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Macrovascular Complication in

Diabetes Mellitus

Hadi Purnomo

Jakarta, 20 Oktober 2001

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PENDAHULUAN

Diabetes kini merupakan masalah kesehatan duniadengan 1! "t kasus

Peningkatan kasus akan ter"adi di negaraberkembang dengan la"u peningkatan 200 #

Diabetes tipe 1 bermani$estasi pada masa kanak%kanak dan de&asa dengan ge"ala berupa penurunan'' tiba%tiba serta hiperglikemia berat

Diabetes tipe 2 lebih ringan daripada diabetes tipe

1, (0 ) *0 # penderitan+a mengalami kegemukanedua tipe diabetes terkait dengan gangguan

"antung, stroke, tekanan darah tinggi, gangguangin"al, sara$ dan kebutaan

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U.S. Hospitalization for

Chronic Complications of Diabetes

Cardiovascular 77%

Other 4%

Ophthalmic 4%

Neuroloic !%

"enal #%

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Penderita DM tipe 2 memiliki kemungkinanuntuk menderita pen+akit "antung koronerhampir (0 #, dimana angka kematiann+a-. lebih tinggi dibandingkan +ang tidak

menderita diabetesPengendalian kadar gula darah +angditandai dengan Hba%1c, tern+ata tidak

berhubungan langsung dengan mortalitaskardiovaskular

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Ha$$ner penderita diabetes tipe 2 +ang

tidak menderita pen+akit "antung koroner

mempun+ai kemungkinan +ang sama

dengan penderita "antung koroner untuk

mendapat komplikasi kardiovaskular

enneth dlk Mortalitas kardiovaskular

penderita diabetes +ang tidak pernah

menderita in$ark "antung setara denganpenderita non diabetes +ang pernah

mendapat in$ark "antung

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adar gula darah PP / post prandialmerupakan $aktor risiko pen+akit "antung

koroner

DCOD tud+3 Mortalitas pen+akit

"antung koroner sangat berhubungan erat

dengan kadar gula darah PP dibandingkangula darah puasa

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DM Kardiovaskuler

Prevalensi PJK 55% (populasi umum 2-%!

Mor"ali"as # Mor$idi"as K

2& le$i' "ini pd pria dia$e"ik

& le$i' "ini pd )ani"a dia$e"ik

Pronosis pas*a +KA $uruk

Ari"mia # anuan konduksi

,skemia $erulan revaskularisasi

,nark # reinark

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4ging population more sedentar+ 5over&eight incidence DM

(0 # o$ death cardiovascular disease

!6 # 7schemic Heart DiseaseDM t+pe 7 8 t+pe 773 28(

DM t&ice incidence o$ 4C 1,6 ) 2 .

death a$ter 4M7

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Pathoph+siolog+ 8 macrovasc compl9

:asculopathic state caused b+ multiple

metabolic derangement 8

H+pergl+cemia

H+perinsulinemia

4bberancies o$ the coagulation s+stem

4ssociated other risk $actors 8 obesit+, old,

h+pertention

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H+perinsulinemiapremature atherosclirotic

disease 4 &eak independent risk $actorD+slipidemia 8 high :;D; 5 total illebrand $actor

$ibrinogen, d9driver, thrombin P47%7 and activit+ $actor

:777

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Diabetes dan komplikasi :askular

Prostaglandinimbalance ?ree redical

Platelet adhesion Platelet aggregation ?ibrinol+sis

Microthombus

Microvascullar

complication

Makrovascullar

complication

H+perglicemia4bnormal lipid

metabolism

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Changes in vasoreactivit+@o production and action

@o scavenging

'lunted vasomotor reactivit+ caused b+ microvascularatherosclerosis

@europathic changes autonomis neuropath+ unopposed s+mpathetic tone plague instabilit+4C, arrh+tmogenicit+, CH?ensor+neuropath+ at+pical chest pain

delanged to hospital4ltere anaerobic mechanism 8 inappropriate $ree$att+ acid metabolism impair vasoreactivit+, arrh+thninogenicit+, decrease contractilit+,

increased in$arct siAe

4ssociated $actors

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Mortalit+ a$ter acute coronar+ s+ndrome in

diabetic patient still high compare to non DM

7nsulin anaerobic metabolism

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$pe&' Diabetes and Coronar(rter Disease

)eople *ith $pe&' D+ have an increased ris,of din prematurel compared to non&D+ -Hih mortalit rate after (+

(cute rate is increased '&/ times)ersists in thromboltic studiesD+&specific factors responsible

0orse 1&ear revascularization)ostanioplast - /4% vs #%)ost&C(23 - #% vs #%

Hih lon&term mortalit

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uggested

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!5

15

45

/5

'5

5

5

5 ' / 4 1

+ort

alit6%7 ) 8 5.55

Diabetic

Non&

Diabetic

9ive&ear mortalit amon diabetics and non diabetics durin

follo* up after mocardial infarction

Duration of follo* up6ears

Herlitz : (cta +ed Scand#;;

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5

5

#5

;5

75

!5

15

45

/5

5 ' / 4 1

Surv

ival6%7

Diabetic

Non&

Diabetic

Survival rates for diabetic and non&diabetic sub et al (m : Cardio##4?74-//4

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Diabetes and Coronar (rter Disease

8 ! ears 7 ears Duration of diabetes

$he /.1&ear incidence 6% of CHD death *ith respect to the

median of Hb(c and duration of diabetes.

%4

'

5

;

!

4

'

5

@uusisto et al Diabetes 4/?#!5!7= ##4

Hb(c A#.;Hb(c 8#.;

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0ea,l related to theduration of the diabetes

Diabetes and Coronar (rter Disease

$pe&' Diabetes

+acrovascular complication

' B/ times hiher than non diabetic

Hih prevalence of cardio&vascular complications

at dianosisOccurs before diabetes develops 63$

nsulin resistance sndrome

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Coronar +ortalit in Diabeticand Non Diabetic +en

5 '5 /5 45 15 !

;5

!5

45

'5

5

5

Diabetic

Non Diabetic45ear

CHDmortalitp

er4555

Sstolic blood pressure 6mmH

;5

!5

45

'5

5

5

Diabetic

Non Diabetic

4 1 ! 7

45ear

CHDmortalitp

er4555

Serum cholesterol 6mmol>

Stamler et al Diabetes Care !-4/4&444= ##/

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Conclusion of 2lood )ressure ControlConclusion of 2lood )ressure ControlStudStud

$he U@)DS has sho*n that tiht blood

pressure controlreduces the ris, of

diabetic macroand microvascular

complications

UKPD

S

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Coronary Angiography in Diabetic Patients

1. Diabetes is associated with more severe

atherosclerosis of the coronary vesselsindependently of other risk factors

2. The effect of diabetes on coronary atherosclerosisis greater in women than in men

. Coronary atherosclerosis e!plains the higher cardiacmortality of diabetic patients". Diabetic patients witho#t P$% &previo#s myocardial

infarction' have a similar degree of coronaryatherosclerosis and mortality rates as non(diabeticpatients with P$%

). Protein#ria is not by itself a marker of coronaryatherosclerosis b#t does identify* especially indiabetic people* a s#bgro#p of patients at high risk

of cardiac death Natali ( et al Diabetoloia '555?4/-!/'&!4

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@eterlibatan Disfunsi ndotel pada )ena,it @ardiovas,ular

Faktor risiko Disfungsi endotel Akibat

Hemodinamik (shear

stress tekanan)

Vasospasme

Hipertensi

DIABETES !I" !H"# T$A"

%ipd (o&'%D%) Trombosis

Hipoksia EDF (*) ET'+

Infeksi (,irus#bakteri)

-elainan imun (allograf) Aterosklerosis

okok

'

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(pproaches for "is, "eductionin $pe&' Diabetic )atients

Stop smo,in

Optimize diabetes control

Screen and treat hprtension

Screen and treat dslipidemia3ive dietar adviceOptimizin diabetes control

+aintainin ideal bod *eiht

>o*erin lipids

ncourae aerobic eEercise

Schernthaner 3Schernthaner 3

##!##!

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Kesimpulan

F Diabetes

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Thank you

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