Diabetes and heart problem

By Dr. Muhammad Hafizullah

I was never a 'statistics man' but now afflicted with diabetes, I enquired my doctor about how common is the illness and what does the future hold for us? The response was rather disappointing! He informed me, “Diabetes mellitus is a scourge which is now assuming the status of an epidemic. Whereas other epidemics follow a certain course and wither away- it has come here to stay for good! In 1997, 124 million were estimated to have diabetes, which accounted for 2.1% of worldwide population. Of them 97% were non insulin dependent.

By 2010 the number of total diabetics in the world will increase to 221 million patients. Diabetes is more common in our population and Pakistan spearheads the prevalence of diabetes in this region. Nearly 7.2% population has diabetes and this will unfortunately increase to 8.7% by 2025.” More annoying was the realization that most of the individuals afflicted with diabetes do not know about it and even those who know it do not have good control of their sugar levels.

Against the backdrop of the high prevalence of diabetes in Pakistan, the NHSP reported a very high unawareness rate for diabetes, with 36.3% of the diabetics being unaware of their condition. The survey also reported one of the lowest control rates for diabetes in the world; less than 3% of the diabetics had their condition in control.

Recently conducted surveys have revealed that knowledge relating to diabetes and its prevention is significantly low even in the urban metropolitan areas; only 40% of the known diabetics treated at tertiary healthcare facilities in Karachi had correct knowledge relating to diabetes and its complications. “What kills a diabetic?” I asked my doctor and the answer was, “At one time infections and variations in sugar level being too high - hyperglycemia and too low - hypoglycemia were the main toll takers but the scenario has changed now.

The real ‘monster’ with high mortality and higher morbidity is ‘accelerated atherosclerosis’ – faster pace of blockages of vessels. The worst effects are through involvement of small and large vessels, affecting all circulatory beds. Though it presents in a variety of ways, it follows a relentless course and renders the host virtually defenseless against a variety of ‘vipers’. Main targets are heart, brain, kidneys, eyes and peripheries.

Complications of diabetes include heart disease, Peripheral vessel disease, blindness, and kidney failure. Kidney failure due to diabetes is one of the major challenges. Diabetes for all practical purposes is the strongest risk factors and is now being considered as equivalent to having established cardiac disease.” My research on the subject of biggest victim of diabetes being heart and brain led to more revelations.

It was distressing to learn that of 150 million people around the world who already have diabetes, they are 2-4 times more likely to develop cardiovascular diseases such as heart attack or stroke than people without diabetes. Most alarming was to realize that more than 50% of patients with newly diagnosed type 2 diabetes have already established coronary artery disease and have evidence of cardiovascular disease.

Atherosclerosis –narrowing and later total closure of vessels – tubes carrying blood is a major cause of death among patients with diabetes mellitus: 75% from narrowing of vessels supplying heart, 25% from blockages in vessels supplying brain and arms and legs.

More than 75% of hospitalizations for individuals with diabetes are for narrowing or blockages of vessels. Diabetic patients have more than double chance of developing high blood pressure. Diabetes has cumulative effect in combination with other risk factors for the causation of narrowing and blockages of vessels.

The effect is unfortunately synergistic. Involvement of vessels in diabetics is more severe and diffuse. Local research conducted in Peshawar showed that the among important factors in heart diseases patients were Age > 40 years, physical inactivity, Diabetic status i.e. fasting blood sugar >126mg/dl,  and Cholesterol > 200mg/dl. Equally depressing were the facts that I learnt about heart problems in the perspective of geographical location.

Heart diseases have emerged as a number one killer in both, the developing and developed world. Though there has been a downward trend in the west in the prevalence of disease, it is on the rise in the developing countries. Heart diseases involving blood supply through tubes called coronary arteries follow a more aggressive course in the South East Asia.

The disease occurs early and follows a rather malignant course. First heart attack occurs five years earlier in South East Asian population as compared to the western population. Occurrence of first heart attack before the age of 40 years is ten times higher in our population.

Death rate across all age groups with heart disease is 40% higher. There is twofold excess of deaths in men before the age of 45years. Prevalence of heart disease before 40 years of age in the young in the West is less than 2% but is more than 12% in South Asians. Though effect on all target organs are profound and diffuse, let us focus on heart for the time being.

More diabetics succumb to coronary artery disease as against non diabetics. Diabetics afflicted with heart attack have higher morbidity and mortality. Lesser number of diabetics is amenable to revascularization as compared to non diabetics due to diffuse involvement of vessels.

Diabetics undergoing the procedures are more likely to have complications during the procedure. The chances of recurrence of symptoms and disease are higher. It is due to incomplete revascularization and the aggressive course it follows.

Revascularization – Bypass operation and angioplasty of such patients poses even higher threat with higher morbidity and mortality. The little ray of hope that I could find laid in aggressive treatment and immaculate control of diabetes. We understand that hypertension and diabetes increase morbidity and mortality. Perhaps the most robust data for reduction in morbidity is for reduction of strokes. The treatment does reduce cardiac events – heart attacks and cardiac failure.

Aggressive treatment reduces complications of Kidneys and decreases renal failure and requirement of dialysis and kidney transplant. Patients afflicted with Diabetes and high blood pressure make a special group and they merit a very aggressive approach where one has to have lower goals both for diabetic control and hypertension controls.