose Fats Wisely

• 8. Protect Your Heart: Heart Healthy Foods 8. Protect Your Heart: Heart Healthy Foods

• 9. Protect your Heart: Check Food Labels 9. Protect your Heart: Check Food Labels

• 10. All About Carbohydrate Counting 10. All About Carbohydrate Counting

• 11. Protect Your Heart by Losing Weight 11. Protect Your Heart by Losing Weight

• 12. All About Physical Activity 12. All About Physical Activity

•13. Getting Started with Physical Activity13. Getting Started with Physical Activity

• 14. Learning How to Change Habits 14. Learning How to Change Habits

• 15. Recognizing and Handling Depression 15. Recognizing and Handling Depression

• 16. Treating High Blood Pressure 16. Treating High Blood Pressure

• 17. Treating High Cholesterol17. Treating High Cholesterol

• 18. Taking Care of Your Heart 18. Taking Care of Your Heart

• 19. Know Warning Signs of a Heart Attack 19. Know Warning Signs of a Heart Attack

• 20. Taking Aspirin to Protect Your Heart 20. Taking Aspirin to Protect Your Heart

• 21. All About Stroke 21. All About Stroke

• 22. All About Peripheral Arterial Disease 22. All About Peripheral Arterial Disease

• 23. Tests for Heart and Blood Vessel Disease 23. Tests for Heart and Blood Vessel Disease

• 24. Managing Your Medicines 24. Managing Your Medicines

• 25. Food and Activity Tracker 25. Food and Activity Tracker

• 26. Blood Glucose Log26. Blood Glucose Log

Self-management: collaborative Self-management: collaborative decision-makingdecision-making

• Informed patient by itself does not improve clinical Informed patient by itself does not improve clinical outcomes; an additional factor is neededoutcomes; an additional factor is needed

• That additional factor appears to be collaborative decision That additional factor appears to be collaborative decision making, which makes the patient an active participant in making, which makes the patient an active participant in his/her managementhis/her management

• Nancy Rush promised to make Ms. Goode a run chart of her Nancy Rush promised to make Ms. Goode a run chart of her HbA1c to increase her involvement in her own careHbA1c to increase her involvement in her own care

Norris et al. Diab Care 2001;24:561. Hunt et al. J Fam Pract 1998;46:207. Piette et Norris et al. Diab Care 2001;24:561. Hunt et al. J Fam Pract 1998;46:207. Piette et al. JIM 2003;18:624. Korsch et al. N Engl J Med 1969;280:535.al. JIM 2003;18:624. Korsch et al. N Engl J Med 1969;280:535.

Bertha Goode’s diabetes run chart:Bertha Goode’s diabetes run chart:hemoglobin A1chemoglobin A1c

0

2

4

6

8

10

12

Jan 'O1 Jul '01 Jan '02 Jul '02 Jan '03

Self-management:Self-management:Goal-settingGoal-setting

• One aspect of collaborative decision-One aspect of collaborative decision-making is goal-setting, which means making is goal-setting, which means making an action plan that is easily making an action plan that is easily achievableachievable

• Remember Bertha Goode’s first Remember Bertha Goode’s first action plan: to stop drinking sodas action plan: to stop drinking sodas and drink water instead. and drink water instead.

• She did not promise to lose 20 She did not promise to lose 20 pounds in a month, which is not pounds in a month, which is not achievableachievable

Reminder system for Reminder system for clinicians and for patientsclinicians and for patients

• Nancy Rush created a reminder prompt Nancy Rush created a reminder prompt sheet (or pop-up on electronic medical sheet (or pop-up on electronic medical record) so that at each visit, it is easy to record) so that at each visit, it is easy to see which tests/ procedures/check up on see which tests/ procedures/check up on action plans are neededaction plans are needed

• Evidence is clear that reminder prompts Evidence is clear that reminder prompts improve diabetes careimprove diabetes care

• Sending patients reminders (e.g. it is time Sending patients reminders (e.g. it is time to get your lab tests) also worksto get your lab tests) also works

Clinical information systemClinical information system

• Diabetes registry is by far the most Diabetes registry is by far the most effective way to create reminder effective way to create reminder promptprompt

Delivery system redesign to Delivery system redesign to create a teamcreate a team

• Studies show that physicians often ignore Studies show that physicians often ignore reminder prompts due to lack of timereminder prompts due to lack of time

• Nancy Rush created a team with training Nancy Rush created a team with training and a clear division of labor. The team and a clear division of labor. The team decided that the medical assistant would decided that the medical assistant would use the reminder prompt and order the use the reminder prompt and order the tests indicated. This was done via tests indicated. This was done via standing orders from the medical directorstanding orders from the medical director

Delivery system redesign to Delivery system redesign to create a teamcreate a team

• Physicians also do not have time to do Physicians also do not have time to do patient education in the ADA 26 patient education in the ADA 26 categories, nor to do goal-setting and categories, nor to do goal-setting and problem-solving about the patient’s goalsproblem-solving about the patient’s goals

• Team needs health educator or diabetes-Team needs health educator or diabetes-trained nursetrained nurse

• Medical assistants can be trained to do Medical assistants can be trained to do goal-setting and problem-solving with goal-setting and problem-solving with patientpatient

Decision supportDecision support

• To make sure physicians and others To make sure physicians and others on the team know up-to-date on the team know up-to-date diabetes guidelines, it is best to have diabetes guidelines, it is best to have those guidelines embedded in the those guidelines embedded in the reminder prompts or in a diabetes reminder prompts or in a diabetes and cardiovascular risk reduction and cardiovascular risk reduction progress noteprogress note

Community resourcesCommunity resources• Nancy Rush’s practice does not have a health Nancy Rush’s practice does not have a health

educator or diabetes nurse. She made arrangements educator or diabetes nurse. She made arrangements for Bertha Goode to see the diabetes educator at a for Bertha Goode to see the diabetes educator at a nearby hospitalnearby hospital

• She has been planning to make a resource guide of She has been planning to make a resource guide of exercise programs in the community, but hasn’t had exercise programs in the community, but hasn’t had time. Bertha Goode said that she could do that for time. Bertha Goode said that she could do that for herself and other patients with diabetesherself and other patients with diabetes

• Sometimes patients are the most valuable Sometimes patients are the most valuable community resource, but we seldom ask them to use community resource, but we seldom ask them to use their time and skills to helptheir time and skills to help

Health system organizationHealth system organization

• In order to make all those care In order to make all those care processes happen, to improve diabetes processes happen, to improve diabetes care, the larger health system mustcare, the larger health system must– Help provide resourcesHelp provide resources– Reward these processes by paying for Reward these processes by paying for

themthem

Dolores RojasDolores Rojas• 47 year old Latina woman, smoker 47 year old Latina woman, smoker • Family history: father had diabetes and died of Family history: father had diabetes and died of

heart attack age 45heart attack age 45• Ms. Rojas has had diabetes for 8 years, with Ms. Rojas has had diabetes for 8 years, with

HbA1c running between 9 and 13. Has not been HbA1c running between 9 and 13. Has not been to clinic for 2 years because went to Mexico to to clinic for 2 years because went to Mexico to help her sick motherhelp her sick mother

• Has FBS 350, BP 164/95, Cholesterol 260, LDL Has FBS 350, BP 164/95, Cholesterol 260, LDL 155, HDL 30, BMI 28 (normal <25), urine 155, HDL 30, BMI 28 (normal <25), urine microalbumin 80, creatinine 1.2microalbumin 80, creatinine 1.2

• No history of cardiac symptoms, normal EKGNo history of cardiac symptoms, normal EKG

What should be her initial What should be her initial management?management?

• Patient educationPatient education• Goal setting for lifestyle changesGoal setting for lifestyle changes• Metformin for blood sugarMetformin for blood sugar• Ace inhibitor for blood pressure and for kidney protectionAce inhibitor for blood pressure and for kidney protection• Statin for cholesterolStatin for cholesterol• If blood pressure not controlled, add HCTZ or beta If blood pressure not controlled, add HCTZ or beta

blockerblocker• Aspirin for cardioprotectionAspirin for cardioprotection• All this has to be negotiated with Ms. Rojas, because she All this has to be negotiated with Ms. Rojas, because she

is unlikely to accept this entire regimenis unlikely to accept this entire regimen

Framingham Risk ScoreFramingham Risk Score• Data from the Framingham Heart Study to Data from the Framingham Heart Study to

estimate risk of having a heart attack or estimate risk of having a heart attack or death from coronary heart disease within 10 death from coronary heart disease within 10 yearsyears– AgeAge– Gender Gender – Total CholesterolTotal Cholesterol– HDL Cholesterol HDL Cholesterol – Current Smoker Current Smoker – Systolic Blood Pressure Systolic Blood Pressure – Currently on any medication to treat high blood pressure Currently on any medication to treat high blood pressure

Note: Some Framingham score sheets use total and HDL Note: Some Framingham score sheets use total and HDL cholesterol, others use LDL and HDL cholesterol cholesterol, others use LDL and HDL cholesterol

Circulation 1998;97:1837-1847.Circulation 1998;97:1837-1847.

Framingham Risk ScoreFramingham Risk Scorepoint systempoint system

• Age Age – 30-34 - 130-34 - 1– 35-39 035-39 0– 40-44 140-44 1– 70-74 770-74 7

• HDLHDL– < 35 2< 35 2– 35-44 135-44 1– 45-59 045-59 0– >60 - 1 >60 - 1

• Systolic blood pressureSystolic blood pressure– < 130 0< 130 0– 130-139 1130-139 1– 140-159 2140-159 2– > 160 3> 160 3

• SmokerSmoker– Yes 2Yes 2– No 0No 0

The more points, the greater riskThe more points, the greater risk

Dolores RojasDolores Rojas

• Smoker, high cholesterol, hypertension, Smoker, high cholesterol, hypertension, diabetes, age 47diabetes, age 47

• She has Framingham risk score of 18%. She has Framingham risk score of 18%. This puts her at intermediate risk (10-This puts her at intermediate risk (10-20%) of a heart attack or coronary death 20%) of a heart attack or coronary death within 10 years. She is very close to within 10 years. She is very close to being at high risk (> 20%). being at high risk (> 20%).

TobaccoTobacco

Treating tobacco use and dependence. Treating tobacco use and dependence. A clinical practice guidelineA clinical practice guideline

U.S. Department of Health and Human Services, Public Health Services. Treating U.S. Department of Health and Human Services, Public Health Services. Treating tobacco use and dependence. Rockville (MD): U.S. Department of Health and tobacco use and dependence. Rockville (MD): U.S. Department of Health and Human Services, Public Health Service; 2000 Jun. 197 p. [311 references]Human Services, Public Health Service; 2000 Jun. 197 p. [311 references]

Available on Available on www.guidelines.govwww.guidelines.gov

Key word to search for: Smoking Key word to search for: Smoking cessationcessation

http://www.guidelines.gov/

HyperlipidemiaHyperlipidemia

Major Risk FactorsMajor Risk FactorsThat Modify LDL GoalsThat Modify LDL Goals

• Cigarette smokingCigarette smoking• Hypertension (BP Hypertension (BP 140/90 mmHg or on 140/90 mmHg or on

antihypertensive medication)antihypertensive medication)• Low HDL cholesterol (<40 mg/dL)Low HDL cholesterol (<40 mg/dL)†† • Family history of premature CHDFamily history of premature CHD

– CHD in male first degree relative <55 yearsCHD in male first degree relative <55 years– CHD in female first degree relative <65 CHD in female first degree relative <65

yearsyears

• Age (men Age (men 45 years; women 45 years; women 55 years)55 years)† HDL cholesterol 60 mg/dL counts as a “negative” risk factor; its

presence removes one risk factor from the total count.

Framingham and ATP IIIFramingham and ATP III

• Unfortunately, the risk categories are Unfortunately, the risk categories are different between Framingham and ATP IIIdifferent between Framingham and ATP III

• How about putting everything into one How about putting everything into one algorithm!algorithm!

• Framingham risk is for people who do not Framingham risk is for people who do not have diabetes or coronary heart diseasehave diabetes or coronary heart disease

• ATP III risk is for people with and without ATP III risk is for people with and without diabetes, with and without coronary heart diabetes, with and without coronary heart diseasedisease

National Cholesterol Education ProjectNational Cholesterol Education ProjectAdult Treatment Panel III (ATP III)Adult Treatment Panel III (ATP III)

• ATP III came out in 2001. In 2004, LDL goal ATP III came out in 2001. In 2004, LDL goal recommendations were lowered. Current recommendations were lowered. Current goals goals [Circulation 2004;110:227-239][Circulation 2004;110:227-239]

• Very high-risk: Coronary heart disease plus Very high-risk: Coronary heart disease plus other risk factors such as diabetes, continued other risk factors such as diabetes, continued smoking, or metabolic syndrome. Also history smoking, or metabolic syndrome. Also history of hospitalization for heart attack. of hospitalization for heart attack.

• Goal: LDL > 70Goal: LDL > 70

National Cholesterol Education ProjectNational Cholesterol Education Project ATP III -- 2004 update ATP III -- 2004 update

• High-risk: High-risk: – a) coronary heart disease a) coronary heart disease – b) carotid or lower extremity vascular b) carotid or lower extremity vascular

disease, or disease, or – c) diabetes, or c) diabetes, or – d) Framingham risk score resulting > 20% d) Framingham risk score resulting > 20%

chance of having a heart attack or coronary chance of having a heart attack or coronary death within 10 years death within 10 years



• Moderately high-risk: Moderately high-risk: – Intermediate Framingham risk score of 10-Intermediate Framingham risk score of 10-

20% risk of heart attack or coronary death 20% risk of heart attack or coronary death within 10 years within 10 years

• Goal: Option of choosing goal of < 100 or Goal: Option of choosing goal of < 100 or

< 130< 130


• Lower/Moderate Risk: Lower/Moderate Risk: – Low Framingham risk score giving under Low Framingham risk score giving under

10% risk of heart attack or coronary death 10% risk of heart attack or coronary death in 10 yearsin 10 years


Drug TherapyDrug TherapyHMG CoA Reductase Inhibitors (Statins)HMG CoA Reductase Inhibitors (Statins)

• Reduce LDL-C 18–55%Reduce LDL-C 18–55%• Major side effectsMajor side effects

– MyopathyMyopathy– Increased liver enzymesIncreased liver enzymes

• ContraindicationsContraindications– Absolute: liver diseaseAbsolute: liver disease– Relative: use with certain drugsRelative: use with certain drugs

HMG CoA Reductase HMG CoA Reductase Inhibitors (Statins) Inhibitors (Statins) (continued)(continued)

Demonstrated Therapeutic BenefitsDemonstrated Therapeutic Benefits

• Reduce major coronary eventsReduce major coronary events• Reduce coronary heart disease mortalityReduce coronary heart disease mortality• Reduce coronary procedures (PTCA/CABG)Reduce coronary procedures (PTCA/CABG)• Reduce strokeReduce stroke• Reduce total mortalityReduce total mortality

People with known coronary heart disease People with known coronary heart disease and people with diabetes > 40 years of age and people with diabetes > 40 years of age should receive statin therapy regardless of should receive statin therapy regardless of cholesterol level. This is a recommendation, cholesterol level. This is a recommendation, not a firm guideline yet. not a firm guideline yet. Lipid Control in the Management of Type 2 Diabetes Mellitus: A Clinical Practice Guideline from the American College of Physicians Ann Intern Med. 2004;140:644-649

New Treatment Goal for lipid management in type 2

diabetes

HypertensionHypertension

Risk of ComplicationsRisk of ComplicationsHypertension and DiabetesHypertension and Diabetes

0

4

8

12

16

60 70 80 90 100 110 120

Diastolic BP

Rel

ativ

e R

isk

of C

omp

lica

tion

s

SHEP Study. JAMA 276:1886, 1996 HOT Trial. Lancet 351: 1757, 1998UKPDS 38: BMJ 317, 703-713, 1998

Chronic Chronic kidney disease kidney disease

DiabetesDiabetes

Compelling Indications for Compelling Indications for Individual Drug ClassesIndividual Drug Classes

Clinical Trial BasisClinical Trial BasisInitial Therapy OptionsInitial Therapy Options Compelling IndicationCompelling Indication

NKF Guideline, Captopril Trial, NKF Guideline, Captopril Trial,

RENAAL, IDNT, REIN, AASKRENAAL, IDNT, REIN, AASK

NKF-ADA Guideline,NKF-ADA Guideline,

UKPDS, ALLHATUKPDS, ALLHAT

ACEI, ARBACEI, ARB

THIAZ, BB, ACE, THIAZ, BB, ACE, ARB, CCBARB, CCB

Compelling Indications for Compelling Indications for Individual Drug ClassesIndividual Drug Classes

Clinical Trial BasisClinical Trial BasisInitial Therapy OptionsInitial Therapy Options Compelling IndicationCompelling Indication

ALLHAT, HOPE, ANBP2, ALLHAT, HOPE, ANBP2,

LIFE, CONVINCELIFE, CONVINCE

ACC/AHA Post-MI Guideline, ACC/AHA Post-MI Guideline, BHAT, SAVE, Capricorn, BHAT, SAVE, Capricorn, EPHESUSEPHESUS

ACC/AHA Heart Failure ACC/AHA Heart Failure Guideline,Guideline, MERIT-HF, MERIT-HF, COPERNICUS, CIBIS, COPERNICUS, CIBIS, SOLVD, AIRE, TRACE, SOLVD, AIRE, TRACE,

ValHEFT, RALESValHEFT, RALES

THIAZ, BB, ACE, CCBTHIAZ, BB, ACE, CCB

BB, ACEI, ALDO ANTBB, ACEI, ALDO ANT

THIAZ, BB, ACEI, ARB, ALDO THIAZ, BB, ACEI, ARB, ALDO ANTANT

High CHD riskHigh CHD risk

Post-myocardialPost-myocardial

infarctioninfarction

Heart failureHeart failure

To determine whether the newer, more costly To determine whether the newer, more costly antihypertensive drugs - CCBs, ACE inhibitors and antihypertensive drugs - CCBs, ACE inhibitors and alpha-blockers - are superior to the older, less alpha-blockers - are superior to the older, less expensive diuretics in preventing CV complications of expensive diuretics in preventing CV complications of hypertension.hypertension.

The diuretics were superior. The diuretics were superior.

ALLHAT

Aspirin: who takes?Aspirin: who takes?

• People at intermediate and high-risk People at intermediate and high-risk by Framingham score by Framingham score

• Also people with diabetes and people Also people with diabetes and people with existing coronary heart diseasewith existing coronary heart disease

• Unless contraindicationsUnless contraindications

2004 ADA guidelines, www.diabetes.org2004 ADA guidelines, www.diabetes.org

Dolores RojasDolores Rojas• By virtue of having diabetes, she is in the By virtue of having diabetes, she is in the

same risk category of someone who same risk category of someone who already has coronary heart disease already has coronary heart disease

• Her ATP III risk is high (LDL goal < 100)Her ATP III risk is high (LDL goal < 100)• She is close to being at very high-risk, She is close to being at very high-risk,

which would place her LDL goal at < 70which would place her LDL goal at < 70• Her blood pressure goal is 130/80Her blood pressure goal is 130/80• Her HbA1c goal is 7Her HbA1c goal is 7• She has a long way to goShe has a long way to go

Chronic care modelChronic care model• For Ms. Rojas, the chronic care For Ms. Rojas, the chronic care

model component of model component of planned visitsplanned visits is crucially important; perhaps she is crucially important; perhaps she needs intensive case management needs intensive case management

• To help her manage critically needed To help her manage critically needed lifestyle changes plus complicated lifestyle changes plus complicated lab monitoring and medications lab monitoring and medications cannot be done in the acute primary cannot be done in the acute primary care visitcare visit

Population managementPopulation management

< 4%< 4% 4-6%4-6% >6%>6%

Prevalence of Diabetes Among AdultsPrevalence of Diabetes Among Adults

1993-19941993-1994

< 4%< 4% 4-6%4-6% >6%>6%


19991999

< 4%< 4% 4-6%4-6% >6%>6%


20002000


• It’s hard enough to manage each of It’s hard enough to manage each of your patients with diabetes (often your patients with diabetes (often with hyperlipidemia and HBP as well)with hyperlipidemia and HBP as well)

• But even more is needed: to manage But even more is needed: to manage the population of patients with the population of patients with diabetes/CV risk in your patient paneldiabetes/CV risk in your patient panel

Population managementPopulation management• You cannot manage your population You cannot manage your population

without knowing who they are, and without knowing who they are, and how they are doinghow they are doing– Number of your patients with diabetesNumber of your patients with diabetes– % of total diabetics with HbA1c > 8 (and % of total diabetics with HbA1c > 8 (and

who they are)who they are)– % of total diabetics with LDL > 100 (and % of total diabetics with LDL > 100 (and

who they are)who they are)– % of total diabetics with BP > 130/80 % of total diabetics with BP > 130/80

(and who they are)(and who they are)


• You also need to know which You also need to know which patients in your panel have not been patients in your panel have not been coming to the clinic, which patients coming to the clinic, which patients have not had HbA1c, LDL, and BP have not had HbA1c, LDL, and BP measured in the past year, because measured in the past year, because those are the most likely to be in those are the most likely to be in poor controlpoor control

Population managementPopulation management• To adequately manage your entire panel, you need a registry. To adequately manage your entire panel, you need a registry.

If it is kept up to date and if someone in the clinic looks at the If it is kept up to date and if someone in the clinic looks at the registry at least once a month, it can answer all those registry at least once a month, it can answer all those questions: questions: – what % are in poor control and who they are what % are in poor control and who they are – what % haven’t been coming and who they arewhat % haven’t been coming and who they are

• With a registry you can risk-stratify patients to determine With a registry you can risk-stratify patients to determine who can be cared for in primary care (Harriet Goode) and who can be cared for in primary care (Harriet Goode) and who needs more intensive planned visits (Dolores Rojas)who needs more intensive planned visits (Dolores Rojas)

• To keep a registry up to date and to use the registry requires To keep a registry up to date and to use the registry requires system redesign; someone on the team needs to be system redesign; someone on the team needs to be responsible for the registryresponsible for the registry

JulioJulio

• Julio is a 13 year old Latino boy who Julio is a 13 year old Latino boy who considers himself perfectly healthy. He considers himself perfectly healthy. He sees his pediatrician for a school physical sees his pediatrician for a school physical and his mother is told that Julio has a BMI and his mother is told that Julio has a BMI in the 90% percentile for his agein the 90% percentile for his age

• Julio is thus at risk for overweightJulio is thus at risk for overweight

• Julio likes to play video games, dislikes Julio likes to play video games, dislikes sports, and eats at McDonald’s frequentlysports, and eats at McDonald’s frequently

BMIBMI• BMI (body mass index) = BMI (body mass index) =

– weight in Kg/(height in meters)weight in Kg/(height in meters)22

• Adults: Adults: – Overweight: BMI 25-29.9Overweight: BMI 25-29.9– Obese: BMI 30 and aboveObese: BMI 30 and above

• Children: use percentile (compared with Children: use percentile (compared with BMI of other children of same age/gender)BMI of other children of same age/gender)– 85-95th percentile: at risk for overweight85-95th percentile: at risk for overweight– >95th percentile: overweight>95th percentile: overweight

www.cdc.gov/growthchartswww.cdc.gov/growthcharts

Prevalence of Obesity Among AdultsPrevalence of Obesity Among Adults

19891989

< 10%< 10% 10-15%10-15% > 15%> 15%

< 10%< 10% 10-15%10-15% > 15%> 15%


19941994

< 10%< 10% 10-15%10-15% > 15%> 15%


19981998

Ogden CL et al. JAMA. 2002;288:1728-1732.

Overweight Prevalence Among US Overweight Prevalence Among US Children and Adolescents, 1971-2000Children and Adolescents, 1971-2000

0

5

10

15

20

2-5 Years 6-11 Years 12-19 Years

NHANES I, 1971-1974NHANES III, 1988-1994NHANES 1999-2000

Pre

vale

nc

e (

%)

Metabolic SyndromeMetabolic Syndrome

The Metabolic SyndromeThe Metabolic Syndrome

Metabolic SyndromeMetabolic Syndrome• Key features to measureKey features to measure

– Abdominal Obesity (waist circumference > 35” females, Abdominal Obesity (waist circumference > 35” females, > 40” males) > 40” males)

– DyslipidemiaDyslipidemia• HDL <40 in males, <50 in femalesHDL <40 in males, <50 in females• Triglycerides (fasting) >150Triglycerides (fasting) >150

– Blood pressure >130/85 Blood pressure >130/85 – Insulin resistance: Impaired Fasting Glucose Insulin resistance: Impaired Fasting Glucose

(FBS between 100 and 126)(FBS between 100 and 126)

• Other features (not measured routinely)Other features (not measured routinely)– Proinflammatory state (elevated C-reactive protein)Proinflammatory state (elevated C-reactive protein)– Prothrombotic state (abnormal coagulation factors)Prothrombotic state (abnormal coagulation factors)


• Prevalence increases with agePrevalence increases with age• One-third of overweight/obese persons in the US One-third of overweight/obese persons in the US

have the syndromehave the syndrome• Almost everyone with metabolic syndrome is Almost everyone with metabolic syndrome is

overweight and physically inactiveoverweight and physically inactive• Latinos and people from South Asia are more Latinos and people from South Asia are more

susceptiblesusceptible• People with metabolic syndrome have greatly People with metabolic syndrome have greatly

increased risk of diabetes and coronary heart increased risk of diabetes and coronary heart diseasedisease

Metabolic SyndromeMetabolic Syndrome• Cause: not proven. Hypothesis: abdominal fat is Cause: not proven. Hypothesis: abdominal fat is

the primary etiologic agentthe primary etiologic agent• Visceral fat cells may produce fatty acids and Visceral fat cells may produce fatty acids and

cytokines that cause insulin resistance, cytokines that cause insulin resistance, inflammatory and pro-thrombotic statesinflammatory and pro-thrombotic states

• Lack of physical activity also causes loss of Lack of physical activity also causes loss of muscle mass which increases insulin resistancemuscle mass which increases insulin resistance

• Regardless of the cause, the underlying risk Regardless of the cause, the underlying risk factors arefactors are– Overweight/obesityOverweight/obesity– Physical inactivityPhysical inactivity– Diet of high saturated fat, simple sugars, high Diet of high saturated fat, simple sugars, high

calories (atherogenic diet)calories (atherogenic diet)

Metabolic SyndromeMetabolic Syndrome• Does Julio have metabolic syndrome? Does Julio have metabolic syndrome? • Probably not yetProbably not yet

– Prevalence increases with agePrevalence increases with age– 2/3 of overweight people in the US do not have 2/3 of overweight people in the US do not have

the syndrome. 1/3 dothe syndrome. 1/3 do– It would be worth checking his fasting glucose It would be worth checking his fasting glucose

to see if it is over 100 (impaired fasting to see if it is over 100 (impaired fasting glucose) glucose)

• With his BMI, diet and physical inactivity, With his BMI, diet and physical inactivity, he is at high risk of developing metabolic he is at high risk of developing metabolic syndromesyndrome

• He is also at risk for diabetesHe is also at risk for diabetes


• ManagementManagement– Weight lossWeight loss– Increased physical activityIncreased physical activity– Diet with fewer saturated fats, simple sugars, Diet with fewer saturated fats, simple sugars,

and calories; more fruits and vegetablesand calories; more fruits and vegetables– Medication management is far less important Medication management is far less important

than lifestyle changes, but may be necessary than lifestyle changes, but may be necessary for blood pressure and cholesterol. Aspirin if for blood pressure and cholesterol. Aspirin if intermediate or high Framingham riskintermediate or high Framingham risk

Metabolic syndrome and Metabolic syndrome and diabetes preventiondiabetes prevention

• Diabetes can be prevented in people with impaired Diabetes can be prevented in people with impaired fasting glucose (between 100 and 126) -- some of fasting glucose (between 100 and 126) -- some of whom have the entire metabolic syndromewhom have the entire metabolic syndrome

• Diabetes Prevention ProgramDiabetes Prevention Program– >> 7% loss of body weight and maintenance of 7% loss of body weight and maintenance of

weight loss, <25% of calories from fat, total weight loss, <25% of calories from fat, total calories 1200-1800/daycalories 1200-1800/day

– >> 150 minutes per week of physical activity 150 minutes per week of physical activity

• 58% reduced incidence of diabetes after 4 years58% reduced incidence of diabetes after 4 years compared with controlscompared with controlsNEJM 346:393-403, 2002

JulioJulio• Julio (age 13) and his family need to be informed of Julio (age 13) and his family need to be informed of

his riskhis risk• If it is possible for him and his family to set some If it is possible for him and his family to set some

lifestyle change goals, that could be enormously lifestyle change goals, that could be enormously importantimportant

• Even if his weight stays the same, his BMI will go Even if his weight stays the same, his BMI will go down as his height increases. This could be down as his height increases. This could be accomplished by reducing caloric intake by a small accomplished by reducing caloric intake by a small amount and increasing exercise by a small amountamount and increasing exercise by a small amount

• The changes required are achievable if Julio and his The changes required are achievable if Julio and his family understand the importance and if Julio feels family understand the importance and if Julio feels confidence in his ability to make the changesconfidence in his ability to make the changes

Complications in Type 2 Diabetes and Complications in Type 2 Diabetes and the Metabolic Syndromethe Metabolic Syndrome

DiabeticDiabeticRetinopathyRetinopathy

DiabeticDiabeticRetinopathyRetinopathy

MacrovascularMacrovascularDiseaseDisease

MacrovascularMacrovascularDiseaseDisease

Ris

kR

isk

Re

lati

ve

Re

lati

ve

To

Gen

era

l Po

pu

lati

on

To

Gen

era

l Po

pu

lati

on

00

11

22

33

44

-15-15 -10-10 -5-5 55 1010 151500-20-20 2020

55

66

Years of DiabetesYears of Diabetes

Insulin ResistanceInsulin Resistance

DyslipidemiaDyslipidemia

HypertensionHypertension

HyperglycemiaHyperglycemia

Adapted from: Kendall DM. Adapted from: Kendall DM. Am J Manag CarAm J Manag Care 7e 7S327-S343, 2001.S327-S343, 2001.

MicroalbuminMicroalbuminNeuropathyNeuropathy

MicroalbuminMicroalbuminNeuropathyNeuropathy

Julio and the chronic care modelJulio and the chronic care model

• Kids should stay away from the health care system as Kids should stay away from the health care system as much as possible. much as possible. System redesignSystem redesign is needed to make is needed to make sure some caregiver is available to spend quite a bit of sure some caregiver is available to spend quite a bit of time with Julio and family in person or by phone or e-time with Julio and family in person or by phone or e-mail mail

• Julio will reduce his BMI through empathetic Julio will reduce his BMI through empathetic engagement in engagement in collaborative goal-settingcollaborative goal-setting -- his action -- his action plans must involve participation in plans must involve participation in community community resourcesresources, especially exercise programs that he , especially exercise programs that he enjoys. enjoys.

• Like everyone else, if Julio doesn’t want to do Like everyone else, if Julio doesn’t want to do something, he won’t do it. something, he won’t do it.

Putting evidence-based medicine Putting evidence-based medicine into practiceinto practice

Evidence-Evidence-

basedbased

medicinemedicine

(EBM)(EBM)

Clinicians Clinicians

actually actually

practicepractice

EBM EBM

Informed, activatedInformed, activated

patients make choices patients make choices

consistent with EBM consistent with EBM

to improve their to improve their

outcomes and lives outcomes and lives

Chronic care model components: Chronic care model components:

decision support, registries, decision support, registries, reminders, practice redesignreminders, practice redesign

Self-management Self-management support to inform and support to inform and activate patients through activate patients through collaborative decision-collaborative decision-makingmaking

Clinical Guidelines WebsitesClinical Guidelines Websites

American Diabetes Association: American Diabetes Association:

http://www.diabetes.org/for-health-professionals-and scientists/cpr.jsp

American College of Cardiology: American College of Cardiology:

http://www.acc.org/clinical/statements.htm

American Heart Association:American Heart Association:

http://www.americanheart.org/presenter.jhtml?identifier=554

National Cholesterol Education Program: National Cholesterol Education Program: http://www.nhlbi.nih.gov/guidelines/cholesterol/index.htm

http://www.diabetes.org/for-health-professionals-and-scientists/cpr.jsp




http://www.acc.org/clinical/statements.htm

http://www.americanheart.org/presenter.jhtml?identifier=554

http://www.nhlbi.nih.gov/guidelines/cholesterol/index.htm

Diabetes and Cardiovascular Risk A review Thomas Bodenheimer MD University of California, San...

Documents

Transcript of Diabetes and Cardiovascular Risk A review Thomas Bodenheimer MD University of California, San...