Attainment of recommended therapeutic targets of modifiable cardiovascular risk factors among individuals with type 2 diabetes mellitus screened at a diabetes clinic in Sri Lanka

Thilak Priyantha Weerarathna,1 Herath Mudiyanselage Meththananda Herath,1 Gayani Liyanage,1 Miyuru Kavinda Weerarathna,2 Vidarsha Senadheera2 1Faculty of Medicine, University of Ruhuna, Matara, Sri Lanka; 2Faculty of Medicine, University of Colombo, Colombo, Sri Lanka Introduction: Implementation of effective measures to control rising burden of cardiovascular diseases among patients with type 2 diabetes mellitus (T2DM) requires information on the adequacy of control and identification of specific groups with suboptimal control of blood glucose, lipids and blood pressure. Methods: A cross-sectional study of patients with T2DM referred from primary care to a diabetes center was carried out to estimate the proportion of patients achieving the recommended therapeutic targets of four major modifiable cardiovascular risk factors: glycosylated hemoglobin (HbA1c <7%), low-density lipoprotein cholesterol <100 mg/dL, systolic blood pressure (SBP) <130 mmHg and diastolic blood pressure (DBP) <80 mmHg and their associations with age, gender, duration of diabetes and body mass index were studied. Results: Mean (SD) age and the duration of the sample of 2422 (65% males) were 52 (11) and 9 (3), respectively. Percentages with optimal HbA1c, low-density lipoprotein cholesterol, SBP and DBP were 25.2%, 24.3%, 32% and 56.7%, respectively. Only 2% had achieved optimal control of all four risk factors. Significantly higher percentages of males were having optimal HbA1C, SBP and DBP, and regression analysis revealed that male gender was significantly associated with optimal control of SBP. Conclusion: Control of cardiovascular risk diseases factors among patients with T2DM managed in the primary care settings needs further improvements in target achievement in all four modifiable risk factors. Keywords: suboptimal control, therapeutic targets, type 2 diabetes mellitus, Sri Lank

Cardiovascular risk assessment in type 2 diabetes mellitus: comparison of the World Health Organization/International Society of Hypertension risk prediction charts versus UK Prospective Diabetes Study risk engine

Herath M Meththananda Herath, Thilak Priyantha Weerarathna, Dilini Umesha Department of Medicine, Faculty of Medicine, University of Ruhuna, Galle, Sri Lanka Introduction: Patients with type 2 diabetes mellitus (T2DM) are at higher risk of developing cardiovascular diseases, and assessment of their cardiac risk is important for preventive strategies. Purpose: The Ministry of Health of Sri Lanka has recommended World Health Organization/International Society of Hypertension (WHO/ISH) charts for cardiac risk assessment in individuals with T2DM. However, the most suitable cardiac risk assessment tool for Sri Lankans with T2DM has not been studied. This study was designed to evaluate the performance of two cardiac risk assessments tools; WHO/ISH charts and UK Prospective Diabetes Study (UKPDS) risk engine. Methods: Cardiac risk assessments were done in 2,432 patients with T2DM attending a diabetes clinic in Southern Sri Lanka using the two risk assessment tools. Validity of two assessment tools was further assessed by their ability to recognize individuals with raised low-density lipoprotein (LDL) and raised diastolic blood pressure in a cohort of newly diagnosed T2DM patients (n=332). Results: WHO/ISH charts identified 78.4% of subjects as low cardiac risk whereas the UKPDS risk engine categorized 52.3% as low cardiac risk (P<0.001). In the risk categories of 10%–<20%, the UKPDS risk engine identified higher proportions of patients (28%) compared to WHO/ISH charts (7%). Approximately 6% of subjects were classified as low cardiac risk (<10%) by WHO/ISH when UKPDS recognized them as cardiac risk of >20%. Agreement between the two tools was poor (κ value =0.144, P<0.01). Approximately 82% of individuals categorized as low cardiac risk by WHO/ISH had higher LDL cholesterol than the therapeutic target of 100 mg/dL. Conclusion: There is a significant discrepancy between the two assessment tools with WHO/ISH risk chart recognizing higher proportions of patients having low cardiac risk than the UKPDS risk engine. Risk assessment by both assessment tools demonstrated poor sensitivity in identifying those with treatable levels of LDL cholesterol and diastolic blood pressure. Keywords: cardiovascular disease, type 2 diabetes, risk assessment, WHO/ISH risk prediction charts, UKPDS risk engin

Association of Male Gender and Younger Age at Diagnosis of Type 2 Diabetes with more Atherogenic Lipid Profile

Background – Recognition of cardiovascular (CVD) risk profile and its patterns at the time of diagnosis of diabetes would enable adoption of most appropriate primary prevention strategies to reduce morbidity and mortality from vascular disease. We aimed to study the prevalence and pattern of modifiable CVD risk factors in patients at the time of diagnosis of type 2 diabetes. Methods- In this  single center, cross sectional study,  412 newly diagnosed patients with type 2 diabetes were studied on prevalence of low density lipoproteins (LDL), triglycerides (TG), high density lipoproteins (HDL) and systolic and diastolic blood pressure (SBP and DBP) . Prevalence of each risk factor was determined according to the American diabetes association criteria. Associations of each risk factor (dependent variable) with gender, age at onset of diabetes, waist circumference (WC) and body mass index (BMI) (independent variables) were studied using logistic regression.Results – Males accounted for 71% of sample and Mean (SD) age 49(11) years. The most prevalent lipid abnormality was LDL > 100 mg (81%) and low HDL and raised TG were detected in 17.1%, 18.5%. SBP> 140 mm Hg and DBP > 90 mm Hg were prevalent in 15% and 12%. Male gender (OR 7.98 – 95% CI 4.39 -14-49) and younger age at onset of diabetes (OR 0.95 95% CI 0.93 -0.98) were significantly associated with lower HDL. The younger age was significantly associated with adverse TG levels (OR 0.95, 95% CI 0.93-0.95) . Significant associations were detected with SBP and DBP with age (OR 1.09, 95% CI 1.05 - 1.13) and OR 1.062 95% CI 1.006 - 1.121).Discussion – Adverse LDL levels are present in 8 out of 10 patients at the time of diagnosis of diabetes. Modifiable CVD risk factors vary according to the age at onset of diabetes with more atherogenic dyslipidemia prevalent in younger and elevated blood pressure in older patients.

Senior Registrar in Medicine,

Value of CT scanning in the diagnosis and management of patient