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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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