text stringlengths 80 6.25k | text_len int64 32 3.12k | src stringclasses 7 values |
|---|---|---|
kan met vragen De manier waarop dit aanspreekpunt vormgegeven wordt kan voor verschillende trajecten anders geregeld zijn Bij de meer complexe trajecten verdient het de voorkeur dat aanspreekpunt en procesbewaking gecombineerd zijn in één functie en ingevuld worden door personen met een zorginhoudelijke Inherent aan het werken volgens de richtlijn is dat op verschillende momenten in het proces de voorgaande stappen gecontroleerd worden De patiënt zal dat merken, deze zal bijvoorbeeld herhaald gevraagd worden naar zijn/haar identiteit en de aard en lokalisatie van de operatie Het is belangrijk om de patiënt duidelijk te maken dat dit de veiligheid moet verhogen en niet een In ziekenhuizen waar specialisten worden opgeleid, worden onder verantwoordelijkheid van de specialist werkzaamheden uitgevoerd door artsen al dan niet in opleiding tot specialist (A(N)IOS) In het geval van multidisciplinaire operaties is er niet één operateur maar zijn er meerdere Iedere operateur is verantwoordelijk voor het vastleggen van de informatie die voor zijn/haar specifieke onderdeel van belang is Eén operateur moet de coördinatie van het chirurgische deel van de ingreep op zich nemen Deze is ervoor verantwoordelijk dat het chirurgische deel van het woordelijkheden zijn dan ook zoals in de richtlijn is aangegeven Vanaf het besluit te (herâ) opereren moet de richtlijn gevolgd worden en dus de benodigde informatie gegenereerd en de als het ware een lus Gegevens die reeds beschikbaar zijn dienen gecontroleerd te worden op Bij sommige (poli)klinische ingrepen wordt de patiënt meteen naar huis ontslagen zonder dat Het kan voorkomen dat patiënten worden verpleegd op afdelingen die daar niet primair voor zijn (verpleging) ervoor eindverantwoordelijk dat op deze afdelingen de juiste zorg geboden kan worden Een oplossing kan zijn om bepaalde afdelingen aan te wijzen als âoverflowâafdelingenâ, Om de patiënt optimaal voor te bereiden op de operatie kan het zijn dat medicatie gestart, aangepast of gestopt moet worden vóór de operatie Het is tevens van groot belang dat er goede afspraken gemaakt worden wie verantwoordelijk is voor het zo nodig afbouwen, In de regel is de anesthesioloog tijdens de verkoeverperiode verantwoordelijk voor het medicatiebeleid De operateur en anesthesioloog moeten voor elke fase afspreken wie wanneer voor welke type medicatie verantwoordelijk is Voor algemene pijnstilling hoort er een ziekenhuisprotocol te zijn Voor specifieke aanbevelingen met betrekking tot postoperatieve Voor aanbevelingen betreffende de overdracht van medicatiegegeven naar andere zorgverleners, wordt verwezen naar de richtlijn âOverdracht van medicatiegegevens in de ketenâ In iedere fase van het traject wordt de medicatie op eenduidige en transparante wijze in het De NVZA heeft in ### de Ziekenhuisapotheekstandaard (ZAS) opgesteld waarin de taken en verantwoordelijkheden rondom geneesmiddelgebruik zijn vastgelegd Voorts is de richtlijn Bij het toedienen van medicatie dient altijd een âdubbel checkâ te worden uitgevoerd In het rapport Toezicht Operatief Proces (TOP #) wordt gesteld dat er een ziekenhuisbeleid moet zijn voor het onderhoud van apparatuur, waarbij voor elk medisch hulpmiddel een gewaarborgde staat van onderhoud geldt Verantwoordelijkheden moeten zijn vastgelegd De onderhoudsstatus moet voor individuele medische apparatuur door de gebruikers gemakkelijk.
| 566 | nvvc |
patiënten worden verpleegd op afdelingen die daar niet primair voor zijn (verpleging) ervoor eindverantwoordelijk dat op deze afdelingen de juiste zorg geboden kan worden Een oplossing kan zijn om bepaalde afdelingen aan te wijzen als âoverflowâafdelingenâ, Om de patiënt optimaal voor te bereiden op de operatie kan het zijn dat medicatie gestart, aangepast of gestopt moet worden vóór de operatie Het is tevens van groot belang dat er goede afspraken gemaakt worden wie verantwoordelijk is voor het zo nodig afbouwen, In de regel is de anesthesioloog tijdens de verkoeverperiode verantwoordelijk voor het medicatiebeleid De operateur en anesthesioloog moeten voor elke fase afspreken wie wanneer voor welke type medicatie verantwoordelijk is Voor algemene pijnstilling hoort er een ziekenhuisprotocol te zijn Voor specifieke aanbevelingen met betrekking tot postoperatieve Voor aanbevelingen betreffende de overdracht van medicatiegegeven naar andere zorgverleners, wordt verwezen naar de richtlijn âOverdracht van medicatiegegevens in de ketenâ In iedere fase van het traject wordt de medicatie op eenduidige en transparante wijze in het De NVZA heeft in ### de Ziekenhuisapotheekstandaard (ZAS) opgesteld waarin de taken en verantwoordelijkheden rondom geneesmiddelgebruik zijn vastgelegd Voorts is de richtlijn Bij het toedienen van medicatie dient altijd een âdubbel checkâ te worden uitgevoerd In het rapport Toezicht Operatief Proces (TOP #) wordt gesteld dat er een ziekenhuisbeleid moet zijn voor het onderhoud van apparatuur, waarbij voor elk medisch hulpmiddel een gewaarborgde staat van onderhoud geldt Verantwoordelijkheden moeten zijn vastgelegd De onderhoudsstatus moet voor individuele medische apparatuur door de gebruikers gemakkelijk moet zijn aangebracht Op deze sticker moet de datum van het eerstvolgende onderhoud vermeld zijn Bij haar bezoeken heeft IGZ gesignaleerd dat op apparatuur nog steeds vaak een Naar de mening van de werkgroep is onbekendheid met de uiterste gebruiksdatum van apparatuur zelden de oorzaak van problemen Veel vaker worden problemen veroorzaakt door samen met onder andere de âafstandâ tussen OK en instrumentele dienst, en de soms De NVKF, de VZI en de WIBAZ (binnenkort verenigd in een koepel voor Medische Technologie) zijn met het Nederlands Instituut voor Accreditatie in de Zorg (NIAZ) overeengekomen dat vanaf medio ### in de toetsing van instellingen de medische technologie een nadrukkelijker plaats krijgt Technisch onderlegde auditoren worden aan elk auditteam toegevoegd om het systeem van de inzet van medische technologie in de instelling door te lichten Reden voor dit initiatief is het grote belang van de medische technologie voor de kwaliteit en veiligheid van de zorg Naar de mening van de werkgroep is de instelling verantwoordelijk voor beheer en onderhoud van apparatuur en voor scholing van de gebruikers Hiernaast heeft de medisch specialist zelf een verantwoordelijkheid voor het (aantoonbaar) bijhouden van de eigen competenties waar het omgaan met apparatuur betreft Voor andere OKâmedewerkers geldt dat de instelling de verantwoordelijkheid heeft te zorgen voor adequate scholing en voor voldoende capaciteit aan goed opgeleid personeel Het moet inzichtelijk zijn hoe deze verantwoordelijkheid is belegd Een persoon die niet geschoold dan wel bekwaam is voor gebruik van bepaalde apparatuur gebruikt.
| 558 | nvvc |
aangebracht Op deze sticker moet de datum van het eerstvolgende onderhoud vermeld zijn Bij haar bezoeken heeft IGZ gesignaleerd dat op apparatuur nog steeds vaak een Naar de mening van de werkgroep is onbekendheid met de uiterste gebruiksdatum van apparatuur zelden de oorzaak van problemen Veel vaker worden problemen veroorzaakt door samen met onder andere de âafstandâ tussen OK en instrumentele dienst, en de soms De NVKF, de VZI en de WIBAZ (binnenkort verenigd in een koepel voor Medische Technologie) zijn met het Nederlands Instituut voor Accreditatie in de Zorg (NIAZ) overeengekomen dat vanaf medio ### in de toetsing van instellingen de medische technologie een nadrukkelijker plaats krijgt Technisch onderlegde auditoren worden aan elk auditteam toegevoegd om het systeem van de inzet van medische technologie in de instelling door te lichten Reden voor dit initiatief is het grote belang van de medische technologie voor de kwaliteit en veiligheid van de zorg Naar de mening van de werkgroep is de instelling verantwoordelijk voor beheer en onderhoud van apparatuur en voor scholing van de gebruikers Hiernaast heeft de medisch specialist zelf een verantwoordelijkheid voor het (aantoonbaar) bijhouden van de eigen competenties waar het omgaan met apparatuur betreft Voor andere OKâmedewerkers geldt dat de instelling de verantwoordelijkheid heeft te zorgen voor adequate scholing en voor voldoende capaciteit aan goed opgeleid personeel Het moet inzichtelijk zijn hoe deze verantwoordelijkheid is belegd Een persoon die niet geschoold dan wel bekwaam is voor gebruik van bepaalde apparatuur gebruikt Zo heeft de Nederlandse medische technologie (###) Deze praktijkgidsen geven praktische aanbevelingen hoe in ziekenhuizen de kwaliteitsborging en het risicomanagement geregeld zouden moeten worden en De praktijkgids Kwaliteitsborging Medische Apparatuur gaat vooral in op de verdeling van de verantwoordelijkheden in het ziekenhuis en het punt dat ziekenhuizen beschikken over een operationeel kwaliteitsbeleid met betrekking tot medische apparatuur Een dergelijk kwaliteitsbeleid dient zich uit te strekken tot alle betrokken diensten en afdelingen (NVZ ###) Het management van de ziekenhuizen is verantwoordelijk voor het helder beleggen van de taken, verantwoordelijkheden en bevoegdheden van de Instrumentele Dienst en andere afdelingen, in het proces van aanschaf, introductie, onderhoud, beheer en gebruik van medische apparatuur Hieronder valt ook de introductie van medische apparatuur bij gebruikers in het De Nederlandse Vereniging voor Klinische Fysica (NVKF) heeft in ### een set prestatieâ indicatoren voor de kwaliteitsborging van medische systemen ontwikkeld Deze indicatoren zijn beschreven aan de hand van een integrale procesbenadering voor borging van kwaliteit en veiligheid rond medische technologie met systematische verbinding naar de levenscyclus van De Orde van Medisch Specialisten (OMS) heeft samen met de NVZ, de Nederlandse Vereniging voor Anesthesiologie (NVA) en de Nederlandse Vereniging voor Heelkunde (NVvH) de leidraad Verantwoordelijkheid medisch specialist bij onderhoud en beheer van medische apparatuur opgesteld (###), waarin de verantwoordelijkheden van de medisch specialist zijn beschreven, met een specifieke paragraaf voor de operatiekamer Zo wordt hierin gesteld dat voor alle medische apparatuur een prospectieve risicoanalyse moet worden uitgevoerd, waarin risicovolle momenten; indeling in een risicoklasse; tracering van werkzaamheden aan medische.
| 568 | nvvc |
Nederlandse medische technologie (###) Deze praktijkgidsen geven praktische aanbevelingen hoe in ziekenhuizen de kwaliteitsborging en het risicomanagement geregeld zouden moeten worden en De praktijkgids Kwaliteitsborging Medische Apparatuur gaat vooral in op de verdeling van de verantwoordelijkheden in het ziekenhuis en het punt dat ziekenhuizen beschikken over een operationeel kwaliteitsbeleid met betrekking tot medische apparatuur Een dergelijk kwaliteitsbeleid dient zich uit te strekken tot alle betrokken diensten en afdelingen (NVZ ###) Het management van de ziekenhuizen is verantwoordelijk voor het helder beleggen van de taken, verantwoordelijkheden en bevoegdheden van de Instrumentele Dienst en andere afdelingen, in het proces van aanschaf, introductie, onderhoud, beheer en gebruik van medische apparatuur Hieronder valt ook de introductie van medische apparatuur bij gebruikers in het De Nederlandse Vereniging voor Klinische Fysica (NVKF) heeft in ### een set prestatieâ indicatoren voor de kwaliteitsborging van medische systemen ontwikkeld Deze indicatoren zijn beschreven aan de hand van een integrale procesbenadering voor borging van kwaliteit en veiligheid rond medische technologie met systematische verbinding naar de levenscyclus van De Orde van Medisch Specialisten (OMS) heeft samen met de NVZ, de Nederlandse Vereniging voor Anesthesiologie (NVA) en de Nederlandse Vereniging voor Heelkunde (NVvH) de leidraad Verantwoordelijkheid medisch specialist bij onderhoud en beheer van medische apparatuur opgesteld (###), waarin de verantwoordelijkheden van de medisch specialist zijn beschreven, met een specifieke paragraaf voor de operatiekamer Zo wordt hierin gesteld dat voor alle medische apparatuur een prospectieve risicoanalyse moet worden uitgevoerd, waarin risicovolle momenten; indeling in een risicoklasse; tracering van werkzaamheden aan medische a v aantoonbare competentie van gebruikers (NVZ Nederlandse Vereniging voor Technisch facilitair management in de Gezondheidszorg (NVTG) hebben hierop gereageerd met een document waarin een aantal voorwaarden zijn beschreven Op moment van schrijven van de richtlijn Postoperatief Traject wordt er door het nationale normalisatie instituut NEN een Nederlands Technische Afspraak (NTA) Beheer medische ### beschikbaar Hiermee worden de bovengenoemde documenten vanaf die datum Onder het omgaan met apparatuur wordt ook verstaan het omgaan met medische gassen Hierover is in ### door de Inspectie voor de Gezondheidszorg een circulaire naar alle De medisch specialist moet als gebruiker van medische apparatuur In het rapport Toezicht Operatief Proces (TOP #) signaleert de Inspectie op het gebied van â richtlijnen infectiepreventie worden onvoldoende nageleefd (met name handhygiëne); â protocollen zijn moeilijk toegankelijk en naleving wordt niet getoetst; De werkgroep herkent de conclusies van de Inspectie Ziekenhuizen dienen protocollen te Op het gebied van perioperatieve infectiepreventie bestaan verschillende richtlijnen en leidraden Deze samenvatting beperkt zich daarom tot het vermelden van de bestaande â Richtlijn Microbiologische veiligheid bij onderhoud aan medische en laboratoriumapparatuur â Richtlijn Bewaren en transporteren van gebruikt instrumentarium voor sterilisatie (WIP â Chirurgisch afdekmateriaal, operatiejassen en clean air suits, gebruikt als medische praktijk Wel is bekend dat voor een goede implementatie de volgende stappen doorlopen Het implementeren van deze richtlijn zal voor veel instellingen betekenen dat de organisatie moet worden aangepast en processen opnieuw moeten worden vormgegeven Dit kost tijd en professionals zullen hierbij organisatorisch ondersteund moeten worden De werkgroep ziet hier.
| 584 | nvvc |
aantoonbare competentie van gebruikers (NVZ Nederlandse Vereniging voor Technisch facilitair management in de Gezondheidszorg (NVTG) hebben hierop gereageerd met een document waarin een aantal voorwaarden zijn beschreven Op moment van schrijven van de richtlijn Postoperatief Traject wordt er door het nationale normalisatie instituut NEN een Nederlands Technische Afspraak (NTA) Beheer medische ### beschikbaar Hiermee worden de bovengenoemde documenten vanaf die datum Onder het omgaan met apparatuur wordt ook verstaan het omgaan met medische gassen Hierover is in ### door de Inspectie voor de Gezondheidszorg een circulaire naar alle De medisch specialist moet als gebruiker van medische apparatuur In het rapport Toezicht Operatief Proces (TOP #) signaleert de Inspectie op het gebied van â richtlijnen infectiepreventie worden onvoldoende nageleefd (met name handhygiëne); â protocollen zijn moeilijk toegankelijk en naleving wordt niet getoetst; De werkgroep herkent de conclusies van de Inspectie Ziekenhuizen dienen protocollen te Op het gebied van perioperatieve infectiepreventie bestaan verschillende richtlijnen en leidraden Deze samenvatting beperkt zich daarom tot het vermelden van de bestaande â Richtlijn Microbiologische veiligheid bij onderhoud aan medische en laboratoriumapparatuur â Richtlijn Bewaren en transporteren van gebruikt instrumentarium voor sterilisatie (WIP â Chirurgisch afdekmateriaal, operatiejassen en clean air suits, gebruikt als medische praktijk Wel is bekend dat voor een goede implementatie de volgende stappen doorlopen Het implementeren van deze richtlijn zal voor veel instellingen betekenen dat de organisatie moet worden aangepast en processen opnieuw moeten worden vormgegeven Dit kost tijd en professionals zullen hierbij organisatorisch ondersteund moeten worden De werkgroep ziet hier systematische manier indicatoren ontwikkeld Deze indicatoren zijn getest op meetbaarheid in In bijlagen # en # worden de methoden en resultaten beschreven van de ontwikkeling van Op basis van de richtlijnen preâ, perâ en postoperatief traject zijn in twee fases op een systematische manier indicatoren ontwikkeld De eerste fase is tijdens de ontwikkeling van de In de eerste fase van de indicatorontwikkeling zijn aanbevelingen uit de richtlijnen preâ en peroperatief traject gescoord door de werkgroep en is in een consensusbijeenkomst overeenstemming bereikt over de belangrijkste indicatoren voor de preâ en peroperatieve veiligheid Deze conceptset indicatoren is vervolgens op kleine schaal getest in een praktijktest De indicatoren ontwikkeld in de eerste fase zijn aangepast op basis van de ervaringen uit de vervolgens getest in een tweede praktijktest Na evaluatie van deze test is een definitieve set van acht indicatoren vastgesteld (zie tabel <DATUM> Details over de gevolgde procedure zijn De indicatoren hebben betrekking op alle patiënten die een chirurgische procedure moeten De indicatoren zijn bedoeld voor alle zorgverleners die betrokken zijn bij een dergelijke ingreep Zorgaanbieders zijn niet verplicht om al deze indicatoren continu te registreren De indicatoren zijn bedoeld om zorgaanbieders te helpen bij interne sturing en verbetering De aanbieders kunnen veelal zelf bepalen welke indicatoren ze wanneer gebruiken Ook kunnen deze indicatoren (of een subset daarvan) door wetenschappelijke verenigingen worden gebruikt bij De implementatie van de richtlijn en het gebruik van de indicatoren is de gezamenlijke.
| 553 | nvvc |
manier indicatoren ontwikkeld Deze indicatoren zijn getest op meetbaarheid in In bijlagen # en # worden de methoden en resultaten beschreven van de ontwikkeling van Op basis van de richtlijnen preâ, perâ en postoperatief traject zijn in twee fases op een systematische manier indicatoren ontwikkeld De eerste fase is tijdens de ontwikkeling van de In de eerste fase van de indicatorontwikkeling zijn aanbevelingen uit de richtlijnen preâ en peroperatief traject gescoord door de werkgroep en is in een consensusbijeenkomst overeenstemming bereikt over de belangrijkste indicatoren voor de preâ en peroperatieve veiligheid Deze conceptset indicatoren is vervolgens op kleine schaal getest in een praktijktest De indicatoren ontwikkeld in de eerste fase zijn aangepast op basis van de ervaringen uit de vervolgens getest in een tweede praktijktest Na evaluatie van deze test is een definitieve set van acht indicatoren vastgesteld (zie tabel <DATUM> Details over de gevolgde procedure zijn De indicatoren hebben betrekking op alle patiënten die een chirurgische procedure moeten De indicatoren zijn bedoeld voor alle zorgverleners die betrokken zijn bij een dergelijke ingreep Zorgaanbieders zijn niet verplicht om al deze indicatoren continu te registreren De indicatoren zijn bedoeld om zorgaanbieders te helpen bij interne sturing en verbetering De aanbieders kunnen veelal zelf bepalen welke indicatoren ze wanneer gebruiken Ook kunnen deze indicatoren (of een subset daarvan) door wetenschappelijke verenigingen worden gebruikt bij De implementatie van de richtlijn en het gebruik van de indicatoren is de gezamenlijke worden dat voor de meeste indicatoren wel gegevens voorhanden zijn (voor grotere groepen patiënten), maar niet altijd compleet of systematisch verzameld Er vindt dus (nog) niet voor alle Op basis van de uitkomsten van de praktijktesten is onderstaand implementatieplan opgesteld In dit plan is weergegeven wat logische stappen zijn voor de implementatie van de richtlijn dan wel stopmomenten en staan suggesties voor betrokkenen met betrekking tot te benaderen personen, uit te voeren activiteiten of algemene tips voor uitvoering van de stap Zie bijlage # In de rapporten Toezicht Operatief Proces geeft IGZ aan op welke termijn zaken geregeld moeten zijn in de ziekenhuizen en zij gaat daar ook actief op controleren Tegelijkertijd roept IGZ de beroepsverenigingen op een richtlijn te maken en geeft zij aan dat de benodigde Na het gereedkomen van de richtlijnen Preâ en Peroperatief Traject heeft IGZ in overleg met ziekenhuizen op orde moeten zijn en getoetst worden door de Inspectie Ziekenhuizen kunnen De werkgroep gaat ervan uit dat na het gereedkomen van de richtlijn Postoperatief Traject â wederom in overleg met de beroepsverenigingen â dit toetsingskader wordt aangepast door IGZ communication breakdowns resulting in injury to surgical patients <PERSOON> and failures in the implementation of evidenceâbased guidelines for clinical practice Med Care , (###) A surgical safety checklist to reduce morbidity and mortality in a global population <PERSOON> J Med, ###, ###â Inspectie voor de Gezondheidszorg (###) Toezicht Operatief Proces Deel #.
| 557 | nvvc |
zijn (voor grotere groepen patiënten), maar niet altijd compleet of systematisch verzameld Er vindt dus (nog) niet voor alle Op basis van de uitkomsten van de praktijktesten is onderstaand implementatieplan opgesteld In dit plan is weergegeven wat logische stappen zijn voor de implementatie van de richtlijn dan wel stopmomenten en staan suggesties voor betrokkenen met betrekking tot te benaderen personen, uit te voeren activiteiten of algemene tips voor uitvoering van de stap Zie bijlage # In de rapporten Toezicht Operatief Proces geeft IGZ aan op welke termijn zaken geregeld moeten zijn in de ziekenhuizen en zij gaat daar ook actief op controleren Tegelijkertijd roept IGZ de beroepsverenigingen op een richtlijn te maken en geeft zij aan dat de benodigde Na het gereedkomen van de richtlijnen Preâ en Peroperatief Traject heeft IGZ in overleg met ziekenhuizen op orde moeten zijn en getoetst worden door de Inspectie Ziekenhuizen kunnen De werkgroep gaat ervan uit dat na het gereedkomen van de richtlijn Postoperatief Traject â wederom in overleg met de beroepsverenigingen â dit toetsingskader wordt aangepast door IGZ communication breakdowns resulting in injury to surgical patients <PERSOON> and failures in the implementation of evidenceâbased guidelines for clinical practice Med Care , (###) A surgical safety checklist to reduce morbidity and mortality in a global population <PERSOON> J Med, ###, ###â Inspectie voor de Gezondheidszorg (###) Toezicht Operatief Proces Deel # Joint Commission on Accreditation of Healthcare Organizations (JCAHO) (###) Universal Protocol for preventing wrong Nederlands Normalisatie Instituut (NEN) (###) Chirurgisch afdekmateriaal, operatiejassen en clean air suits, gebruikt als Nederlandse Vereniging van Ziekenhuizen (NVZ) (###) Kwaliteitsborging van medische systemen Praktische gids voor Nederlandse Vereniging van Ziekenhuizen (NVZ) (###) Praktijkgids Risicomanagement en Medische technologie Nederlandse Vereniging voor Anesthesiologie, & Nederlandse Vereniging voor Heelkunde (NVvH) (###) Richtlijn Het Nederlandse Vereniging voor Anesthesiologie (NVA), & Nederlandse Vereniging voor Heelkunde (NVvH) (###) Richtlijn Nederlandse Vereniging voor Anesthesiologie (NVA) (###) Standpunt Verkoeverperiode en de inrichting en de organisatie Nederlandse Vereniging voor Anesthesiologie (NVA) (###) <PERSOON>) Nederlandse Vereniging voor Heelkunde (NVvH) (###) Normering Chirurgische Behandelingen, versie # # Nederlandse Vereniging voor Intensive Care (NVIC) (###) Richtlijn Criteria voor opname en ontslag van Intensive Care Orde van Medisch Specialisten (###) Leidraad Verantwoordelijkheid medisch specialist bij onderhoud en beheer van the <PERSOON>) checklist Qual Saf Health Care , ##, ###â# (###) Effect of a comprehensive surgical safety system on patient outcomes <PERSOON> J Med , ### (##), ###â## checklist during urgent operations in a global patient population Safe Surgery Saves Lives Investigators and Study estimation of the global volume of surgery a modelling strategy based on available data Lancet, ###, ###â## Werkgroep Infectiepreventie (###).
| 667 | nvvc |
SECTIE # Personeel â Opleiding, Continue Medische Educatie en verantwoordelijkheden <DATUM> # Verantwoordelijkheden medisch hoofd van het standaard en advanced laboratorium <DATUM> # Voorzieningen voor het maken en opslaan van onderzoek data # De echocardiografie is een onmisbaar instrument bij het vaststellen en vervolgen van vele echocardiografie aanzienlijke training en expertise vereist, terwijl ook de apparatuur en organisatie daarbij van groot belang zijn Voor een optimale diagnostische kwaliteit dient zowel het laboratorium alsook de er in werkzame laboranten en cardiologen en hun organisatie aan bepaalde vereisten voldoen Dit document heeft tot doel die vereisten te omschrijven Deze versie vervangt de eerdere ⢠Het medisch hoofd van een advanced echolab dient in het bezit te zijn van het EACVI (of ASE) ⢠Een beschrijving van het belang van ergonomische omstandigheden voor de echografist; ⢠De vermelding dat het de verantwoordelijkheid is van de aanvrager dat de uitslag van het Na goedkeuring door de leden van de NVVC zal de commissie kwaliteit van de NVVC de In het algemeen worden de Europese richtlijnen van de European Association of Cardiovascular Imaging (EACVI) gevolgd Afwijkingen specifiek voor de Nederlandse situatie zullen in dit document expliciet worden aangegeven Het competentieniveau van beeldvormende cardiologen wordt in de vernieuwde opleiding tot cardioloog aangeduid met I, II a, II b en III Voorts wordt aangegeven welke vaardigheden en ervaring nodig zijn om een bepaald competentieniveau te bezitten voor cardiologen Naar analogie van de richtlijnen van de EACVI wordt onderscheid gemaakt in twee niveaus hoogste niveau, het advanced lab, die een opleiding in de echocardiografie verzorgen of speciale procedures verrichten worden hogere eisen gesteld dan aan standaard laboratoria die alleen ischaemiedetectie geen vereiste, indien een andere imagingmodaliteit voor dit doel gebruikt is bevoegd zelfstandig cardiologen en na accreditatie door de SBHFL, echolaboranten op te Het medisch hoofd is een cardioloog, en voldoet afhankelijk van de setting aan de volgende criteria Opleiding Competentieniveau IIb, gedefinieerd in het landelijk opleidingsdocument cardiologie (ref a Voor behoud van de klinische vaardigheid geldt volgens richtlijnen van de EACVI (ref ##) b Het medisch hoofd moet ## CME punten behalen op het gebied van cardiale imaging in # d Heeft de verantwoordelijkheid de praktische vaardigheden op peil te houden Voor behoud van de klinische vaardigheid gelden de volgende richtlijnen volgens de EACVI (ref ##) b het medisch hoofd moet ## CME punten behalen op het gebied van cardiale imaging in # c het medisch hoofd dient in het bezit te zijn van een geldig TTE & TEE certificaat van de.
| 559 | nvvc |
de European Association of Cardiovascular Imaging (EACVI) gevolgd Afwijkingen specifiek voor de Nederlandse situatie zullen in dit document expliciet worden aangegeven Het competentieniveau van beeldvormende cardiologen wordt in de vernieuwde opleiding tot cardioloog aangeduid met I, II a, II b en III Voorts wordt aangegeven welke vaardigheden en ervaring nodig zijn om een bepaald competentieniveau te bezitten voor cardiologen Naar analogie van de richtlijnen van de EACVI wordt onderscheid gemaakt in twee niveaus hoogste niveau, het advanced lab, die een opleiding in de echocardiografie verzorgen of speciale procedures verrichten worden hogere eisen gesteld dan aan standaard laboratoria die alleen ischaemiedetectie geen vereiste, indien een andere imagingmodaliteit voor dit doel gebruikt is bevoegd zelfstandig cardiologen en na accreditatie door de SBHFL, echolaboranten op te Het medisch hoofd is een cardioloog, en voldoet afhankelijk van de setting aan de volgende criteria Opleiding Competentieniveau IIb, gedefinieerd in het landelijk opleidingsdocument cardiologie (ref a Voor behoud van de klinische vaardigheid geldt volgens richtlijnen van de EACVI (ref ##) b Het medisch hoofd moet ## CME punten behalen op het gebied van cardiale imaging in # d Heeft de verantwoordelijkheid de praktische vaardigheden op peil te houden Voor behoud van de klinische vaardigheid gelden de volgende richtlijnen volgens de EACVI (ref ##) b het medisch hoofd moet ## CME punten behalen op het gebied van cardiale imaging in # c het medisch hoofd dient in het bezit te zijn van een geldig TTE & TEE certificaat van de heeft de verantwoordelijkheid de praktische vaardigheden op peil te houden <DATUM> Verantwoordelijkheden medisch hoofd van het standaard en advanced a het medisch hoofd is verantwoordelijk voor de kwaliteit en organisatie van de b het medisch hoofd kan het hele echolaboratorium superviseren of bepaalde specifieke taken c het medisch hoofd is er verantwoordelijk voor dat de medische en technische staf volgens e het ziekenhuis dient zich te conformeren aan de kwaliteitseisen, zoals die in deze SOP geformuleerd zijn en zal randvoorwaarden scheppen, waardoor aan deze kwaliteitseisen kan Elk lid van de medische staf heeft een in <LOCATIE> geldig artsendiploma en is bij voorkeur Voor behoud van de echovaardigheid geldt de richtlijn van de American College of Cardiology b dient minstens ## studiepunten te behalen op het gebied van cardiovasculaire imaging in c hoeft niet in het bezit te zijn van het EACVI-examen echocardiografie, maar dat verdient wel Alle leden van de technische staf moeten gekwalificeerd echocardiografisch laborant zijn, dan wel in Opleiding de leden van de technische staf moeten voldoen aan één van de volgende twee criteria a minimaal ## uren echocardiografie gerelateerd relevant onderwijs/educatie over een d organisatie van en toezicht op tijdig en voldoende onderhoud van de echo- en andere e samenwerken met het medisch hoofd, medische staf en technische staf; f technische opleiding en nascholing van de technische staf, structureel echo onderwijs minimaal # maal per kwartaal en casusbespreking # maal per week;.
| 557 | nvvc |
heeft de verantwoordelijkheid de praktische vaardigheden op peil te houden <DATUM> Verantwoordelijkheden medisch hoofd van het standaard en advanced a het medisch hoofd is verantwoordelijk voor de kwaliteit en organisatie van de b het medisch hoofd kan het hele echolaboratorium superviseren of bepaalde specifieke taken c het medisch hoofd is er verantwoordelijk voor dat de medische en technische staf volgens e het ziekenhuis dient zich te conformeren aan de kwaliteitseisen, zoals die in deze SOP geformuleerd zijn en zal randvoorwaarden scheppen, waardoor aan deze kwaliteitseisen kan Elk lid van de medische staf heeft een in <LOCATIE> geldig artsendiploma en is bij voorkeur Voor behoud van de echovaardigheid geldt de richtlijn van de American College of Cardiology b dient minstens ## studiepunten te behalen op het gebied van cardiovasculaire imaging in c hoeft niet in het bezit te zijn van het EACVI-examen echocardiografie, maar dat verdient wel Alle leden van de technische staf moeten gekwalificeerd echocardiografisch laborant zijn, dan wel in Opleiding de leden van de technische staf moeten voldoen aan één van de volgende twee criteria a minimaal ## uren echocardiografie gerelateerd relevant onderwijs/educatie over een d organisatie van en toezicht op tijdig en voldoende onderhoud van de echo- en andere e samenwerken met het medisch hoofd, medische staf en technische staf; f technische opleiding en nascholing van de technische staf, structureel echo onderwijs minimaal # maal per kwartaal en casusbespreking # maal per week; eisen met betrekking tot veiligheid, privacy en comfort voor zowel de patiënt als de technische staf <DATUM> # Het adequaat vervaardigen van een echocardiogram vereist een juiste en ergonomisch Dat vereist voldoende ruimte voor een bed waarbij veranderingen in positie mogelijk zijn, voor de Er moet worden voorzien in adequate en toegewijde ruimte voor de beoordeling van opgeslagen cardioloog Een bespreekruimte moet ter beschikking zijn voor data evaluatie, interpretatie en discussie met de echolaboranten en/of verwijzend arts, indien nodig Er moet voldoende ruimte zijn voor opslag van zowel de beelden als het echoverslag op een server en deze is bij voorkeur ook <DATUM> Voorzieningen voor het maken en opslaan van onderzoek data <DATUM> # Een systeem voor opname en archivering van echocardiografische data (beelden, metingen en <DATUM> # Een permanente opslag van beelden en echoverslagen volgens wettelijke eisen Volgens de vijftien jaar âof zoveel langer als uit de zorg van een goed hulpverlener voortvloeitâ Deze toevoeging slaat op de situatie dat een arts alleen in staat is om goede zorg te (blijven) bieden als de gegevens langer bewaard blijven, zoals bij chronische of aangeboren aandoeningen De echocardiografische data moeten beschikbaar zijn voor vergelijking met nieuwe studies De studies moeten worden gearchiveerd in het originele format op een server Het gebruik van videotapes is bij ingang van deze nieuwe SOP niet meer acceptabel Het echolaboratorium moet de beschikking hebben over <DATUM> #.
| 546 | nvvc |
privacy en comfort voor zowel de patiënt als de technische staf <DATUM> # Het adequaat vervaardigen van een echocardiogram vereist een juiste en ergonomisch Dat vereist voldoende ruimte voor een bed waarbij veranderingen in positie mogelijk zijn, voor de Er moet worden voorzien in adequate en toegewijde ruimte voor de beoordeling van opgeslagen cardioloog Een bespreekruimte moet ter beschikking zijn voor data evaluatie, interpretatie en discussie met de echolaboranten en/of verwijzend arts, indien nodig Er moet voldoende ruimte zijn voor opslag van zowel de beelden als het echoverslag op een server en deze is bij voorkeur ook <DATUM> Voorzieningen voor het maken en opslaan van onderzoek data <DATUM> # Een systeem voor opname en archivering van echocardiografische data (beelden, metingen en <DATUM> # Een permanente opslag van beelden en echoverslagen volgens wettelijke eisen Volgens de vijftien jaar âof zoveel langer als uit de zorg van een goed hulpverlener voortvloeitâ Deze toevoeging slaat op de situatie dat een arts alleen in staat is om goede zorg te (blijven) bieden als de gegevens langer bewaard blijven, zoals bij chronische of aangeboren aandoeningen De echocardiografische data moeten beschikbaar zijn voor vergelijking met nieuwe studies De studies moeten worden gearchiveerd in het originele format op een server Het gebruik van videotapes is bij ingang van deze nieuwe SOP niet meer acceptabel Het echolaboratorium moet de beschikking hebben over <DATUM> # een Entrustable Professional Activities, EPA), dient bij een spoedeisende klinische aanvraag binnen routineaanvraag binnen een week, overeenkomend met de leidraad kritieke bevindingen van de <DATUM> # Het laboratorium beschikt over een in het document beheersysteem vastgelegd protocol over de wijze waarop omgegaan wordt met onverwachte bevindingen, die consequenties hebben voor <DATUM> # De veiligheid van patiënten en werknemers is verzekerd via werkafspraken en de protocollen zijn goedgekeurd door het medisch hoofd en vastgelegd in het document beheersysteem <DATUM> # Al het echolaboratoriumpersoneel onderschrijft, conform de wettelijke eisen, de professionele principes aangaande patiënt-arts vertrouwelijkheid zoals vastgelegd door landelijke en/of lokale <DATUM> # Het echolaboratorium moet voldoen aan de wettelijk vastgestelde eisen aangaande de <DATUM> # Standaard echocardiografie wordt als veilig beschouwd voor zowel patiënt als echolaborant de patiënt, doordat het enerzijds een semi-invasieve ingreep betreft en anderzijds door de belasting van het cardiovasculaire systeem van de patiënt Om deze reden moet een echolaboratorium waarbij deze speciale echocardiografische procedures worden uitgevoerd een noodprocedure hebben en <DATUM> # Het echolaboratorium moet een geautoriseerd en actueel protocol hebben dat voorziet in het omgaan met acute medische noodgevallen en het reanimatieprotocol conform de richtlijnen van de <DATUM> # Om visualisatie van shunts en het endocard te faciliteren kan gebruik gemaakt worden van echocontrast, waarbij gebruikt gemaakt kan worden van geagiteerd NaCl #,#%, of commercieel verkrijgbaar trans pulmonaal contrast Voor het laatste dienen veiligheidsmaatregelen genomen te worden om een eventueel optredende allergische reactie te signaleren en behandelen ( zie <DATUM> # ).
| 572 | nvvc |
binnen een week, overeenkomend met de leidraad kritieke bevindingen van de <DATUM> # Het laboratorium beschikt over een in het document beheersysteem vastgelegd protocol over de wijze waarop omgegaan wordt met onverwachte bevindingen, die consequenties hebben voor <DATUM> # De veiligheid van patiënten en werknemers is verzekerd via werkafspraken en de protocollen zijn goedgekeurd door het medisch hoofd en vastgelegd in het document beheersysteem <DATUM> # Al het echolaboratoriumpersoneel onderschrijft, conform de wettelijke eisen, de professionele principes aangaande patiënt-arts vertrouwelijkheid zoals vastgelegd door landelijke en/of lokale <DATUM> # Het echolaboratorium moet voldoen aan de wettelijk vastgestelde eisen aangaande de <DATUM> # Standaard echocardiografie wordt als veilig beschouwd voor zowel patiënt als echolaborant de patiënt, doordat het enerzijds een semi-invasieve ingreep betreft en anderzijds door de belasting van het cardiovasculaire systeem van de patiënt Om deze reden moet een echolaboratorium waarbij deze speciale echocardiografische procedures worden uitgevoerd een noodprocedure hebben en <DATUM> # Het echolaboratorium moet een geautoriseerd en actueel protocol hebben dat voorziet in het omgaan met acute medische noodgevallen en het reanimatieprotocol conform de richtlijnen van de <DATUM> # Om visualisatie van shunts en het endocard te faciliteren kan gebruik gemaakt worden van echocontrast, waarbij gebruikt gemaakt kan worden van geagiteerd NaCl #,#%, of commercieel verkrijgbaar trans pulmonaal contrast Voor het laatste dienen veiligheidsmaatregelen genomen te worden om een eventueel optredende allergische reactie te signaleren en behandelen ( zie <DATUM> # ) Het medisch hoofd is ervoor verantwoordelijk dat er een beleidsnota bestaat, waarbij de kwaliteit wordt gegarandeerd van alle procedures, die in het echolaboratorium worden verricht Deze Instrumentarium dat gebruikt wordt voor diagnostisch onderzoek vergt goed onderhoud waardoor het echocardiografisch onderzoek veilig en verantwoord is De accuraatheid van data is essentieel bij de beoordeling en het diagnostisch gebruik Richtlijnen voor instrumentariumonderhoud zijn (maar a vervanging echoapparaat verdient aanbeveling cf de richtlijn van de EACVI tenminste #x/# d vastleggen van de procedures rond het schoonmaken c q reinigen van onderdelen, filters, e Onderhoud en reparaties worden verricht door technisch en gekwalificeerd personeel, het Elk vervaardigd echocardiografisch onderzoek moet door een cardioloog als eindverantwoordelijke Jaarlijkse registratie van het aantal procedures binnen het echolaboratorium en van elk lid van de onderwijs minimaal # maal per kwartaal en casusbespreking minimaal # maal per week Eventueel regionaal georganiseerde bijeenkomsten, zodat aan de SBHFL urencriteria voor nascholing voldaan Regelmatig interindividueel testen op het vervaardigen en interpreteren van omschreven aspecten van echocardiogrammen ter evaluatie van kwaliteit, accuraatheid en juistheid van het onderzoek Zowel artsen als echolaboranten moeten betrokken zijn bij deze vorm van testen Verschillen in de uitvoering en interpretatie moeten worden geëvalueerd voor het verkrijgen van uniforme dusdanig georganiseerd zijn dat correctie van resultaten mogelijk is en de discretie van zowel artsen, <DATUM> # Het is aanbevelenswaardig dat een advanced lab samenwerkt met omringende standard labs in de regio om te komen tot eenduidige kwaliteit en regionale nascholing zoals vermeld in punt <DATUM> #.
| 570 | nvvc |
ervoor verantwoordelijk dat er een beleidsnota bestaat, waarbij de kwaliteit wordt gegarandeerd van alle procedures, die in het echolaboratorium worden verricht Deze Instrumentarium dat gebruikt wordt voor diagnostisch onderzoek vergt goed onderhoud waardoor het echocardiografisch onderzoek veilig en verantwoord is De accuraatheid van data is essentieel bij de beoordeling en het diagnostisch gebruik Richtlijnen voor instrumentariumonderhoud zijn (maar a vervanging echoapparaat verdient aanbeveling cf de richtlijn van de EACVI tenminste #x/# d vastleggen van de procedures rond het schoonmaken c q reinigen van onderdelen, filters, e Onderhoud en reparaties worden verricht door technisch en gekwalificeerd personeel, het Elk vervaardigd echocardiografisch onderzoek moet door een cardioloog als eindverantwoordelijke Jaarlijkse registratie van het aantal procedures binnen het echolaboratorium en van elk lid van de onderwijs minimaal # maal per kwartaal en casusbespreking minimaal # maal per week Eventueel regionaal georganiseerde bijeenkomsten, zodat aan de SBHFL urencriteria voor nascholing voldaan Regelmatig interindividueel testen op het vervaardigen en interpreteren van omschreven aspecten van echocardiogrammen ter evaluatie van kwaliteit, accuraatheid en juistheid van het onderzoek Zowel artsen als echolaboranten moeten betrokken zijn bij deze vorm van testen Verschillen in de uitvoering en interpretatie moeten worden geëvalueerd voor het verkrijgen van uniforme dusdanig georganiseerd zijn dat correctie van resultaten mogelijk is en de discretie van zowel artsen, <DATUM> # Het is aanbevelenswaardig dat een advanced lab samenwerkt met omringende standard labs in de regio om te komen tot eenduidige kwaliteit en regionale nascholing zoals vermeld in punt <DATUM> # Quinones et al ACC/AHA Clinical Competence Statement on <PERSOON> of PhysiciansâAmerican Society of Internal Medicine Task Force on Clinical Competence Bierig SM et al American Society of Echocardiography minimum standards for the cardiac <PERSOON>, et al Guidelines and Recommendations for <PERSOON> from <PERSOON> of the American College of Cardiology Foundation Appropriate American Society of Nuclear Cardiology, Heart Failure Society of <PERSOON>, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Critical Care Medicine, Society of Cardiovascular Computed Tomography and Society for <PERSOON> et al EAE recommendations for training, competence and quality improvement in Apparatuur die gebruikt wordt voor transthoracale echocardiografie (TTE) moet minimaal voldoen b monitor van voldoende grootte en kwaliteit voor beoordeling van alle modaliteiten; op het scherm moet zichtbaar zijn naam instelling, naam patiënt, datum en tijdstip onderzoek, ECG f netwerkverbinding met de server waar de opslag van zowel beelden als voorlopig en TTE dient volgens een standaardprotocol te worden uitgevoerd De procedure dient te worden <DATUM> # Voordat een studie wordt uitgevoerd moet de juistheid van de indicatie worden beoordeeld <DATUM> # Aanvraag procedure op het aanvraagformulier moet vermeld staan naam aanvrager, soort echo, reden voor het echo, de klinische vraagstelling samen met adequate klinische informatie <DATUM> # Planning Er moet voldoende tijd worden ingepland voor elk echocardiografisch onderzoek (beelden opnemen en verslag maken) Standaard ##-## minuten.
| 561 | nvvc |
Quinones et al ACC/AHA Clinical Competence Statement on <PERSOON> of PhysiciansâAmerican Society of Internal Medicine Task Force on Clinical Competence Bierig SM et al American Society of Echocardiography minimum standards for the cardiac <PERSOON>, et al Guidelines and Recommendations for <PERSOON> from <PERSOON> of the American College of Cardiology Foundation Appropriate American Society of Nuclear Cardiology, Heart Failure Society of <PERSOON>, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Critical Care Medicine, Society of Cardiovascular Computed Tomography and Society for <PERSOON> et al EAE recommendations for training, competence and quality improvement in Apparatuur die gebruikt wordt voor transthoracale echocardiografie (TTE) moet minimaal voldoen b monitor van voldoende grootte en kwaliteit voor beoordeling van alle modaliteiten; op het scherm moet zichtbaar zijn naam instelling, naam patiënt, datum en tijdstip onderzoek, ECG f netwerkverbinding met de server waar de opslag van zowel beelden als voorlopig en TTE dient volgens een standaardprotocol te worden uitgevoerd De procedure dient te worden <DATUM> # Voordat een studie wordt uitgevoerd moet de juistheid van de indicatie worden beoordeeld <DATUM> # Aanvraag procedure op het aanvraagformulier moet vermeld staan naam aanvrager, soort echo, reden voor het echo, de klinische vraagstelling samen met adequate klinische informatie <DATUM> # Planning Er moet voldoende tijd worden ingepland voor elk echocardiografisch onderzoek (beelden opnemen en verslag maken) Standaard ##-## minuten <DATUM> # Bij aanvang van het onderzoek dient de identiteit van de patiënt gecontroleerd te worden om <DATUM> # Het TTE verslag moet binnen het echolaboratorium uniform zijn Alle artsen/laboranten, die echocardiogrammen verslaan in het echolaboratorium gebruiken uniforme diagnostische criteria en het standaard echoverslag Het echoverslag geeft de inhoud en resultaten van het onderzoek weer <DATUM> # In spoedeisende situaties kan een FoCUS echo gemaakt worden, wat een beperkt echocardiografisch onderzoek is, waarbij globaal de linker en rechter kamerfunctie, de vullingsstatus <DATUM> # De opnames kunnen gemaakt worden door een professional, die hiervoor bekwaam is (d w z een opleiding hiervoor gehad via vakverenigingen voor bv anesthesie, intensive care of <DATUM> # De beelden die gemaakt zijn, dienen opgeslagen te worden en er dient een verslag gemaakt te worden, waaruit duidelijk blijkt dat het hier om de verslaglegging gaat van een Focus echo en niet om <DATUM> # Afwijkende bevindingen dienen besproken te worden met een cardioloog, die beslist of een <PERSOON> RM, et al Recommendations for chamber quantification a report from the American Quantification Writing Group, developed in conjunction with the European Association of <PERSOON> et al European Heart Journal â Cardiovascular Imaging doi <DATUM> # Apparatuur die gebruikt wordt voor transoesophageale echocardiografie (TEE) moet voldoen aan dezelfde eisen als voor transthoracale echocardiografie (Deel II, Sectie #, apparatuur) a moet compatibel zijn met de echoapparatuur van het echolaboratorium het echo en de klinische vraagstelling.
| 584 | nvvc |
van het onderzoek dient de identiteit van de patiënt gecontroleerd te worden om <DATUM> # Het TTE verslag moet binnen het echolaboratorium uniform zijn Alle artsen/laboranten, die echocardiogrammen verslaan in het echolaboratorium gebruiken uniforme diagnostische criteria en het standaard echoverslag Het echoverslag geeft de inhoud en resultaten van het onderzoek weer <DATUM> # In spoedeisende situaties kan een FoCUS echo gemaakt worden, wat een beperkt echocardiografisch onderzoek is, waarbij globaal de linker en rechter kamerfunctie, de vullingsstatus <DATUM> # De opnames kunnen gemaakt worden door een professional, die hiervoor bekwaam is (d w z een opleiding hiervoor gehad via vakverenigingen voor bv anesthesie, intensive care of <DATUM> # De beelden die gemaakt zijn, dienen opgeslagen te worden en er dient een verslag gemaakt te worden, waaruit duidelijk blijkt dat het hier om de verslaglegging gaat van een Focus echo en niet om <DATUM> # Afwijkende bevindingen dienen besproken te worden met een cardioloog, die beslist of een <PERSOON> RM, et al Recommendations for chamber quantification a report from the American Quantification Writing Group, developed in conjunction with the European Association of <PERSOON> et al European Heart Journal â Cardiovascular Imaging doi <DATUM> # Apparatuur die gebruikt wordt voor transoesophageale echocardiografie (TEE) moet voldoen aan dezelfde eisen als voor transthoracale echocardiografie (Deel II, Sectie #, apparatuur) a moet compatibel zijn met de echoapparatuur van het echolaboratorium het echo en de klinische vraagstelling patiënt besproken, tenzij de klinische toestand dit niet toelaat bv geintubeerd op de ICU, en <DATUM> # Voordat een studie wordt uitgevoerd moet de juistheid van de indicatie worden beoordeeld en eventueel additionele informatie worden verkregen alsmede de afwezigheid van contra-indicaties <DATUM> # Planning Er moet voldoende tijd worden ingepland voor elke TEE, afhankelijk van de minuten, met een additionele ##-## minuten bij een complexe studie vanaf binnenkomst patiënt onjuist uitgevoerd, reden waarom een TEE alleen mag worden uitgevoerd door een adequaat <DATUM> # Alle assisterende echolaboranten en verpleegkundigen moeten op de hoogte zijn van de lokaal vastgestelde procedures en protocollen bij het assisteren van semi-invasieve procedures <DATUM> # Voorbereiding van de patiënt patiënt moet ten minste # uur nuchter zijn (liefst # uur), waarbij water is toegestaan tot # uur voor het onderzoek Uitzondering hierop zijn de <DATUM> # Om een TEE veilig uit te voeren moeten lokaal opgestelde richtlijnen aangaande de veiligheid aanwezig zijn en opgevolgd worden Alle procedures moeten door degene die het onderzoek verricht, worden uitgelegd aan de patiënt of voogd van een patiënt, die geen toestemming kan moet worden gebruikt Apparatuur moet aanwezig zijn om zo nodig de bloeddruk en de saturatie te kunnen meten vóór, gedurende en na de TEE en indien nodig moet zuurstof kunnen worden toegediend Afzuigapparatuur moet aanwezig zijn Voor het adequaat reageren bij het optreden van <DATUM> # TEE met sedatie.
| 583 | nvvc |
tenzij de klinische toestand dit niet toelaat bv geintubeerd op de ICU, en <DATUM> # Voordat een studie wordt uitgevoerd moet de juistheid van de indicatie worden beoordeeld en eventueel additionele informatie worden verkregen alsmede de afwezigheid van contra-indicaties <DATUM> # Planning Er moet voldoende tijd worden ingepland voor elke TEE, afhankelijk van de minuten, met een additionele ##-## minuten bij een complexe studie vanaf binnenkomst patiënt onjuist uitgevoerd, reden waarom een TEE alleen mag worden uitgevoerd door een adequaat <DATUM> # Alle assisterende echolaboranten en verpleegkundigen moeten op de hoogte zijn van de lokaal vastgestelde procedures en protocollen bij het assisteren van semi-invasieve procedures <DATUM> # Voorbereiding van de patiënt patiënt moet ten minste # uur nuchter zijn (liefst # uur), waarbij water is toegestaan tot # uur voor het onderzoek Uitzondering hierop zijn de <DATUM> # Om een TEE veilig uit te voeren moeten lokaal opgestelde richtlijnen aangaande de veiligheid aanwezig zijn en opgevolgd worden Alle procedures moeten door degene die het onderzoek verricht, worden uitgelegd aan de patiënt of voogd van een patiënt, die geen toestemming kan moet worden gebruikt Apparatuur moet aanwezig zijn om zo nodig de bloeddruk en de saturatie te kunnen meten vóór, gedurende en na de TEE en indien nodig moet zuurstof kunnen worden toegediend Afzuigapparatuur moet aanwezig zijn Voor het adequaat reageren bij het optreden van <DATUM> # TEE met sedatie Iedere vorm van diepere sedatie dient te worden gegeven door een sedatiemedewerker, die dan Verwezen wordt naar het document âSedatie en/of analgesie (PSA) op locaties buiten de <DATUM> # Herstel van de patiënt Voordat patiënt na een TEE wordt ontslagen vanaf het echolaboratorium/de afdeling moet de patiënt voldoende geobserveerd zijn om er verzekerd van te zijn dat er geen complicaties zijn opgetreden ten gevolge van de TEE of de toegediende medicatie De patiënt en/of familie worden geïnstrueerd over eventueel noodzakelijke nazorg Tevens moet de patiënt informatie krijgen over hoe contact op te nemen na ontslag bij het optreden van eventuele Onderstaand protocol is opgesteld in overleg met de toenmalige WIP (Werkgroep Infectie Preventie) en IGZ in ### ( tegenwoordig IGJ ) De WIP heeft zichzelf opgeheven per <DATUM> en aangezien er geen nieuwe literatuur over dit onderwerp verschenen is sinds ###, anders dan de gepubliceerde richtlijn van de WIP, zijn onderstaande aanbevelingen dan ook onverminderd van kracht Dit protocol voor reiniging en desinfectie van TEE transducers is in ### tot stand gekomen met bijdrage van Landelijke Commissie voor Hygiëne en Veiligheid van het <PERSOON> Instituut voor Volksgezondheid en Te allen tijde dient de patiënt onderzocht te worden met een adequaat gereinigde en een complicatie of infectie mogelijk t g v de TEE te achterhalen welke andere patiënten mogelijk ook geïnfecteerd zijn, dient per patiënt te worden geregistreerd bv in een logboek welke probe is gebruikt Bij gebruik van reiniging of desinfectie doekjes wordt ook het nummer van het gebruikte a.
| 588 | nvvc |
worden gegeven door een sedatiemedewerker, die dan Verwezen wordt naar het document âSedatie en/of analgesie (PSA) op locaties buiten de <DATUM> # Herstel van de patiënt Voordat patiënt na een TEE wordt ontslagen vanaf het echolaboratorium/de afdeling moet de patiënt voldoende geobserveerd zijn om er verzekerd van te zijn dat er geen complicaties zijn opgetreden ten gevolge van de TEE of de toegediende medicatie De patiënt en/of familie worden geïnstrueerd over eventueel noodzakelijke nazorg Tevens moet de patiënt informatie krijgen over hoe contact op te nemen na ontslag bij het optreden van eventuele Onderstaand protocol is opgesteld in overleg met de toenmalige WIP (Werkgroep Infectie Preventie) en IGZ in ### ( tegenwoordig IGJ ) De WIP heeft zichzelf opgeheven per <DATUM> en aangezien er geen nieuwe literatuur over dit onderwerp verschenen is sinds ###, anders dan de gepubliceerde richtlijn van de WIP, zijn onderstaande aanbevelingen dan ook onverminderd van kracht Dit protocol voor reiniging en desinfectie van TEE transducers is in ### tot stand gekomen met bijdrage van Landelijke Commissie voor Hygiëne en Veiligheid van het <PERSOON> Instituut voor Volksgezondheid en Te allen tijde dient de patiënt onderzocht te worden met een adequaat gereinigde en een complicatie of infectie mogelijk t g v de TEE te achterhalen welke andere patiënten mogelijk ook geïnfecteerd zijn, dient per patiënt te worden geregistreerd bv in een logboek welke probe is gebruikt Bij gebruik van reiniging of desinfectie doekjes wordt ook het nummer van het gebruikte a sterk buigen Wees bij het hanteren ervan dus voorzichtig en dompel de elektronische delen d maak in een bak een oplossing van een voor dit doel toegelaten detergens en water; e reinig het knoppenhuis met een (in de detergens oplossing gedompelde en goed f reinig vervolgens de transducer met de opnieuw in de detergens oplossing gedompelde g spoel de transducer af met water zodat alle detergens resten verdwenen zijn; h inspecteer de transducer nogmaals zorgvuldig of alle vervuiling visueel verdwenen is en of de neem de transducer af met de doek gedrenkt in alcohol ##% en zorg er voor dat het in ieder e pas nadat de alcohol geheel verdampt is mag de transducer opnieuw worden gebruikt; NB Het gebruik van alcohol wordt afgeraden door de producenten van transducers Desinfecterende alcohol kan namelijk het oppervlak van de transducer aantasten Wij verwijzen dan ook naar de Een alternatief voor bovenstaand protocol is reinigen en desinfecteren met Chloordioxide (bijvoorbeeld Tristel Wipes), eveneens goedgekeurd door de WIP en IGZ Alternatieven genoemd in Het gebruik van Chloordioxide (bv Tristel Wipes), zie ook de bijgeleverde handleiding a haal na gebruik van het reinigingsdoekje een doekje (wipe) uit een gesloten zakje; c bedek het doekje met de desinfecterende oplossing in de hoeveelheid die de fabrikant adviseert, zorg ervoor dat er niet te veel tijd tussen aanbrengen op het doekje en gebruik zit; d bestrijk het gehele oppervlakte van de TEE probe, zodat het geheel bedekt is met de.
| 572 | nvvc |
Wees bij het hanteren ervan dus voorzichtig en dompel de elektronische delen d maak in een bak een oplossing van een voor dit doel toegelaten detergens en water; e reinig het knoppenhuis met een (in de detergens oplossing gedompelde en goed f reinig vervolgens de transducer met de opnieuw in de detergens oplossing gedompelde g spoel de transducer af met water zodat alle detergens resten verdwenen zijn; h inspecteer de transducer nogmaals zorgvuldig of alle vervuiling visueel verdwenen is en of de neem de transducer af met de doek gedrenkt in alcohol ##% en zorg er voor dat het in ieder e pas nadat de alcohol geheel verdampt is mag de transducer opnieuw worden gebruikt; NB Het gebruik van alcohol wordt afgeraden door de producenten van transducers Desinfecterende alcohol kan namelijk het oppervlak van de transducer aantasten Wij verwijzen dan ook naar de Een alternatief voor bovenstaand protocol is reinigen en desinfecteren met Chloordioxide (bijvoorbeeld Tristel Wipes), eveneens goedgekeurd door de WIP en IGZ Alternatieven genoemd in Het gebruik van Chloordioxide (bv Tristel Wipes), zie ook de bijgeleverde handleiding a haal na gebruik van het reinigingsdoekje een doekje (wipe) uit een gesloten zakje; c bedek het doekje met de desinfecterende oplossing in de hoeveelheid die de fabrikant adviseert, zorg ervoor dat er niet te veel tijd tussen aanbrengen op het doekje en gebruik zit; d bestrijk het gehele oppervlakte van de TEE probe, zodat het geheel bedekt is met de alle delen van de probe moeten tenminste eenmaal geraakt worden door het doekje h Registreer het nummer van het gebruikte doekje i c m de naam van de patiënt <DATUM> # De WIP-richtlijn geeft aan dat zowel opslag als transport in een afgesloten opbergmiddel (bv schone, droge en stofvrije bak of kast) Tevens wordt een maximale bewaartermijn van # maand <DATUM> # Voor vervoer moet de transducer goed worden beschermd Dit kan bijvoorbeeld plaatsvinden in een ruime bak, waarin een schone doek ligt ,en waarin de transducer vrij kan liggen zonder b gebruik daarna niet-steriele handschoenen en leg een paar extra niet-steriele handschoenen d introduceer de transducer terwijl de bijtring in de mond zit; g wanneer beide handen gebruikt zijn bij introductie, verwissel dan de handschoen van de h let op dat een hand de transducer stuurt en de andere hand het knoppenhuis bedient Wanneer dit om wat voor reden dan ook niet gelukt is, verwissel dan weer de handschoen van de hand die het knoppenhuis bedient voor een schone handschoen; i na het beëindigen van het onderzoek en verwijdering van de transducer, koppelt een tweede k het gebruik een condoom over de transducer wordt sterk aangeraden, zeker indien machinale reiniging of thermische desinfectie niet mogelijk is of de producent van de transducer dit adviseert Het gebruik van een condoom verandert de procedure van reiniging a.
| 541 | nvvc |
alle delen van de probe moeten tenminste eenmaal geraakt worden door het doekje h Registreer het nummer van het gebruikte doekje i c m de naam van de patiënt <DATUM> # De WIP-richtlijn geeft aan dat zowel opslag als transport in een afgesloten opbergmiddel (bv schone, droge en stofvrije bak of kast) Tevens wordt een maximale bewaartermijn van # maand <DATUM> # Voor vervoer moet de transducer goed worden beschermd Dit kan bijvoorbeeld plaatsvinden in een ruime bak, waarin een schone doek ligt ,en waarin de transducer vrij kan liggen zonder b gebruik daarna niet-steriele handschoenen en leg een paar extra niet-steriele handschoenen d introduceer de transducer terwijl de bijtring in de mond zit; g wanneer beide handen gebruikt zijn bij introductie, verwissel dan de handschoen van de h let op dat een hand de transducer stuurt en de andere hand het knoppenhuis bedient Wanneer dit om wat voor reden dan ook niet gelukt is, verwissel dan weer de handschoen van de hand die het knoppenhuis bedient voor een schone handschoen; i na het beëindigen van het onderzoek en verwijdering van de transducer, koppelt een tweede k het gebruik een condoom over de transducer wordt sterk aangeraden, zeker indien machinale reiniging of thermische desinfectie niet mogelijk is of de producent van de transducer dit adviseert Het gebruik van een condoom verandert de procedure van reiniging a en dus met een spanning van ### Volt Lekstroom kan gevaar voor de patiënt opleveren b De transducer dient op eventuele lekstroom te worden getest indien een beschadiging is opgetreden of indien bij inspectie bv tijdens de reiniging er een afwijking wordt gezien die op een beschadiging lijkt Verder is het verplicht om de transducer minimaal eens in de # maanden te testen op lekstroom, ook wanneer er geen beschadiging is opgetreden en de <DATUM> # Het jaarlijks te verrichten aantal TEEâs binnen het echolaboratorium moet voldoende zijn om de vaardigheid bij het maken en interpreteren van TEEâs te behouden Jaarlijks moeten daarvoor <DATUM> # Om klinische vaardigheid te behouden worden door de EACVI en de ASE de volgende a Iedere arts, die TEE onderzoek verricht, moet jaarlijks minimaal ## procedures uitvoeren (evt b Voor het medisch hoofd van een advanced lab geldt een additionele ## procedures, die vaak Standard Practice for Cleaning and Disinfection of Flexible Fiberoptic and Video Endoscopes Used in the Examination of the <PERSOON> for Testing and Flachskampf FA, et al Guidelines from the Working Group Recommendations for performing Valvular Heart Disease; Working Group on Echocardiography of the European Society of Sedatie en/ of analgesie (PSA) op locaties buiten de operatiekamer deel #, belangrijkste WIP ### hygiene maatregelen bij echografisch onderzoek en transoesophageale <DATUM> # Apparatuur die gebruikt wordt voor stressechocardiografie moet voldoen aan dezelfde eisen Stress echocardiografie dient volgens een standaardprotocol te worden uitgevoerd De procedure <DATUM> # Aanvraagprocedure.
| 567 | nvvc |
voor de patiënt opleveren b De transducer dient op eventuele lekstroom te worden getest indien een beschadiging is opgetreden of indien bij inspectie bv tijdens de reiniging er een afwijking wordt gezien die op een beschadiging lijkt Verder is het verplicht om de transducer minimaal eens in de # maanden te testen op lekstroom, ook wanneer er geen beschadiging is opgetreden en de <DATUM> # Het jaarlijks te verrichten aantal TEEâs binnen het echolaboratorium moet voldoende zijn om de vaardigheid bij het maken en interpreteren van TEEâs te behouden Jaarlijks moeten daarvoor <DATUM> # Om klinische vaardigheid te behouden worden door de EACVI en de ASE de volgende a Iedere arts, die TEE onderzoek verricht, moet jaarlijks minimaal ## procedures uitvoeren (evt b Voor het medisch hoofd van een advanced lab geldt een additionele ## procedures, die vaak Standard Practice for Cleaning and Disinfection of Flexible Fiberoptic and Video Endoscopes Used in the Examination of the <PERSOON> for Testing and Flachskampf FA, et al Guidelines from the Working Group Recommendations for performing Valvular Heart Disease; Working Group on Echocardiography of the European Society of Sedatie en/ of analgesie (PSA) op locaties buiten de operatiekamer deel #, belangrijkste WIP ### hygiene maatregelen bij echografisch onderzoek en transoesophageale <DATUM> # Apparatuur die gebruikt wordt voor stressechocardiografie moet voldoen aan dezelfde eisen Stress echocardiografie dient volgens een standaardprotocol te worden uitgevoerd De procedure <DATUM> # Aanvraagprocedure naam aanvrager, soort echo (low versus high dose dobutamine, inspanning, low dose voor vitaliteit of beoordeling contractiele <DATUM> # Planning Er moet voldoende tijd worden ingepland standaard ## minuten Een additionele ##-## minuten kan nodig zijn i v m de noodzaak van een intraveneuze toegangsweg of indien het <DATUM> # Stressechocardiografie is een diagnostische onderzoek dat, indien niet correct uitgevoerd en <DATUM> # Nauwkeurig uitvoeren van stressechocardiografie vereist dat de echolaborant en de arts voldoende zijn opgeleid en ervaring hebben in het vervaardigen en beoordelen van uitvoeren minstens <LEEFTIJD> jaar ervaring hebben in de echocardiografie met name beeldacquisitie, display, <DATUM> # De verschillende soorten stressechocardiografie moeten worden uitgevoerd volgens de vigerende protocollen van de EACVI/ASE, met de mogelijkheid voor toediening van contrast voor LV opacificatie ter verbetering van visualisatie van de endocardcontour Contrast dient gebruikt te worden als meer dan # segmenten niet goed beoordeeld kunnen worden <DATUM> # Stressechocardiografie moet worden uitgevoerd in een echolaboratorium dat is uitgerust om de veiligheid van de patiënt te verzekeren en gelegenheid biedt voor snelle acquisitie van post stress a Stressechocardiografie moet worden uitgelegd aan de patiënt en/of voogd van diegene die zelf geen toestemming kan geven Toestemming moet worden verkregen en vastgelegd in het EPD in overeenstemming met regels en voorschriften van het ziekenhuis of instelling; b Patiënten die een echocardiogram met farmacologische stress of aanvullende c.
| 567 | nvvc |
naam aanvrager, soort echo (low versus high dose dobutamine, inspanning, low dose voor vitaliteit of beoordeling contractiele <DATUM> # Planning Er moet voldoende tijd worden ingepland standaard ## minuten Een additionele ##-## minuten kan nodig zijn i v m de noodzaak van een intraveneuze toegangsweg of indien het <DATUM> # Stressechocardiografie is een diagnostische onderzoek dat, indien niet correct uitgevoerd en <DATUM> # Nauwkeurig uitvoeren van stressechocardiografie vereist dat de echolaborant en de arts voldoende zijn opgeleid en ervaring hebben in het vervaardigen en beoordelen van uitvoeren minstens <LEEFTIJD> jaar ervaring hebben in de echocardiografie met name beeldacquisitie, display, <DATUM> # De verschillende soorten stressechocardiografie moeten worden uitgevoerd volgens de vigerende protocollen van de EACVI/ASE, met de mogelijkheid voor toediening van contrast voor LV opacificatie ter verbetering van visualisatie van de endocardcontour Contrast dient gebruikt te worden als meer dan # segmenten niet goed beoordeeld kunnen worden <DATUM> # Stressechocardiografie moet worden uitgevoerd in een echolaboratorium dat is uitgerust om de veiligheid van de patiënt te verzekeren en gelegenheid biedt voor snelle acquisitie van post stress a Stressechocardiografie moet worden uitgelegd aan de patiënt en/of voogd van diegene die zelf geen toestemming kan geven Toestemming moet worden verkregen en vastgelegd in het EPD in overeenstemming met regels en voorschriften van het ziekenhuis of instelling; b Patiënten die een echocardiogram met farmacologische stress of aanvullende c d Adequaat personeel, d w z een voor stressecho opgeleide echolaborant en laborant voor infuus- en ECG monitoring en de superviserende arts, is aanwezig in het echo laboratorium a Gedurende de beeldacquisitiefase en gedurende de herstelfase van het onderzoek moeten de vitale functies van een patiënt periodiek worden geëvalueerd in overeenstemming met Alle artsen die echocardiogrammen beoordelen in het echolaboratorium moeten het eens zijn over Het verslag moet nauwkeurig de inhoud en de resultaten van onderzoek weergeven e of gewenste hartfrequentie en/of adequate stress wel of niet bereikt werd een samenvatting van de resultaten van het onderzoek, inclusief positieve en negatieve Het jaarlijks verrichtte aantal stressechocardiogrammen binnen het echolaboratorium moet voldoende zijn om de vaardigheid bij het vervaardigen en beoordelen van stressechocardiografie te behouden Hierbij wordt onderscheid gemaakt tussen high dose dobutamine stressechocardiografie voor ischaemiedetectie en low dose stressechocardiografie voor beoordelen van vitaliteit en contractiele reserve van de linker kamer bij kleplijden Aan deze laatste wordt geen volume-eis Voor ischaemiedetectie is in de literatuur aangetoond dat de sensitiviteit en specificiteit zeer afhankelijk zijn van de vaardigheid en ervaring van het uitvoerende team Om deze klinische vaardigheid te behouden worden zowel door de ASE als de EACVI als richtlijn meer dan ### procedures per jaar geadviseerd (ref # en #) De Werkgroep Echocardiografie is echter van mening dat bij al opgebouwde expertise een minimum aantal van ## stressecho onderzoeken per jaar voor <PERSOON> GC, Hepinstall MJ, Kidd GM, et al Safety of stress echocardiography supervised by.
| 558 | nvvc |
European Heart Journal Advance Access published <PERSOON> ##, ### the European Society of Cardiology (ESC) and developed in collaboration ESC Committee for Practice Guidelines (CPG) <PERSOON>) (Spain), <PERSOON>), Helmut Baumgartner (Germany), <PERSOON>), HeÌctor Bueno (Spain), <PERSOON>), <PERSOON> (UK), <PERSOON>), <PERSOON>), <PERSOON>), <PERSOON-##>), <PERSOON-##>), <PERSOON-##>(Germany> UK), Juhani Knuuti (Finland), <PERSOON-##>), <PERSOON-##>), Per <PERSOON-##>), <PERSOON-##>), <PERSOON-##>), <PERSOON-##>), <PERSOON-##>), <PERSOON-##>) (Norway), <PERSOON-##>), <PERSOON-##>), <PERSOON-##>), <PERSOON-##>), Helmut Baumgartner (Germany), <PERSOON-##> (UK), <PERSOON-##>), <PERSOON>), <PERSOON-##>), <PERSOON-##>), <PERSOON-##>), <PERSOON-##>), <PERSOON-##>), Juhani Knuuti (Finland), <PERSOON-##>), <PERSOON-##>), <PERSOON-##>), <PERSOON-##>), <PERSOON-##>), <PERSOON-##>), <PERSOON-##>), ZÌeljko Reiner (Croatia), Naveed Sattar (UK), <PERSOON-##> SchaÌchinger (Germany), <PERSOON-##>), *Corresponding authors <PERSOON-##> two chairmen equally contributed to the document <PERSOON-##>Ìn, Cardiology Unit, Department of <PERSOON-##> +#<DATUM> ###, Fax +#<DATUM> ## ##, Email lars ryde(EMAIL); Chairperson EASD Professor <PERSOON-##> Of Cardiovascular & Diabetes Research, University Of <PERSOON-##> +## <TELEFOONNUMMER>, Fax +## <TELEFOONNUMMER>, Email p j gran(EMAIL) uk Other ESC entities having participated in the development of this document Associations Acute Cardiovascular Care Association (ACCA), European Association of Cardiovascular Imaging (EACVI), European Association for Cardiovascular Prevention & Rehabilitation (EACPR), European Association of Percutaneous Cardiovascular Interventions (EAPCI), European Heart Rhythm Association (EHRA), Heart Failure Association (HFA) Councils Cardiovascular Nursing and Allied Professions, Council for Cardiology Practice, Council on <PERSOON-##> content of these European Society of Cardiology (ESC) Guidelines has been published for personal and educational use only No commercial use is authorized No part of the ESC Guidelines may be translated or reproduced in any form without written permission from the ESC Permission can be obtained upon submission of a written request to Oxford University Press, the publisher of the European Heart Journal and the party authorized to handle such permissions on behalf of the <PERSOON-##> ESC Guidelines represent the views of the ESC and EASD and were arrived at after careful consideration of the available evidence at the time they were written Health professionals are encouraged to take them fully into account when exercising their clinical judgement <PERSOON-##> guidelines do not, however, override the individual responsibility of health.
| 755 | nvvc |
<PERSOON> +## <TELEFOONNUMMER>, Fax +## <TELEFOONNUMMER>, Email p j gran(EMAIL) uk Other ESC entities having participated in the development of this document Associations Acute Cardiovascular Care Association (ACCA), European Association of Cardiovascular Imaging (EACVI), European Association for Cardiovascular Prevention & Rehabilitation (EACPR), European Association of Percutaneous Cardiovascular Interventions (EAPCI), European Heart Rhythm Association (EHRA), Heart Failure Association (HFA) Councils Cardiovascular Nursing and Allied Professions, Council for Cardiology Practice, Council on <PERSOON> content of these European Society of Cardiology (ESC) Guidelines has been published for personal and educational use only No commercial use is authorized No part of the ESC Guidelines may be translated or reproduced in any form without written permission from the ESC Permission can be obtained upon submission of a written request to Oxford University Press, the publisher of the European Heart Journal and the party authorized to handle such permissions on behalf of the <PERSOON> ESC Guidelines represent the views of the ESC and EASD and were arrived at after careful consideration of the available evidence at the time they were written Health professionals are encouraged to take them fully into account when exercising their clinical judgement <PERSOON> guidelines do not, however, override the individual responsibility of health or carer It is also the health professionalâs responsibility to verify the rules and regulations applicable to drugs and devices at the time of prescription & <PERSOON> European Society of Cardiology ### All rights reserved For permissions please email journals permission(EMAIL) Downloaded from (WEBLINK) by guest on September ##, ### <PERSOON>), <PERSOON>Ìmberg (Sweden), <PERSOON>), <PERSOON>), Margus Viigimaa (Estonia), Charalambos Vlachopoulos (Greece), <PERSOON>) <PERSOON> disclosure forms of the authors and reviewers are available on the ESC website (WEBLINK) Guidelines â Diabetes mellitus â Cardiovascular disease â Impaired glucose tolerance â Patient management â Prevention â Epidemiology â Prognosis â Diagnostics â Risk factors â Pharmacological # Management of stable and unstable coronary artery disease in <DATUM> Optimal medical treatment for patients with chronic <DATUM> Recommendations for diagnosis of disorders of glucose <DATUM> Pathophysiology of insulin resistance in type # diabetes # Cardiovascular risk assessment in patients with dysglycaemia <DATUM> Risk scores developed for people without diabetes <DATUM> Evaluation of cardiovascular risk in people with prediabetes #.
| 599 | nvvc |
time of prescription & <PERSOON> European Society of Cardiology ### All rights reserved For permissions please email journals permission(EMAIL) Downloaded from (WEBLINK) by guest on September ##, ### <PERSOON>), <PERSOON>Ìmberg (Sweden), <PERSOON>), <PERSOON>), Margus Viigimaa (Estonia), Charalambos Vlachopoulos (Greece), <PERSOON>) <PERSOON> disclosure forms of the authors and reviewers are available on the ESC website (WEBLINK) Guidelines â Diabetes mellitus â Cardiovascular disease â Impaired glucose tolerance â Patient management â Prevention â Epidemiology â Prognosis â Diagnostics â Risk factors â Pharmacological # Management of stable and unstable coronary artery disease in <DATUM> Optimal medical treatment for patients with chronic <DATUM> Recommendations for diagnosis of disorders of glucose <DATUM> Pathophysiology of insulin resistance in type # diabetes # Cardiovascular risk assessment in patients with dysglycaemia <DATUM> Risk scores developed for people without diabetes <DATUM> Evaluation of cardiovascular risk in people with prediabetes # <DATUM> Risk assessment based on biomarkers and imaging # Prevention of cardiovascular disease in patients with diabetes Avoiding Cardiovascular Events through Combination Therapy in Patients Living with Systolic Atrial fibrillation Clopidogrel Trial with Irbesartan for prevention of Vascular Events Atrial fibrillation Clopidogrel Trial with Irbesartan for prevention of Vascular Events Aspirin Atrial fibrillation Clopidogrel Trial with Irbesartan for prevention of <PERSOON> of Intensive Treatment in People with Screen Detected Diabetes Action in Diabetes and Vascular Disease Preterax and Diamicron Modified Release Controlled Evaluation Aliskiren Trial in Type # Diabetes Using CardioRenal Endpoints <DATUM> Prevalence and incidence of heart failure in type # diabetes <DATUM> Diabetes mellitus and heart failure morbidity and mortality Candesartan in Heart Failure Assessment of Reduction in Mortality and Morbidity (# point each), Stroke, Bleeding history or predisposition, Labile INR, Elderly ( ##), Drugs/ Revascularization for unprotected left main coronary artery stenosis comparison of percutaneous SYNergy between percutaneous coronary intervention with TAXus and cardiac surgery joining forces to write guidelines on the management of diabetes mellitus (DM), pre-diabetes, and cardiovascular disease (CVD), designed to assist clinicians and other healthcare workers to make evidencebased management decisions <PERSOON> growing awareness of the strong relevant to their joint interests, the first of which were published in ### Some assert that too many guidelines are being produced.
| 598 | nvvc |
<DATUM> Risk assessment based on biomarkers and imaging # Prevention of cardiovascular disease in patients with diabetes Avoiding Cardiovascular Events through Combination Therapy in Patients Living with Systolic Atrial fibrillation Clopidogrel Trial with Irbesartan for prevention of Vascular Events Atrial fibrillation Clopidogrel Trial with Irbesartan for prevention of Vascular Events Aspirin Atrial fibrillation Clopidogrel Trial with Irbesartan for prevention of <PERSOON> of Intensive Treatment in People with Screen Detected Diabetes Action in Diabetes and Vascular Disease Preterax and Diamicron Modified Release Controlled Evaluation Aliskiren Trial in Type # Diabetes Using CardioRenal Endpoints <DATUM> Prevalence and incidence of heart failure in type # diabetes <DATUM> Diabetes mellitus and heart failure morbidity and mortality Candesartan in Heart Failure Assessment of Reduction in Mortality and Morbidity (# point each), Stroke, Bleeding history or predisposition, Labile INR, Elderly ( ##), Drugs/ Revascularization for unprotected left main coronary artery stenosis comparison of percutaneous SYNergy between percutaneous coronary intervention with TAXus and cardiac surgery joining forces to write guidelines on the management of diabetes mellitus (DM), pre-diabetes, and cardiovascular disease (CVD), designed to assist clinicians and other healthcare workers to make evidencebased management decisions <PERSOON> growing awareness of the strong relevant to their joint interests, the first of which were published in ### Some assert that too many guidelines are being produced basic and clinical science is a long time and major trials have reported in this period, making it necessary to update the previous <PERSOON> processes involved in generating these Guidelines have been brief, the EASD and the ESC appointed Chairs to represent each organization and to direct the activities of the Task Force Its members were chosen for their particular areas of expertise relevant to different aspects of the guidelines, for their standing in the field, and to represent the diversity that characterizes modern Europe Each member details of which are held at the European Heart House and available at in pairs and the ESC recommendations for the development of guidelines were followed, using the standard classes of recommendation, Initial editing and review of the manuscripts took place at the Task These Guidelines are the product of countless hours of hard work, Randomized Evaluation of the Long-term anticoagulant therapy with dabigatran etexilate Significant Macular Edema (ME) With Center Involvement Secondary to Diabetes Mellitus of the two organizations It is our hope that this huge effort has generated guidelines that will provide a greater understanding of the relationship between these two complex conditions and an accessible and useful adjunct to the clinical decision-making process that will <PERSOON> task of developing Guidelines covers not only the integration of the most recent research, but also the creation of educational tools more than ##% would have had type # DM (T#DM) This number is estimated to increase to ### million by ### and it is thought that.
| 560 | nvvc |
have reported in this period, making it necessary to update the previous <PERSOON> processes involved in generating these Guidelines have been brief, the EASD and the ESC appointed Chairs to represent each organization and to direct the activities of the Task Force Its members were chosen for their particular areas of expertise relevant to different aspects of the guidelines, for their standing in the field, and to represent the diversity that characterizes modern Europe Each member details of which are held at the European Heart House and available at in pairs and the ESC recommendations for the development of guidelines were followed, using the standard classes of recommendation, Initial editing and review of the manuscripts took place at the Task These Guidelines are the product of countless hours of hard work, Randomized Evaluation of the Long-term anticoagulant therapy with dabigatran etexilate Significant Macular Edema (ME) With Center Involvement Secondary to Diabetes Mellitus of the two organizations It is our hope that this huge effort has generated guidelines that will provide a greater understanding of the relationship between these two complex conditions and an accessible and useful adjunct to the clinical decision-making process that will <PERSOON> task of developing Guidelines covers not only the integration of the most recent research, but also the creation of educational tools more than ##% would have had type # DM (T#DM) This number is estimated to increase to ### million by ### and it is thought that In addition, it is insulin resistance (IR) # <PERSOON> majority of new cases of T#DM occur in the context of westernized lifestyles, high-fat diets and decreased exercise, leading to increasing levels of obesity, IR, compensatory hyperinsulinaemia and, ultimately, beta-cell failure and <PERSOON> clustering of vascular risk seen in association with IR, often referred to as the metabolic syndrome, has led to the view that cardiovascular risk appears early, prior to the development of T#DM, whilst the strong relationship frank hyperglycaemia appears These concepts highlight the progressive nature of both T#DM and associated cardiovascular risk, which pose specific challenges at different stages of the life of an individual associated with specific groups all indicate the need to manage risk in an individualized manner, empowering the patient to take a major As the world in generalâand Europe in particularâchanges in response to demographic and cultural shifts in societies, so the patterns of disease and their implications vary <PERSOON> Middle East, the <PERSOON> rim and parts of both North and <PERSOON> have experienced massive increases in the prevalence of DM over the past ## years, changes mirrored in European populations over the same period Awareness of specific issues associated with gender and race and, particularly, the effects of DM in womenâincluding epigenetics and in utero influences on non-communicable diseasesâare becoming of major importance In ### approximately ## million adult Europeans were thought to have DM, half of them diagnosed, and the and their offspring provide further public health challenges that agencies are attempting to address worldwide.
| 589 | nvvc |
# <PERSOON> majority of new cases of T#DM occur in the context of westernized lifestyles, high-fat diets and decreased exercise, leading to increasing levels of obesity, IR, compensatory hyperinsulinaemia and, ultimately, beta-cell failure and <PERSOON> clustering of vascular risk seen in association with IR, often referred to as the metabolic syndrome, has led to the view that cardiovascular risk appears early, prior to the development of T#DM, whilst the strong relationship frank hyperglycaemia appears These concepts highlight the progressive nature of both T#DM and associated cardiovascular risk, which pose specific challenges at different stages of the life of an individual associated with specific groups all indicate the need to manage risk in an individualized manner, empowering the patient to take a major As the world in generalâand Europe in particularâchanges in response to demographic and cultural shifts in societies, so the patterns of disease and their implications vary <PERSOON> Middle East, the <PERSOON> rim and parts of both North and <PERSOON> have experienced massive increases in the prevalence of DM over the past ## years, changes mirrored in European populations over the same period Awareness of specific issues associated with gender and race and, particularly, the effects of DM in womenâincluding epigenetics and in utero influences on non-communicable diseasesâare becoming of major importance In ### approximately ## million adult Europeans were thought to have DM, half of them diagnosed, and the and their offspring provide further public health challenges that agencies are attempting to address worldwide Figure # Investigational algorithm outlining the principles for the diagnosis and management of cardiovascular disease (CVD) in diabetes mellitus (DM) patients with a primary diagnosis of DM or a primary diagnosis of <PERSOON> recommended investigations should be considered according to individual needs and clinical judgement and are not meant as a general recommendation to be undertaken by all patients ACS ¼ acute coronary syndrome; ECG ¼ electrocardiogram; FPG ¼ fasting plasma glucose; HbA#c ¼ glycated haemoglobin A#c; IGT ¼ impaired glucose tolerance; MI ¼ myocardial infarction; OGTT ¼ oral glucose tolerance test related to CVD, which caused physicians in the fields of DM and cardiovascular medicine to join forces to research and manage these conditions (Figure #) At the same time, this has encouraged organizations such as the ESC and EASD to work together and these guidelines are a reflection of that powerful collaboration current state of the art in how to prevent and manage the diverse problems associated with the effects of DM on the heart and vasculature in a holistic manner In describing the mechanisms of disease, we hope to approaches, an algorithm for achieving the best care for patients in an individualized setting It should be noted that these guidelines are important considering that those who, in their daily practice, manage these patients frequently have their main expertise in either DM or CVD or general practice.
| 563 | nvvc |
Figure # Investigational algorithm outlining the principles for the diagnosis and management of cardiovascular disease (CVD) in diabetes mellitus (DM) patients with a primary diagnosis of DM or a primary diagnosis of <PERSOON> recommended investigations should be considered according to individual needs and clinical judgement and are not meant as a general recommendation to be undertaken by all patients ACS ¼ acute coronary syndrome; ECG ¼ electrocardiogram; FPG ¼ fasting plasma glucose; HbA#c ¼ glycated haemoglobin A#c; IGT ¼ impaired glucose tolerance; MI ¼ myocardial infarction; OGTT ¼ oral glucose tolerance test related to CVD, which caused physicians in the fields of DM and cardiovascular medicine to join forces to research and manage these conditions (Figure #) At the same time, this has encouraged organizations such as the ESC and EASD to work together and these guidelines are a reflection of that powerful collaboration current state of the art in how to prevent and manage the diverse problems associated with the effects of DM on the heart and vasculature in a holistic manner In describing the mechanisms of disease, we hope to approaches, an algorithm for achieving the best care for patients in an individualized setting It should be noted that these guidelines are important considering that those who, in their daily practice, manage these patients frequently have their main expertise in either DM or CVD or general practice It has been a privilege for the Chairs to have been trusted with the opportunity to develop these guidelines whilst working with some of the most widely acknowledged experts in this field We want to extend our thanks to all members of the Task Force who gave so thanks to the guidelines team at the European Heart House, in particular <PERSOON>Ìs, <PERSOON> and <PERSOON> (WHO) and the American Diabetes Association (ADA) # â # Glycated haemoglobin A#c (HbA#c) has been recommended as a diagnostic test for DM,#,# but there remain concerns regarding its sensitivity in predicting DM and HbA#c values ,<DATUM> do not exclude DM that may be detected by blood glucose aetiological categories of DM have been identified type # diabetes Type # diabetes is characterized by deficiency of insulin due to deficiency Typically, T#DM occurs in young, slim individuals presenting with polyuria, thirst and weight loss, with a propensity to ketosis However, T#DM may occur at any age,## sometimes with slow progression In the latter condition, latent auto-immune DM in adults or slowly progressive insulin dependence ##,## Auto-antibodies targeting pancreatic beta-cells are a marker of T#DM, although they Table # Comparison of ### World Health Organization (WHO) and ###/### and ### American Diabetes FPG ¼ fasting plasma glucose; IGT ¼ impaired glucose tolerance; IFG ¼ impaired fasting glucose; #hPG ¼ #-h post-load plasma glucose are not detectable in all patients and decrease with age, compared with other ethnicities and geographic regions, T#DM is more.
| 592 | nvvc |
whilst working with some of the most widely acknowledged experts in this field We want to extend our thanks to all members of the Task Force who gave so thanks to the guidelines team at the European Heart House, in particular <PERSOON>Ìs, <PERSOON> and <PERSOON> (WHO) and the American Diabetes Association (ADA) # â # Glycated haemoglobin A#c (HbA#c) has been recommended as a diagnostic test for DM,#,# but there remain concerns regarding its sensitivity in predicting DM and HbA#c values ,<DATUM> do not exclude DM that may be detected by blood glucose aetiological categories of DM have been identified type # diabetes Type # diabetes is characterized by deficiency of insulin due to deficiency Typically, T#DM occurs in young, slim individuals presenting with polyuria, thirst and weight loss, with a propensity to ketosis However, T#DM may occur at any age,## sometimes with slow progression In the latter condition, latent auto-immune DM in adults or slowly progressive insulin dependence ##,## Auto-antibodies targeting pancreatic beta-cells are a marker of T#DM, although they Table # Comparison of ### World Health Organization (WHO) and ###/### and ### American Diabetes FPG ¼ fasting plasma glucose; IGT ¼ impaired glucose tolerance; IFG ¼ impaired fasting glucose; #hPG ¼ #-h post-load plasma glucose are not detectable in all patients and decrease with age, compared with other ethnicities and geographic regions, T#DM is more Insulin resistance and an impaired first-phase insulin secretion causing postprandial hyperglycaemia characterize the early stage of T#DM This is followed by a deteriorating second-phase insulin response and persistent hyperglycaemia in the fasting state ##,## T#DM typically develops after middle age and comprises over ##% of adults with DM most return to a euglycaemic state, but they are at increased risk for A large Canadian study found that the probability of DM developing Other specific types of diabetes include (i) single genetic mutations that lead to rare forms of DM such as maturity-onset DM of the young; (ii) DM secondary to other pathological conditions or diseases (pancreatitis, trauma or surgery of the pancreas) and (iii) IGT can only be recognized by the results of an oral glucose tolerance that the timing of the test begins when the patient starts to drink) Current clinical criteria issued by the World Health organization and <PERSOON> WHO criteria are based on fasting plasma glucose (FPG) and #hPG concentrations They recommend use of an OGTT in the absence of overt hyperglycaemia # <PERSOON> ADA criteria encourage the use of HbA#c, fasting glycaemia and OGTT, in that order # <PERSOON> argument for FPG or HbA#c over #hPG is primarily related to feasibility <PERSOON> advantages and disadvantages of using glucose testing and HbA#c testing are summarized in a WHO report from ###,# and are still the subject of some IFG is <DATUM> mmol/L (### mg/dL),# while WHO recommends the original cut-off point of <DATUM> mmol/L (### mg/dL) #.
| 642 | nvvc |
T#DM This is followed by a deteriorating second-phase insulin response and persistent hyperglycaemia in the fasting state ##,## T#DM typically develops after middle age and comprises over ##% of adults with DM most return to a euglycaemic state, but they are at increased risk for A large Canadian study found that the probability of DM developing Other specific types of diabetes include (i) single genetic mutations that lead to rare forms of DM such as maturity-onset DM of the young; (ii) DM secondary to other pathological conditions or diseases (pancreatitis, trauma or surgery of the pancreas) and (iii) IGT can only be recognized by the results of an oral glucose tolerance that the timing of the test begins when the patient starts to drink) Current clinical criteria issued by the World Health organization and <PERSOON> WHO criteria are based on fasting plasma glucose (FPG) and #hPG concentrations They recommend use of an OGTT in the absence of overt hyperglycaemia # <PERSOON> ADA criteria encourage the use of HbA#c, fasting glycaemia and OGTT, in that order # <PERSOON> argument for FPG or HbA#c over #hPG is primarily related to feasibility <PERSOON> advantages and disadvantages of using glucose testing and HbA#c testing are summarized in a WHO report from ###,# and are still the subject of some IFG is <DATUM> mmol/L (### mg/dL),# while WHO recommends the original cut-off point of <DATUM> mmol/L (### mg/dL) # DM and that this number will increase to over ## million by ##<DATUM> In ### million women worldwide died with DM in ###, most from billion Euros in ### and is projected to increase to ## billion by ### A problem when diagnosing T#DM is the lack of a unique biological Type # diabetes mellitus does not cause specific symptoms for many years, which explains why approximately half of the cases of T#DM which progresses with the development of beta-cell failure to frank DM with increased risk of vascular complications <PERSOON> present definition of DM is based on the level of glucose at which retinopathy occurs, but macrovascular complications such as coronary, cerebrovascular and peripheral artery disease (PAD) appear earlier and, using current glycaemic criteria, are often present at the time when T#DM is diagnosed Over ##% of people with T#DM develop CVD, a more should be given a higher priority when cut-points for hyperglycaemia criteria in Europe (DECODE) study (Figure #) reported data on disorders of glucose metabolism in European populations ## <PERSOON> limited data on HbA#c in these populations indicate major discrepancies, compared with results from an OGTT,## although this was not confirmed in the Evaluation of Screening and Early Detection Strategies for T#DM and IGT (DETECT-#) as further elaborated upon between ## and ## years and ##â##% above ## years have previously Figure # Mean FPG fasting (two lower lines) and #hPG (two in the DECODE study ## Mean #hPG increases particularly after concentrations than men, a difference that becomes more pronounced above the age of ## years.
| 660 | nvvc |
## million by ##<DATUM> In ### million women worldwide died with DM in ###, most from billion Euros in ### and is projected to increase to ## billion by ### A problem when diagnosing T#DM is the lack of a unique biological Type # diabetes mellitus does not cause specific symptoms for many years, which explains why approximately half of the cases of T#DM which progresses with the development of beta-cell failure to frank DM with increased risk of vascular complications <PERSOON> present definition of DM is based on the level of glucose at which retinopathy occurs, but macrovascular complications such as coronary, cerebrovascular and peripheral artery disease (PAD) appear earlier and, using current glycaemic criteria, are often present at the time when T#DM is diagnosed Over ##% of people with T#DM develop CVD, a more should be given a higher priority when cut-points for hyperglycaemia criteria in Europe (DECODE) study (Figure #) reported data on disorders of glucose metabolism in European populations ## <PERSOON> limited data on HbA#c in these populations indicate major discrepancies, compared with results from an OGTT,## although this was not confirmed in the Evaluation of Screening and Early Detection Strategies for T#DM and IGT (DETECT-#) as further elaborated upon between ## and ## years and ##â##% above ## years have previously Figure # Mean FPG fasting (two lower lines) and #hPG (two in the DECODE study ## Mean #hPG increases particularly after concentrations than men, a difference that becomes more pronounced above the age of ## years testing, it is important to underline that capillary values may differ from plasma values more in the post-load than in the fasting state reflects an ability to maintain adequate basal insulin secretion, in combination with hepatic insulin sensitivity sufficient to control hepatic insulin sensitivity in peripheral tissues It is important to pay attention # Waist ci rcumfe rence measu red below # Have you ever been found to have high Test designed by Professor Jaakko Tuomilehto Department of Public Health, University of Helsinki, and <PERSOON>, MFS, National ##-year risk of type # diabetes in adults (Modified from Lindstrom This tool, available in almost all European languages, predicts with ##% accuracy ##,## It has been validated in most European populations It is necessary to separate individuals into three different scenarios (i) the general population; (ii) people with assumed abnormalities (e g obese, hypertensive, or with a family history of DM) and people with assumed abnormalities, the appropriate screening strategy is to start with a DM risk score and to investigate individuals with a high value with an OGTT or a combination of HbA#c and FPG ##,## In CVD patients, no diabetes risk score is needed but an OGTT is indicated if HbA#c and/or FPG are inconclusive, since people belonging to these are risk factors for <PERSOON> most convincing evidence for such relationship was provided by the collaborative DECODE study, analysing several European cohort studies with baseline OGTT data ## â ##.
| 645 | nvvc |
testing, it is important to underline that capillary values may differ from plasma values more in the post-load than in the fasting state reflects an ability to maintain adequate basal insulin secretion, in combination with hepatic insulin sensitivity sufficient to control hepatic insulin sensitivity in peripheral tissues It is important to pay attention # Waist ci rcumfe rence measu red below # Have you ever been found to have high Test designed by Professor Jaakko Tuomilehto Department of Public Health, University of Helsinki, and <PERSOON>, MFS, National ##-year risk of type # diabetes in adults (Modified from Lindstrom This tool, available in almost all European languages, predicts with ##% accuracy ##,## It has been validated in most European populations It is necessary to separate individuals into three different scenarios (i) the general population; (ii) people with assumed abnormalities (e g obese, hypertensive, or with a family history of DM) and people with assumed abnormalities, the appropriate screening strategy is to start with a DM risk score and to investigate individuals with a high value with an OGTT or a combination of HbA#c and FPG ##,## In CVD patients, no diabetes risk score is needed but an OGTT is indicated if HbA#c and/or FPG are inconclusive, since people belonging to these are risk factors for <PERSOON> most convincing evidence for such relationship was provided by the collaborative DECODE study, analysing several European cohort studies with baseline OGTT data ## â ## A high #hPG predicted of affirmative evidence that the prognosis of CVD related to T#DM Treatment in People with Screen Detected Diabetes in Primary benefit progression of microvascular disease, which may make screening for T#DM beneficial ## In addition, there is an interest in identifying people with IGT, since most will progress to T#DM and this progression can be retarded by lifestyle interventions ## â ## <PERSOON> diagnosis of DM has traditionally been based on the level of blood glucose that relates to a risk of developing micro- rather than macrovascular in nine studies across five countries ## It was concluded that a HbA#c needs to be measured to establish a diagnosis Caveats exist in relation to this position, as extensively reviewed by Hare et al ## Problems exist in relation to pregnancy, polycystic ovary syndrome,## haemoglobinopathies and acute illness mitigating against its use under such circumstances Moreover, the probability of a false negative test result, compared with the OGTT, is substantial when attempting to detect A study in Spanish people with high risk, i e ##/## points in the HbA#c as the primary diagnostic test in specific populations # There detecting undiagnosed DM in the setting of coronary heart disease HbA#c in the range # #â<DATUM> requires lifestyle advice and individual risk factor management alone, and that further information on #hPG <PERSOON> approaches for early detection of T#DM and other disorders of glucose metabolism are.
| 600 | nvvc |
#hPG predicted of affirmative evidence that the prognosis of CVD related to T#DM Treatment in People with Screen Detected Diabetes in Primary benefit progression of microvascular disease, which may make screening for T#DM beneficial ## In addition, there is an interest in identifying people with IGT, since most will progress to T#DM and this progression can be retarded by lifestyle interventions ## â ## <PERSOON> diagnosis of DM has traditionally been based on the level of blood glucose that relates to a risk of developing micro- rather than macrovascular in nine studies across five countries ## It was concluded that a HbA#c needs to be measured to establish a diagnosis Caveats exist in relation to this position, as extensively reviewed by Hare et al ## Problems exist in relation to pregnancy, polycystic ovary syndrome,## haemoglobinopathies and acute illness mitigating against its use under such circumstances Moreover, the probability of a false negative test result, compared with the OGTT, is substantial when attempting to detect A study in Spanish people with high risk, i e ##/## points in the HbA#c as the primary diagnostic test in specific populations # There detecting undiagnosed DM in the setting of coronary heart disease HbA#c in the range # #â<DATUM> requires lifestyle advice and individual risk factor management alone, and that further information on #hPG <PERSOON> approaches for early detection of T#DM and other disorders of glucose metabolism are tests to determine the likelihood for T#DM and (iii) collecting approaches leave the current glycaemic state ambiguous and glycaemia However, the results from such a simple first-level screening can markedly reduce the numbers who need to be referred for further testing of glycaemia and other CVD risk factors Option two is particularly suited DM, while the third option is better suited to the general population perform well and it does not matter which one is used, as underlined using previously diagnosed DM (dark bar) as the common reference category Data are adjusted for age, sex, cohort, body mass index, systolic blood CVD ¼ cardiovascular disease; DM ¼ diabetes mellitus; FPG ¼ fasting plasma glucose; #hPG ¼ #-h post-load plasma glucose IGT ¼ impaired glucose tolerance; RRR ¼ relative risk reduction; SLIM ¼ Study on lifestyle-intervention and IGT <LOCATIE> Absolute risk reduction numbers would have added value but could not be reported since such information is lacking in several of the studies <PERSOON> Zensharen study recruited people with IFG, while other studies recruited people with IGT cardiovascular risk factors, while a high FPG alone was not predictive once #hPG was taken into account <PERSOON> highest excess CVD mortality in the population was observed in people with IGT, especially Several studies have shown that increasing HbA#c is associated with increasing CVD risk ## â ## Studies that compared all three Figure # Hazard ratios and ##% confidence intervals (vertical bars) for CVD mortality for FPG (hatched bars) and #hPG (dotted bars) intervals.
| 601 | nvvc |
ambiguous and glycaemia However, the results from such a simple first-level screening can markedly reduce the numbers who need to be referred for further testing of glycaemia and other CVD risk factors Option two is particularly suited DM, while the third option is better suited to the general population perform well and it does not matter which one is used, as underlined using previously diagnosed DM (dark bar) as the common reference category Data are adjusted for age, sex, cohort, body mass index, systolic blood CVD ¼ cardiovascular disease; DM ¼ diabetes mellitus; FPG ¼ fasting plasma glucose; #hPG ¼ #-h post-load plasma glucose IGT ¼ impaired glucose tolerance; RRR ¼ relative risk reduction; SLIM ¼ Study on lifestyle-intervention and IGT <LOCATIE> Absolute risk reduction numbers would have added value but could not be reported since such information is lacking in several of the studies <PERSOON> Zensharen study recruited people with IFG, while other studies recruited people with IGT cardiovascular risk factors, while a high FPG alone was not predictive once #hPG was taken into account <PERSOON> highest excess CVD mortality in the population was observed in people with IGT, especially Several studies have shown that increasing HbA#c is associated with increasing CVD risk ## â ## Studies that compared all three Figure # Hazard ratios and ##% confidence intervals (vertical bars) for CVD mortality for FPG (hatched bars) and #hPG (dotted bars) intervals ##,## As reviewed in the T#DM,## randomized clinical trials (RCTs) demonstrate that lifestyle modification, based on modest weight loss and increased physical activity, prevents or delays progression in high-risk individuals with IGT Thus, those at high risk for T#DM and those with established IGT should be given appropriate lifestyle counselling (Table #) A tool kit, including practical advice for healthcare personnel, has recently been developed ## <PERSOON> seemingly lower risk reduction in the Indian and Chinese trials was due to the higher incidence of T#DM in these populations and the absolute risk reductions cases per ### person-years It was estimated that lifestyle intervention has to be provided to <DATUM> high-risk individuals for an average of # years to prevent one case of DM Thus the intervention is highly efficient ## A ##-year follow-up of men with IGT who participated in (and similar to that in men with normal glucose tolerance) than reduced incidence of T#DM ## During an extended #-year followup of the Finnish DPS study,## there was a marked and sustained reduction in the incidence of T#DM in people who had participated in between the intervention and control groups but the DPS participants, who had IGT at baseline, had lower all-cause mortality and of the US Diabetes Prevention Programme Outcomes Study, the incidence of T#DM in the original lifestyle intervention group glucose tolerance; OGTT ¼ oral glucose tolerance test; T#DM ¼ type # mortality and CVD risk revealed that the association is strongest for #hPG and that the risk observed with FPG and HbA#c is no longer significant after controlling for the effect of #hPG.
| 624 | nvvc |
on modest weight loss and increased physical activity, prevents or delays progression in high-risk individuals with IGT Thus, those at high risk for T#DM and those with established IGT should be given appropriate lifestyle counselling (Table #) A tool kit, including practical advice for healthcare personnel, has recently been developed ## <PERSOON> seemingly lower risk reduction in the Indian and Chinese trials was due to the higher incidence of T#DM in these populations and the absolute risk reductions cases per ### person-years It was estimated that lifestyle intervention has to be provided to <DATUM> high-risk individuals for an average of # years to prevent one case of DM Thus the intervention is highly efficient ## A ##-year follow-up of men with IGT who participated in (and similar to that in men with normal glucose tolerance) than reduced incidence of T#DM ## During an extended #-year followup of the Finnish DPS study,## there was a marked and sustained reduction in the incidence of T#DM in people who had participated in between the intervention and control groups but the DPS participants, who had IGT at baseline, had lower all-cause mortality and of the US Diabetes Prevention Programme Outcomes Study, the incidence of T#DM in the original lifestyle intervention group glucose tolerance; OGTT ¼ oral glucose tolerance test; T#DM ¼ type # mortality and CVD risk revealed that the association is strongest for #hPG and that the risk observed with FPG and HbA#c is no longer significant after controlling for the effect of #hPG Women with newly diagnosed T#DM have a higher relative risk for impact of gender on the occurrence of coronary artery disease (CAD) mortality reported that the overall relative risk (the ratio of patients) aimed at estimating sex-related risk of fatal CAD, reported higher mortality in patients with DM than those without (<DATUM> vs people with and without DM was significantly greater among women # ##) Thus the gender difference in CVD risk seen in the general population is much smaller in people with DM and the reason for this is still unclear A recent British study revealed a greater adverse influence of DM per se on adiposity, Homeostasis Model Assessment of Insulin Resistance (HOMA-IR) and downstream blood pressure, lipids, endothelial dysfunction and systemic inflammation in women, compared with men, which may contribute to their greater relative risk of CAD ## PG, associated with clustering of cardiovascular risk and the development of macrovascular disease prior to diagnosis (<PERSOON> early glucometabolic impairment is characterized by a progressive decrease in insulin sensitivity and increased glucose levels that remain CVD will be addressed in the following sections <PERSOON> development monocyte recruitment, foam cell formation and subsequent development of fatty streaks Over many years, this leads to atherosclerotic plaques, which, in the presence of enhanced inflammatory content, become unstable and rupture to promote occlusive thrombus formation Atheroma from people with DM has more lipid, inflammatory changes and thrombus than those free from DM.
| 588 | nvvc |
Women with newly diagnosed T#DM have a higher relative risk for impact of gender on the occurrence of coronary artery disease (CAD) mortality reported that the overall relative risk (the ratio of patients) aimed at estimating sex-related risk of fatal CAD, reported higher mortality in patients with DM than those without (<DATUM> vs people with and without DM was significantly greater among women # ##) Thus the gender difference in CVD risk seen in the general population is much smaller in people with DM and the reason for this is still unclear A recent British study revealed a greater adverse influence of DM per se on adiposity, Homeostasis Model Assessment of Insulin Resistance (HOMA-IR) and downstream blood pressure, lipids, endothelial dysfunction and systemic inflammation in women, compared with men, which may contribute to their greater relative risk of CAD ## PG, associated with clustering of cardiovascular risk and the development of macrovascular disease prior to diagnosis (<PERSOON> early glucometabolic impairment is characterized by a progressive decrease in insulin sensitivity and increased glucose levels that remain CVD will be addressed in the following sections <PERSOON> development monocyte recruitment, foam cell formation and subsequent development of fatty streaks Over many years, this leads to atherosclerotic plaques, which, in the presence of enhanced inflammatory content, become unstable and rupture to promote occlusive thrombus formation Atheroma from people with DM has more lipid, inflammatory changes and thrombus than those free from DM cytokines from adipose tissue directly impairs insulin sensitivity oxygen species (ROS) production blunts activation of insulin receptor substrate # (IRS-#) and PI#K-Akt signalling, leading to downregulation of insulin responsive glucose transporter # (GLUT-#) ##,## FFA-induced impairment of the PI#K pathway blunts Akt activity and Ser###, resulting in decreased production of nitric oxide (NO), endothelial dysfunction,## and vascular remodelling (increased intima-media thickness), important predictors of CVD (Figure #) ##,## In turn, accumulation of ROS activates transcription factor NF-kB, leading to increased expression of inflammatory adhesion molecules and cytokines ## Chronic IR stimulates pancreatic secretion of insulin, generating a complex phenotype that includes progressive beta cell dysfunction,## decreased insulin levels and increased PG Evidence the first targets of high glucose, with a direct net increase in superoxide a vicious circle involving ROS-induced activation of protein kinase polyol flux, advanced glycation end-products (AGEs) and their receptors (RAGEs), PKC and hexosamine pathway (HSP) (Figure #) Recent involved in the persistence of vascular dysfunction despite normalization of glucose levels This phenomenon has been called âmetabolic memoryâ and may explain why macro- and microvascular complications progress, despite intensive glycaemic control, in patients with adipose tissue has emerged as a key process in metabolic inflammation and IR ## In addition, the insulin-resistant macrophage increases Figure # Hyperglycaemia, insulin resistance, and cardiovascular disease AGE ¼ advanced glycated end-products; FFA ¼ free fatty acids; GLUT# ¼ glucose transporter #; HDL-C ¼ high-density lipoprotein cholesterol; LDL ¼ low-density lipoprotein particles; NO ¼ nitric oxide; PAI-# ¼.
| 629 | nvvc |
sensitivity oxygen species (ROS) production blunts activation of insulin receptor substrate # (IRS-#) and PI#K-Akt signalling, leading to downregulation of insulin responsive glucose transporter # (GLUT-#) ##,## FFA-induced impairment of the PI#K pathway blunts Akt activity and Ser###, resulting in decreased production of nitric oxide (NO), endothelial dysfunction,## and vascular remodelling (increased intima-media thickness), important predictors of CVD (Figure #) ##,## In turn, accumulation of ROS activates transcription factor NF-kB, leading to increased expression of inflammatory adhesion molecules and cytokines ## Chronic IR stimulates pancreatic secretion of insulin, generating a complex phenotype that includes progressive beta cell dysfunction,## decreased insulin levels and increased PG Evidence the first targets of high glucose, with a direct net increase in superoxide a vicious circle involving ROS-induced activation of protein kinase polyol flux, advanced glycation end-products (AGEs) and their receptors (RAGEs), PKC and hexosamine pathway (HSP) (Figure #) Recent involved in the persistence of vascular dysfunction despite normalization of glucose levels This phenomenon has been called âmetabolic memoryâ and may explain why macro- and microvascular complications progress, despite intensive glycaemic control, in patients with adipose tissue has emerged as a key process in metabolic inflammation and IR ## In addition, the insulin-resistant macrophage increases Figure # Hyperglycaemia, insulin resistance, and cardiovascular disease AGE ¼ advanced glycated end-products; FFA ¼ free fatty acids; GLUT# ¼ glucose transporter #; HDL-C ¼ high-density lipoprotein cholesterol; LDL ¼ low-density lipoprotein particles; NO ¼ nitric oxide; PAI-# ¼ #-kinase; RAGE ¼ AGE receptor; ROS ¼ reactive oxygen species; SR-B ¼ scavenger receptor B; tPA ¼ tissue plasminogen activator receptor B (SR-B), promoting foam cell formation and atherosclerosis These findings are reversed by peroxisome proliferatoractivated receptor gamma (PPARg) activation, which enhances Insulin resistance results in increased FFA release to the liver due to LDL particles (Figure #) ## This LDL subtype plays an important may be lost in T#DM patients due to alterations of the protein predictor of cardiovascular risk, stronger than isolated high triglycerides or a low HDL cholesterol ## In T#DM patients, IR and hyperglycaemia participate to the pathogenesis of a prothrombotic state characterized by increased plasminogen reduced tissue plasminogen activator (tPA) levels (Figure #) ## Among mechanisms contribute to platelet dysfunction, affecting the adhesion and activation, as well as aggregation, phases of plateletmediated thrombosis Hyperglycaemia alters platelet Ca#+ homeostasis, leading to cytoskeleton abnormalities and increased secretion and ROS generation Since the cardiovascular risk burden is not eradicated by intensive glycaemic control associated with optimal multifactorial treatment, mechanism-based therapeutic strategies are <PERSOON> metabolic syndrome (MetS) is defined as a cluster of risk factors attention, there has been an active debate concerning the terminology and diagnostic criteria related to its definition ## However, the medical community agrees that the term âMetSâ is appropriate to represent the combination of multiple risk factors Although smoking) patients with MetS have a two-fold increase of CVD risk Circulating cells derived from bone marrow have emerged as critical to endothelial repair.
| 648 | nvvc |
scavenger receptor B; tPA ¼ tissue plasminogen activator receptor B (SR-B), promoting foam cell formation and atherosclerosis These findings are reversed by peroxisome proliferatoractivated receptor gamma (PPARg) activation, which enhances Insulin resistance results in increased FFA release to the liver due to LDL particles (Figure #) ## This LDL subtype plays an important may be lost in T#DM patients due to alterations of the protein predictor of cardiovascular risk, stronger than isolated high triglycerides or a low HDL cholesterol ## In T#DM patients, IR and hyperglycaemia participate to the pathogenesis of a prothrombotic state characterized by increased plasminogen reduced tissue plasminogen activator (tPA) levels (Figure #) ## Among mechanisms contribute to platelet dysfunction, affecting the adhesion and activation, as well as aggregation, phases of plateletmediated thrombosis Hyperglycaemia alters platelet Ca#+ homeostasis, leading to cytoskeleton abnormalities and increased secretion and ROS generation Since the cardiovascular risk burden is not eradicated by intensive glycaemic control associated with optimal multifactorial treatment, mechanism-based therapeutic strategies are <PERSOON> metabolic syndrome (MetS) is defined as a cluster of risk factors attention, there has been an active debate concerning the terminology and diagnostic criteria related to its definition ## However, the medical community agrees that the term âMetSâ is appropriate to represent the combination of multiple risk factors Although smoking) patients with MetS have a two-fold increase of CVD risk Circulating cells derived from bone marrow have emerged as critical to endothelial repair reduced EPCs are features of T#DM and T#DM Hence, these cells may become a potential therapeutic target for the management of <PERSOON> aim of risk assessment is to categorize the population into those approaches in the individual <PERSOON> ### Joint European Society guidelines on CVD prevention recommended that patients with DM, and at least one other CV risk factor or target organ damage, should be considered to be at very high risk and all other patients with DM to be at high risk ## Developing generally applicable risk scores is difficult, because of confounders associated with ethnicity, cultural differences, metabolic and inflammatory markersâand, importantly, CAD and stroke scores are different All this underlines the great importance of managing patients with DM according to evidence-based, Framingham Study risk equations based on age, sex, blood pressure, cholesterol (total and HDL) and smoking, with DM status as a populations ##,## In patients with DM, results are inconsistent, underestimating CVD risk in a UK population and overestimating it in a Study demonstrate that standard risk factors, including DM measured at baseline, are related to the incidence of CVD events after ## years for fatal coronary heart disease and CVD was not developed for application in patients with <PERSOON> developed a risk equation for cardiovascular death, incorporating glucose tolerance status and FPG ## This risk score was associated with an ##% underestimation of cardiovascular risk ## In patients with T#DM, reduced IS predisposes to impaired myocardial structure and function and partially explains the exaggerated prevalence of heart failure in this population.
| 602 | nvvc |
potential therapeutic target for the management of <PERSOON> aim of risk assessment is to categorize the population into those approaches in the individual <PERSOON> ### Joint European Society guidelines on CVD prevention recommended that patients with DM, and at least one other CV risk factor or target organ damage, should be considered to be at very high risk and all other patients with DM to be at high risk ## Developing generally applicable risk scores is difficult, because of confounders associated with ethnicity, cultural differences, metabolic and inflammatory markersâand, importantly, CAD and stroke scores are different All this underlines the great importance of managing patients with DM according to evidence-based, Framingham Study risk equations based on age, sex, blood pressure, cholesterol (total and HDL) and smoking, with DM status as a populations ##,## In patients with DM, results are inconsistent, underestimating CVD risk in a UK population and overestimating it in a Study demonstrate that standard risk factors, including DM measured at baseline, are related to the incidence of CVD events after ## years for fatal coronary heart disease and CVD was not developed for application in patients with <PERSOON> developed a risk equation for cardiovascular death, incorporating glucose tolerance status and FPG ## This risk score was associated with an ##% underestimation of cardiovascular risk ## In patients with T#DM, reduced IS predisposes to impaired myocardial structure and function and partially explains the exaggerated prevalence of heart failure in this population Patients with unexplained dilated cardiomyopathy were ##% more the coronary circulation, leads to myocardial hypertrophy and fibrosis with ventricular stiffness and chamber dysfunction (Figure #) ## Data from the DECODE study showed that high #hPG, but not <PERSOON> In Communities (ARIC) study prospectively evaluated whether adding C-reactive protein or ## other novel risk factors individually to a basic risk model would improve None of these novel markers added to the risk score ### <PERSOON> study involving ### DM patients evaluated baseline UKPDS risk of the patients from the low- to the high-risk group <PERSOON> ##-year cardiovascular event rate was higher in patients with a UKPDS score ##% when skin AGEs were above the median (## vs ##%) ### This In patients with T#DM, albuminuria is a risk factor for future CV short-term outcome CAC and myocardial perfusion scintigraphy findings were synergistic for the prediction of short-term detection of carotid plaques,### arterial stiffness by pulse wave velocity,### and cardiac autonomic neuropathy (CAN) by standard only by systematic electrocardiogram (ECG) screening ### Silent myocardial ischaemia (SMI) may be detected by ECG stress test, myocardial scintigraphy or stress echocardiography Silent myocardial ischaemia affects ##â##% of DM patients who have additional risk from alterations of coronary endothelium function or coronary microcirculation SMI is a major cardiac risk factor, especially when associated with coronary stenoses on angiography, and the predictive value of SMI and silent coronary stenoses added to routine risk estimate ### However, in asymptomatic patients, routine screening for treated.
| 629 | nvvc |
more the coronary circulation, leads to myocardial hypertrophy and fibrosis with ventricular stiffness and chamber dysfunction (Figure #) ## Data from the DECODE study showed that high #hPG, but not <PERSOON> In Communities (ARIC) study prospectively evaluated whether adding C-reactive protein or ## other novel risk factors individually to a basic risk model would improve None of these novel markers added to the risk score ### <PERSOON> study involving ### DM patients evaluated baseline UKPDS risk of the patients from the low- to the high-risk group <PERSOON> ##-year cardiovascular event rate was higher in patients with a UKPDS score ##% when skin AGEs were above the median (## vs ##%) ### This In patients with T#DM, albuminuria is a risk factor for future CV short-term outcome CAC and myocardial perfusion scintigraphy findings were synergistic for the prediction of short-term detection of carotid plaques,### arterial stiffness by pulse wave velocity,### and cardiac autonomic neuropathy (CAN) by standard only by systematic electrocardiogram (ECG) screening ### Silent myocardial ischaemia (SMI) may be detected by ECG stress test, myocardial scintigraphy or stress echocardiography Silent myocardial ischaemia affects ##â##% of DM patients who have additional risk from alterations of coronary endothelium function or coronary microcirculation SMI is a major cardiac risk factor, especially when associated with coronary stenoses on angiography, and the predictive value of SMI and silent coronary stenoses added to routine risk estimate ### However, in asymptomatic patients, routine screening for treated in patients at a particularly high risk, such as those with evidence of peripheral artery disease (PAD) or high CAC score or with proteinuria, and in people who wish to start a vigorous exercise programme ### and SMI may account for a part of the cardiovascular residual risk that remains, even after control of conventional risk factors <PERSOON> detection of these disorders contributes to a more accurate risk estimate and should lead to a more intensive control of modifiable risk â There is a need to learn how to prevent or delay T#DM â There is a need for biomarkers and diagnostic strategies useful for â Prediction of CV risk in people with pre-diabetes is poorly understood <PERSOON> United Kingdom Prospective Diabetes Study (UKPDS) risk <PERSOON> Framingham Study Stroke has only undergone validation in <PERSOON> UKPDS for stroke underestimated the risk of fatal stroke in a <PERSOON> Action in Diabetes and Vascular Disease Preterax and from the international ADVANCE cohort ### This model, which incorporates age at diagnosis, known duration of DM, sex, pulse pressure, an acceptable discrimination and good calibration during internal validation <PERSOON> external applicability of the model was tested on an independent cohort of individuals with T#DM, where similar discrimination was A recent meta-analysis reviewed ## risk scores, ## from predominantly white populations (USA and Europe) and two from Chinese using risk scores specific to DM provides a more accurate estimate results in the populations in which they were developed, but validation is needed in other populations.
| 631 | nvvc |
such as those with evidence of peripheral artery disease (PAD) or high CAC score or with proteinuria, and in people who wish to start a vigorous exercise programme ### and SMI may account for a part of the cardiovascular residual risk that remains, even after control of conventional risk factors <PERSOON> detection of these disorders contributes to a more accurate risk estimate and should lead to a more intensive control of modifiable risk â There is a need to learn how to prevent or delay T#DM â There is a need for biomarkers and diagnostic strategies useful for â Prediction of CV risk in people with pre-diabetes is poorly understood <PERSOON> United Kingdom Prospective Diabetes Study (UKPDS) risk <PERSOON> Framingham Study Stroke has only undergone validation in <PERSOON> UKPDS for stroke underestimated the risk of fatal stroke in a <PERSOON> Action in Diabetes and Vascular Disease Preterax and from the international ADVANCE cohort ### This model, which incorporates age at diagnosis, known duration of DM, sex, pulse pressure, an acceptable discrimination and good calibration during internal validation <PERSOON> external applicability of the model was tested on an independent cohort of individuals with T#DM, where similar discrimination was A recent meta-analysis reviewed ## risk scores, ## from predominantly white populations (USA and Europe) and two from Chinese using risk scores specific to DM provides a more accurate estimate results in the populations in which they were developed, but validation is needed in other populations review concluded that data on the efficacy of dietary intervention in T#DM are scarce and of relatively poor quality ### <PERSOON> ADA position statement, Nutrition Recommendations and Interventions for trial of the effects of long-term weight loss on glycaemia and prevention of CVD events in T#DM One-year results of the intensive lifestyle intervention showed an average <DATUM> weight loss, a significant reduction in HbA#c and a reduction in several CVD risk factorsâ benefits that were sustained after four years ###,### <PERSOON> trial was, however, stopped for reasons of futility in ###, since no difference Dietary interventions recommended by the EASD Diabetes and Nutrition Study Group are less prescriptive than many earlier sets of can be adopted and emphasize that an appropriate intake of total low-fat protein sources predominate are more important than the precise proportions of total energy provided by the major macronutrients It is also considered that salt intake should be restricted It has been suggested that there is no benefit in a high-protein- over a high-carbohydrate diet in T#DM ### Specific dietary recommendations include limiting saturated and trans fats and alcohol intake, monitoring carbohydrate consumption and increasing dietary fibre Oils rich in monounsaturated fatty acids are useful fat sources and may provide ## â##% total energy, provided that total fat intake Total fat intake should not exceed ##% of total energy For those who are overweight, fat intake ,##% may facilitate weight loss Consumption of two to three servings ofâpreferablyâoily fish each week and plant sources of n-# fatty acids (e g.
| 624 | nvvc |
efficacy of dietary intervention in T#DM are scarce and of relatively poor quality ### <PERSOON> ADA position statement, Nutrition Recommendations and Interventions for trial of the effects of long-term weight loss on glycaemia and prevention of CVD events in T#DM One-year results of the intensive lifestyle intervention showed an average <DATUM> weight loss, a significant reduction in HbA#c and a reduction in several CVD risk factorsâ benefits that were sustained after four years ###,### <PERSOON> trial was, however, stopped for reasons of futility in ###, since no difference Dietary interventions recommended by the EASD Diabetes and Nutrition Study Group are less prescriptive than many earlier sets of can be adopted and emphasize that an appropriate intake of total low-fat protein sources predominate are more important than the precise proportions of total energy provided by the major macronutrients It is also considered that salt intake should be restricted It has been suggested that there is no benefit in a high-protein- over a high-carbohydrate diet in T#DM ### Specific dietary recommendations include limiting saturated and trans fats and alcohol intake, monitoring carbohydrate consumption and increasing dietary fibre Oils rich in monounsaturated fatty acids are useful fat sources and may provide ## â##% total energy, provided that total fat intake Total fat intake should not exceed ##% of total energy For those who are overweight, fat intake ,##% may facilitate weight loss Consumption of two to three servings ofâpreferablyâoily fish each week and plant sources of n-# fatty acids (e g oil, nuts and some green leafy vegetables) are recommended to <PERSOON> intake of trans fatty acids should be as small as possible, preferably none from industrial origin and limited to ,#% of total energy Carbohydrate may range from ##â##% of total energy Metabolic characteristics suggest that the most appropriate intakes for individuals with DM are within this range There is no justification for the recommendation of very low carbohydrate diets in DM Carbohydrate quantities, sources and distribution should be selected to facilitate near-normal long-term glycaemic control In those treated with insulin or oral hypoglycaemic agents, timing and dosage of the medication should match quantity and nature of carbohydrate When range, it is important to emphasize foods rich in dietary fibre and causes long-term weight loss and reduces the rate of incident about half of which should be soluble Daily consumption of â¥# servings of fibre-rich vegetables or fruit and â¥# servings of legumes per week can provide minimum requirements for fibre intake Cerealbased foods should be wholegrain and high in fibre Alcohol drinking in moderate amounts, not exceeding two glasses with a lower risk of CVD, compared with teetotallers and heavy alcohol drinkers, both in individuals with and without DM ### Excessive CVD in people with T#DM,### but it should be noted that boiled People with DM who are current smokers should be offered a structured smoking cessation programme including pharmacological Detailed instruction on smoking cessation should be given according.
| 607 | nvvc |
nuts and some green leafy vegetables) are recommended to <PERSOON> intake of trans fatty acids should be as small as possible, preferably none from industrial origin and limited to ,#% of total energy Carbohydrate may range from ##â##% of total energy Metabolic characteristics suggest that the most appropriate intakes for individuals with DM are within this range There is no justification for the recommendation of very low carbohydrate diets in DM Carbohydrate quantities, sources and distribution should be selected to facilitate near-normal long-term glycaemic control In those treated with insulin or oral hypoglycaemic agents, timing and dosage of the medication should match quantity and nature of carbohydrate When range, it is important to emphasize foods rich in dietary fibre and causes long-term weight loss and reduces the rate of incident about half of which should be soluble Daily consumption of â¥# servings of fibre-rich vegetables or fruit and â¥# servings of legumes per week can provide minimum requirements for fibre intake Cerealbased foods should be wholegrain and high in fibre Alcohol drinking in moderate amounts, not exceeding two glasses with a lower risk of CVD, compared with teetotallers and heavy alcohol drinkers, both in individuals with and without DM ### Excessive CVD in people with T#DM,### but it should be noted that boiled People with DM who are current smokers should be offered a structured smoking cessation programme including pharmacological Detailed instruction on smoking cessation should be given according â Lifestyles that influence the risk of CVD among people with DM â It is not known whether the remission in T#DM seen after bariatric Smoking cessation guided by structured advice is recommended in all subjects with DM and IGT It is recommended that in the prevention of T#DM and control of DM total fat intake should be (##%, saturated fat Any diet with reduced energy intake can be recommended in lowering excessive body weight in DM Moderate to vigorous physical activity of â¥### min/week is recommended for the prevention and control of T#DM, and Aerobic exercise and resistance training are recommended in the prevention of T#DM and control of DM, but best when Vitamin or micronutrient supplementation to reduce the risk of T#DM or CVD in DM is not recommended CVD ¼ cardiovascular disease; DM ¼ diabetes mellitus; T#DM ¼ type # diabetes mellitus Physical activity is important in the prevention of the development of improve insulin action and PG, lipids, blood pressure and cardiovascular risk ### Regular exercise is necessary for continuing benefit however, data from a number of RCTs support the need for reinforcement by healthcare workers ### â ### Systematic reviews###,### found that structured aerobic exercise or resistance exercise reduced HbA#c by about # #% in T#DM Since a decrease in HbA#c is associated with a long-term decrease in CVD events and a reduction in microvascular complications,### long-term exercise regimens that lead to an improvement in glycaemic control may ameliorate the appearance has a more favourable impact on HbA#c than aerobic or resistance training alone.
| 612 | nvvc |
people with DM â It is not known whether the remission in T#DM seen after bariatric Smoking cessation guided by structured advice is recommended in all subjects with DM and IGT It is recommended that in the prevention of T#DM and control of DM total fat intake should be (##%, saturated fat Any diet with reduced energy intake can be recommended in lowering excessive body weight in DM Moderate to vigorous physical activity of â¥### min/week is recommended for the prevention and control of T#DM, and Aerobic exercise and resistance training are recommended in the prevention of T#DM and control of DM, but best when Vitamin or micronutrient supplementation to reduce the risk of T#DM or CVD in DM is not recommended CVD ¼ cardiovascular disease; DM ¼ diabetes mellitus; T#DM ¼ type # diabetes mellitus Physical activity is important in the prevention of the development of improve insulin action and PG, lipids, blood pressure and cardiovascular risk ### Regular exercise is necessary for continuing benefit however, data from a number of RCTs support the need for reinforcement by healthcare workers ### â ### Systematic reviews###,### found that structured aerobic exercise or resistance exercise reduced HbA#c by about # #% in T#DM Since a decrease in HbA#c is associated with a long-term decrease in CVD events and a reduction in microvascular complications,### long-term exercise regimens that lead to an improvement in glycaemic control may ameliorate the appearance has a more favourable impact on HbA#c than aerobic or resistance training alone #% fall in HbA#c, compared with with a fall in HbA#c of # #% ,### min/week with a fall of # #% Overall, interventions of physical activity advice were associated with lower HbA#c levels only when combined with dietary advice ### control,### â ### which also exerts a favourable, although smaller, influence on CVD that becomes apparent after many years ###,### However, intensive glucose control, combined with effective blood pressure control and lipid lowering, appear to markedly shorten the time Although there is a strong relationship between glycaemia and microvascular disease, the situation regarding macrovascular disorders is less clear Hyperglycaemia in the high normal range, with minor elevations in a dose-dependent fashion However, the effects of improving glycaemia on cardiovascular risk remain uncertain and recent RCTs which there are several, include the presence of multiple comorbidities in long-standing T#DM and the complex risk phenotype A total of <DATUM> T#DM participants at high cardiovascular risk were randomized to intensive glucose control achieving an HbA#c years the study was terminated due to higher mortality in the intensive arm (<DATUM> vs <DATUM> patient deaths/year), which was pronounced in those with multiple cardiovascular risk factors and with poorer glycaemic control, although the role of hypoglycaemia in the CVD outcomes is not entirely clear Further analysis revealed that combination with an inability to control glucose according to target, follow-up of ACCORD did not support the hypothesis that severe A total of <DATUM> T#DM participants at high cardiovascular risk # ## â#.
| 640 | nvvc |
#% fall in HbA#c, compared with with a fall in HbA#c of # #% ,### min/week with a fall of # #% Overall, interventions of physical activity advice were associated with lower HbA#c levels only when combined with dietary advice ### control,### â ### which also exerts a favourable, although smaller, influence on CVD that becomes apparent after many years ###,### However, intensive glucose control, combined with effective blood pressure control and lipid lowering, appear to markedly shorten the time Although there is a strong relationship between glycaemia and microvascular disease, the situation regarding macrovascular disorders is less clear Hyperglycaemia in the high normal range, with minor elevations in a dose-dependent fashion However, the effects of improving glycaemia on cardiovascular risk remain uncertain and recent RCTs which there are several, include the presence of multiple comorbidities in long-standing T#DM and the complex risk phenotype A total of <DATUM> T#DM participants at high cardiovascular risk were randomized to intensive glucose control achieving an HbA#c years the study was terminated due to higher mortality in the intensive arm (<DATUM> vs <DATUM> patient deaths/year), which was pronounced in those with multiple cardiovascular risk factors and with poorer glycaemic control, although the role of hypoglycaemia in the CVD outcomes is not entirely clear Further analysis revealed that combination with an inability to control glucose according to target, follow-up of ACCORD did not support the hypothesis that severe A total of <DATUM> T#DM participants at high cardiovascular risk # ## â# Severe hypoglycaemia was reduced by two thirds in the intensive arm of the studies had a different baseline CVD risk, with a higher rate of ### T#DM patients were randomized to intensive or standard glucose control, achieving an HbA#c of <DATUM> (## mmol/mol) in the intensive therapy group, compared with <DATUM> (## mmol/mol) in the years) at high CVD risk plus IFG, IGT or T#DM to receive insulin glargine (with a target fasting blood glucose level of <DATUM> mmol/L (â¤## mg/ dL) or to standard care After a median follow-up of <DATUM> years, the rates of incident CV outcomes were similar in the insulin glargine and standard care groups Rates of severe hypoglycaemia were # ## vs # ## per ### person-years Median weight increased by <DATUM> kg in the insulin glargine group and fell by # # kg in the standard care group There was no VADT, ACCORD and ADVANCE suggested that an HbA#c reduction of #% was associated with a ##% relative risk reduction (RRR) in nonfatal MI but without benefits on stroke or all-cause mortality ### benefit from more-intensive glucose-lowering strategies This interpretation is supported by ORIGIN, which did not demonstrate with increased hypoglycaemia This suggests that intensive glycaemic taking into account age, duration of T#DM and history of CVD Diabetes Control and Complications Trial (DCCT) and Epidemiology of Diabetes Interventions and Complications (EDIC) In ##% of the cohort were followed for an additional ## years under.
| 660 | nvvc |
was reduced by two thirds in the intensive arm of the studies had a different baseline CVD risk, with a higher rate of ### T#DM patients were randomized to intensive or standard glucose control, achieving an HbA#c of <DATUM> (## mmol/mol) in the intensive therapy group, compared with <DATUM> (## mmol/mol) in the years) at high CVD risk plus IFG, IGT or T#DM to receive insulin glargine (with a target fasting blood glucose level of <DATUM> mmol/L (â¤## mg/ dL) or to standard care After a median follow-up of <DATUM> years, the rates of incident CV outcomes were similar in the insulin glargine and standard care groups Rates of severe hypoglycaemia were # ## vs # ## per ### person-years Median weight increased by <DATUM> kg in the insulin glargine group and fell by # # kg in the standard care group There was no VADT, ACCORD and ADVANCE suggested that an HbA#c reduction of #% was associated with a ##% relative risk reduction (RRR) in nonfatal MI but without benefits on stroke or all-cause mortality ### benefit from more-intensive glucose-lowering strategies This interpretation is supported by ORIGIN, which did not demonstrate with increased hypoglycaemia This suggests that intensive glycaemic taking into account age, duration of T#DM and history of CVD Diabetes Control and Complications Trial (DCCT) and Epidemiology of Diabetes Interventions and Complications (EDIC) In ##% of the cohort were followed for an additional ## years under ### During to both T#DM and T#DM, although the outcomes are less apparent in T#DM with established complications, for which the number Control and Complications Trial (DCCT) and the UKPDS demonstrated a continuous relationship between increasing HbA#c and In the DCCT, a decrease in HbA#c of #% (<DATUM> mmol/mol) significantly lowered the risk of the development and progression of retinopathy and nephropathy,### although the absolute reduction was low <PERSOON> HbA#c target of ,# #% (,## mmol/mol) to reduce microvascular disease is a generally accepted level ### â ###,###,### <PERSOON> evidence for an HbA#c target in relation to macrovascular risk is less compelling, in part due to the complexities surrounding the chronic, progressive nature of DM and the effects of metabolic memory ###,###,### with acknowledgement of the need to pay attention to the individual early in the course of the disorder in younger people and without attendant co-morbidities Fasting plasma glucose (FPG) should be (,### â### mg/dL) on an individualized basis Successful glucoselowering therapy is assisted by self-monitoring of blood glucose, most notably in patients with insulin-treated DM ### When nearnormoglycaemia is the objective, post-prandial glycaemia needs to be taken into account in addition to fasting glycaemia However, although post-prandial hyperglycaemia is associated with an increased to whether treatment targets addressing post-prandial hyperglycaemia are of added benefit to CVD outcomes ### â ### might be considered in selected patients with short disease duration, the accumulated results from T#DM cardiovascular trials suggest the potential side-effects are related to the mode of action of the drug.
| 695 | nvvc |
T#DM and T#DM, although the outcomes are less apparent in T#DM with established complications, for which the number Control and Complications Trial (DCCT) and the UKPDS demonstrated a continuous relationship between increasing HbA#c and In the DCCT, a decrease in HbA#c of #% (<DATUM> mmol/mol) significantly lowered the risk of the development and progression of retinopathy and nephropathy,### although the absolute reduction was low <PERSOON> HbA#c target of ,# #% (,## mmol/mol) to reduce microvascular disease is a generally accepted level ### â ###,###,### <PERSOON> evidence for an HbA#c target in relation to macrovascular risk is less compelling, in part due to the complexities surrounding the chronic, progressive nature of DM and the effects of metabolic memory ###,###,### with acknowledgement of the need to pay attention to the individual early in the course of the disorder in younger people and without attendant co-morbidities Fasting plasma glucose (FPG) should be (,### â### mg/dL) on an individualized basis Successful glucoselowering therapy is assisted by self-monitoring of blood glucose, most notably in patients with insulin-treated DM ### When nearnormoglycaemia is the objective, post-prandial glycaemia needs to be taken into account in addition to fasting glycaemia However, although post-prandial hyperglycaemia is associated with an increased to whether treatment targets addressing post-prandial hyperglycaemia are of added benefit to CVD outcomes ### â ### might be considered in selected patients with short disease duration, the accumulated results from T#DM cardiovascular trials suggest the potential side-effects are related to the mode of action of the drug ### In brief, therapeutic agents for managing hyperglycaemia can be broadly characterized as belonging to one of three groups (i) insulin providers [insulin, weight loss-associated with GLP-# receptor agonists), although transient nausea occurring in about ##% of those treated may persist for #â# weeks after initiation of therapy Pioglitazone is a PPARg agonist with effects, which lowers glucose by ameliorating insulin resistance, while kinase activation <PERSOON> agents tend to reduce insulin requirements in regimen, delivered either by multiple insulin injections or using an concern over the use of metformin has been the risk of lactic acidosis, especially in patients with impaired renal function and hepatic disease In systematic reviews of trial data with selected patients, lactic acidosis is not over-represented ### Despite this, metformin is not guidelines are more flexible, allowing use down to a eGFR of ## mL/ is often required soon after diagnosis Early aggressive therapy seems Concerns initiated by possible adverse cardiovascular effects of rosiglitazone### raised questions as to the cardiovascular safety of metformin being adopted as first line treatment in overweight T#DMâit is important to underline that, overall, there is no clear evidence to support this view and there is a suggestion that, in combination with sulphonylurea, there may be detrimental effects related United Kingdom Prospective Diabetes Study (UKPDS) Although a clear reduction in microvascular complications was evident, the reduction in MI was only ##% (P ¼ # ###) In the extension phase of the study, a risk reduction in MI remained at ##%, which.
| 677 | nvvc |
brief, therapeutic agents for managing hyperglycaemia can be broadly characterized as belonging to one of three groups (i) insulin providers [insulin, weight loss-associated with GLP-# receptor agonists), although transient nausea occurring in about ##% of those treated may persist for #â# weeks after initiation of therapy Pioglitazone is a PPARg agonist with effects, which lowers glucose by ameliorating insulin resistance, while kinase activation <PERSOON> agents tend to reduce insulin requirements in regimen, delivered either by multiple insulin injections or using an concern over the use of metformin has been the risk of lactic acidosis, especially in patients with impaired renal function and hepatic disease In systematic reviews of trial data with selected patients, lactic acidosis is not over-represented ### Despite this, metformin is not guidelines are more flexible, allowing use down to a eGFR of ## mL/ is often required soon after diagnosis Early aggressive therapy seems Concerns initiated by possible adverse cardiovascular effects of rosiglitazone### raised questions as to the cardiovascular safety of metformin being adopted as first line treatment in overweight T#DMâit is important to underline that, overall, there is no clear evidence to support this view and there is a suggestion that, in combination with sulphonylurea, there may be detrimental effects related United Kingdom Prospective Diabetes Study (UKPDS) Although a clear reduction in microvascular complications was evident, the reduction in MI was only ##% (P ¼ # ###) In the extension phase of the study, a risk reduction in MI remained at ##%, which ### It should be noted that this study was performed when lipid lowering and blood pressure were less effectively managed, partially due to the lack of availability of potent, currently available drugs Thus UKPDS was performed when other important parts of a multifactorial management were less efficient One may speculate that it may have been easier to verify a beneficial effect of glucose-lowering agents at that time, than required to demonstrate an effect and (iii) early glucose control is important (metabolic memory) meta-analysis also suggest a benefit after a long duration of treatment ##% CI # ##â# ##; P ¼ # ###) in T#DM patients at high risk of macrovascular disease ### However, because the primary outcome in PROactive did not achieve statistical significance, the interpretation of these fluid retention secondary to renal effects, and this is associated with peripheral oedoma and worsening of established heart failure in susceptible individuals Diuretic therapy can be initiated to ameliorate these sideeffects In the STOP-NIDDM trial, acarbose, when given to patients mortality ### Meglitinides have not been formally tested in T#DM but, in T#DM ###,### Impaired hypoglycaemic awareness increases with duration of DM and is a significant risk factor for hypoglycaemia, which must be taken into account when glucose-lowering therapy is considered ### In addition to the short-term risks of cardiac arrhythmia and cardiovascular events, longer-term risks include dementia and cognitive dysfunction ###,### <PERSOON> outcome of glucose-lowering studies has reviewed this topic, providing evidence for a number of adverse.
| 638 | nvvc |
should be noted that this study was performed when lipid lowering and blood pressure were less effectively managed, partially due to the lack of availability of potent, currently available drugs Thus UKPDS was performed when other important parts of a multifactorial management were less efficient One may speculate that it may have been easier to verify a beneficial effect of glucose-lowering agents at that time, than required to demonstrate an effect and (iii) early glucose control is important (metabolic memory) meta-analysis also suggest a benefit after a long duration of treatment ##% CI # ##â# ##; P ¼ # ###) in T#DM patients at high risk of macrovascular disease ### However, because the primary outcome in PROactive did not achieve statistical significance, the interpretation of these fluid retention secondary to renal effects, and this is associated with peripheral oedoma and worsening of established heart failure in susceptible individuals Diuretic therapy can be initiated to ameliorate these sideeffects In the STOP-NIDDM trial, acarbose, when given to patients mortality ### Meglitinides have not been formally tested in T#DM but, in T#DM ###,### Impaired hypoglycaemic awareness increases with duration of DM and is a significant risk factor for hypoglycaemia, which must be taken into account when glucose-lowering therapy is considered ### In addition to the short-term risks of cardiac arrhythmia and cardiovascular events, longer-term risks include dementia and cognitive dysfunction ###,### <PERSOON> outcome of glucose-lowering studies has reviewed this topic, providing evidence for a number of adverse Insulin, meglitinides and sulphonylureas are particularly associated with hypoglycaemia, which is a ##% of people with T#DM have chronic kidney disease (CKD) may need to be modified, either because a particular agent is contraindicated in CKD or because the dosage needs to be altered ### Metformin, acarbose and most sulphonylureas should be avoided in stage # â# CKD, whilst insulin therapy and pioglitazone can be used in their progressive CKD with the exception of linagliptin, which is well tolerated in these circumstances <PERSOON> SGLT# inhibitors have not been Elderly people Older people have a higher atherosclerotic disease burden, reduced renal function and greater co-morbidity Life expectancy is reduced, especially in the presence of long-term complications Glycaemic targets for elderly people with long-standing or more complicated disease should be less ambitious than for younger, healthier individuals If lower targets cannot be achieved with simple interventions, transitioning upwards as age increases and capacity for self-care, cognitive, psychological and economic status and support systems decline ### eGFR ¼ estimated glomerular filtration rate; GLP-# ¼ glucagon-like peptide-#; DDP ¼ Diabetes Prevention Program; SGLT# ¼ sodium glucose co-transporter # effects of polypharmacy and inconvenience of intensified glucoselowering regimens have to be carefully evaluated for each individual with DM (for further information see Section #) From a public prove advantageous On the other hand, the intensified glucoselowering treatment may impose a considerable burden and possible achieve the best compromise between glucose control and vascular CVD ¼ cardiovascular disease; DM ¼ diabetes mellitus; HbA#c ¼ glycated.
| 630 | nvvc |
associated with hypoglycaemia, which is a ##% of people with T#DM have chronic kidney disease (CKD) may need to be modified, either because a particular agent is contraindicated in CKD or because the dosage needs to be altered ### Metformin, acarbose and most sulphonylureas should be avoided in stage # â# CKD, whilst insulin therapy and pioglitazone can be used in their progressive CKD with the exception of linagliptin, which is well tolerated in these circumstances <PERSOON> SGLT# inhibitors have not been Elderly people Older people have a higher atherosclerotic disease burden, reduced renal function and greater co-morbidity Life expectancy is reduced, especially in the presence of long-term complications Glycaemic targets for elderly people with long-standing or more complicated disease should be less ambitious than for younger, healthier individuals If lower targets cannot be achieved with simple interventions, transitioning upwards as age increases and capacity for self-care, cognitive, psychological and economic status and support systems decline ### eGFR ¼ estimated glomerular filtration rate; GLP-# ¼ glucagon-like peptide-#; DDP ¼ Diabetes Prevention Program; SGLT# ¼ sodium glucose co-transporter # effects of polypharmacy and inconvenience of intensified glucoselowering regimens have to be carefully evaluated for each individual with DM (for further information see Section #) From a public prove advantageous On the other hand, the intensified glucoselowering treatment may impose a considerable burden and possible achieve the best compromise between glucose control and vascular CVD ¼ cardiovascular disease; DM ¼ diabetes mellitus; HbA#c ¼ glycated <PERSOON> prevalence of hypertension is higher in patients with T#DM than more than ##% of patients diagnosed with T#DM have arterial hypertension ### According to current pathophysiological considerations, this is related to (i) hyperinsulinaemia linked to increased Obesity, aging and the appearance of renal disease further increase risk factors for CVD While the development of T#DM doubles the cardiovascular risk in men and more than triples the risk in women, it should be recognised that blood pressure management needs to In general, measures to lower elevated blood pressure should be applied in all patients with DM, due to the substantially enhanced cardiovascular risk associated with increased blood pressure levels in such patients RCTs in T#DM have shown the positive effects on cardiovascular outcomes of lowering blood pressure at least below ### mm Hg systolic and ## mm Hg diastolic ### â ### <PERSOON> Hypertension Optimal Treatment (HOT) trial demonstrated that risk However, the mean diastolic blood pressure in this group was still post-hoc observational analysis of the UKPDS trial, DM-related mortality decreased ##% with each ## mm Hg drop, down to a systolic In the more recent ACCORD trial, more than ### patients were (BP) ### mm Hg] over a mean follow-up of <DATUM> years <PERSOON> relative reduction of the composite endpoint (non-fatal MI, non-fatal stroke, or CVD death) by the intensive treatment did not reach statistical significance ### <PERSOON> average number of blood pressure-reducing drugs was <DATUM> in the intensive group, against <DATUM> in the standard group.
| 635 | nvvc |
higher in patients with T#DM than more than ##% of patients diagnosed with T#DM have arterial hypertension ### According to current pathophysiological considerations, this is related to (i) hyperinsulinaemia linked to increased Obesity, aging and the appearance of renal disease further increase risk factors for CVD While the development of T#DM doubles the cardiovascular risk in men and more than triples the risk in women, it should be recognised that blood pressure management needs to In general, measures to lower elevated blood pressure should be applied in all patients with DM, due to the substantially enhanced cardiovascular risk associated with increased blood pressure levels in such patients RCTs in T#DM have shown the positive effects on cardiovascular outcomes of lowering blood pressure at least below ### mm Hg systolic and ## mm Hg diastolic ### â ### <PERSOON> Hypertension Optimal Treatment (HOT) trial demonstrated that risk However, the mean diastolic blood pressure in this group was still post-hoc observational analysis of the UKPDS trial, DM-related mortality decreased ##% with each ## mm Hg drop, down to a systolic In the more recent ACCORD trial, more than ### patients were (BP) ### mm Hg] over a mean follow-up of <DATUM> years <PERSOON> relative reduction of the composite endpoint (non-fatal MI, non-fatal stroke, or CVD death) by the intensive treatment did not reach statistical significance ### <PERSOON> average number of blood pressure-reducing drugs was <DATUM> in the intensive group, against <DATUM> in the standard group and declining renal functionâincreased from <DATUM> to <DATUM> with aggressive treatment Since the risk âbenefit ratio tipped towards harm, this study does not support a reduction of systolic blood pressure below Hg was related to a greater reduction in stroke but did not affect â <PERSOON> consequences of polypharmacy for quality of life and the most appropriate choice of treatment in DM-patients with comorbidities, particularly in the elderly, are unclear â <PERSOON> level of glycaemia (FPG, #hPG, HbA#c) at which CV benefits can be seen in T#DM is not known, since no studies with this In summary, present evidence makes it reasonable to reduce blood that further reduction might be associated with an increased risk of serious adverse events, especially in patients of advanced age and with longer duration of T#DM Thus the risks and benefits of more intensive blood pressure management need to be carefully considered on an individual basis <PERSOON> main aim when treating hypertension in patients with DM achieve this goal, a combination of blood pressure-lowering drugs is needed in most patients In patients with hypertension and used, but evidence strongly supports the inclusion of an inhibitor should be borne in mind that many DM patients do not reach the to that reported with glycaemic control and statins,### there is no hypertensive legacy or memory effect ### As a consequence, sustained control and monitoring and consistent medical adjustment and hypertension are consistent with the Re-appraisal of the European Guidelines on Hypertension (###)### and the updated European Guidelines for hypertension ### ###.
| 644 | nvvc |
# to <DATUM> with aggressive treatment Since the risk âbenefit ratio tipped towards harm, this study does not support a reduction of systolic blood pressure below Hg was related to a greater reduction in stroke but did not affect â <PERSOON> consequences of polypharmacy for quality of life and the most appropriate choice of treatment in DM-patients with comorbidities, particularly in the elderly, are unclear â <PERSOON> level of glycaemia (FPG, #hPG, HbA#c) at which CV benefits can be seen in T#DM is not known, since no studies with this In summary, present evidence makes it reasonable to reduce blood that further reduction might be associated with an increased risk of serious adverse events, especially in patients of advanced age and with longer duration of T#DM Thus the risks and benefits of more intensive blood pressure management need to be carefully considered on an individual basis <PERSOON> main aim when treating hypertension in patients with DM achieve this goal, a combination of blood pressure-lowering drugs is needed in most patients In patients with hypertension and used, but evidence strongly supports the inclusion of an inhibitor should be borne in mind that many DM patients do not reach the to that reported with glycaemic control and statins,### there is no hypertensive legacy or memory effect ### As a consequence, sustained control and monitoring and consistent medical adjustment and hypertension are consistent with the Re-appraisal of the European Guidelines on Hypertension (###)### and the updated European Guidelines for hypertension ##<DATUM> â <PERSOON> evidence base for efficacy or harm for microvascular complications for both individual blood pressure-lowering drugs alone or â <PERSOON> understanding of the role of arterial stiffness in predicting CV risk in patients with DM, over and above the role of conventional usually insufficient for adequate blood pressure control (for details Pharmacological treatment has only been tested in a few RCTs However, several RCTs with sizeable DM subgroups reported specifically on the outcome in this subgroup ### â ### It appears that an angiotensin-receptor-blocker (ARB), is of particular value, especially when treating hypertension in patients with DM at high cardiovascular risk ###,###,### â ### Evidence also supports the efficacy therapy when the intention is to prevent or retard the occurrence of microalbuminuria in hypertensive patients with DM ### Dual further benefit in the ONgoing Telmisartan Alone and in combination with more adverse events In the Aliskiren Trial in Type # Diabetes Using Cardio-Renal Endpoints (ALTITUDE) trial, the addition of aliskiren to RAAS blockade in patients with T#DM at high risk for cardiovascular and renal events did not result in a decrease in cardiovascular events and may even have been harmful ###,### Since DM patients tend to have high blood pressure during the night, administration of A matter that has been intensively discussed over the past decades with an increased risk of developing T#DM, compared with treatment with calcium channel blockers and inhibitors of the RAAS ### It is not known whether treatment with beta-blockers and/or thiazides or thiazide-like diuretics in patients with established T#DM.
| 635 | nvvc |
â <PERSOON> evidence base for efficacy or harm for microvascular complications for both individual blood pressure-lowering drugs alone or â <PERSOON> understanding of the role of arterial stiffness in predicting CV risk in patients with DM, over and above the role of conventional usually insufficient for adequate blood pressure control (for details Pharmacological treatment has only been tested in a few RCTs However, several RCTs with sizeable DM subgroups reported specifically on the outcome in this subgroup ### â ### It appears that an angiotensin-receptor-blocker (ARB), is of particular value, especially when treating hypertension in patients with DM at high cardiovascular risk ###,###,### â ### Evidence also supports the efficacy therapy when the intention is to prevent or retard the occurrence of microalbuminuria in hypertensive patients with DM ### Dual further benefit in the ONgoing Telmisartan Alone and in combination with more adverse events In the Aliskiren Trial in Type # Diabetes Using Cardio-Renal Endpoints (ALTITUDE) trial, the addition of aliskiren to RAAS blockade in patients with T#DM at high risk for cardiovascular and renal events did not result in a decrease in cardiovascular events and may even have been harmful ###,### Since DM patients tend to have high blood pressure during the night, administration of A matter that has been intensively discussed over the past decades with an increased risk of developing T#DM, compared with treatment with calcium channel blockers and inhibitors of the RAAS ### It is not known whether treatment with beta-blockers and/or thiazides or thiazide-like diuretics in patients with established <PERSOON> observation from UKPDS, that control of hyperglycaemiaâin contrast to an effective blood pressure controlâhad a relatively minor influence on cardiovascular outcome, indicates that negative metabolic effects may be less important when treating hypertension in patients with of a diuretic and a beta-blockerâshould be avoided as first-line treatment in hypertensive patients with metabolic syndrome, the objective of lowering blood pressure seems more important than minor recent meta-analysis emphasized the priority of blood pressure lowering over choice of drug class ### In the absence of cardiac comorbidity, beta-blockers are not the first choice for the treatment Events through Combination Therapy in Patients Living with Systolic in combination treatment with an ACE-I ### In ### patients with with amlodipine and ### in the group treated with hydrochlorothiazide as the add-on to benazepril (P ¼ # ###), despite a similar reduction of blood pressure in both groups ⢠Dyslipidaemia represents a cluster of lipid and lipoprotein ⢠Increased waist circumference and elevation of TGs is a simple tool blockers; DM ¼ diabetes mellitus; RAAS ¼ renin angiotensin aldosterone In individuals with T#DM and good glycaemic control, the pattern of (HDL-C) is within the upper normal range or slightly elevated This pattern is linked to insulin therapy, which increases lipoprotein lipase activity in adipose tissue, and the turnover rate of very lowdensity lipoprotein (VLDL) particles However, qualitative changes A cluster of lipid and apoprotein abnormalities accompanies T#DM, affecting all lipoprotein classes (Table #).
| 624 | nvvc |
<PERSOON> observation from UKPDS, that control of hyperglycaemiaâin contrast to an effective blood pressure controlâhad a relatively minor influence on cardiovascular outcome, indicates that negative metabolic effects may be less important when treating hypertension in patients with of a diuretic and a beta-blockerâshould be avoided as first-line treatment in hypertensive patients with metabolic syndrome, the objective of lowering blood pressure seems more important than minor recent meta-analysis emphasized the priority of blood pressure lowering over choice of drug class ### In the absence of cardiac comorbidity, beta-blockers are not the first choice for the treatment Events through Combination Therapy in Patients Living with Systolic in combination treatment with an ACE-I ### In ### patients with with amlodipine and ### in the group treated with hydrochlorothiazide as the add-on to benazepril (P ¼ # ###), despite a similar reduction of blood pressure in both groups ⢠Dyslipidaemia represents a cluster of lipid and lipoprotein ⢠Increased waist circumference and elevation of TGs is a simple tool blockers; DM ¼ diabetes mellitus; RAAS ¼ renin angiotensin aldosterone In individuals with T#DM and good glycaemic control, the pattern of (HDL-C) is within the upper normal range or slightly elevated This pattern is linked to insulin therapy, which increases lipoprotein lipase activity in adipose tissue, and the turnover rate of very lowdensity lipoprotein (VLDL) particles However, qualitative changes A cluster of lipid and apoprotein abnormalities accompanies T#DM, affecting all lipoprotein classes (Table #) Other features comprise elevations of TG-rich lipoprotein (TRLs), including chylomicron and VLDL remnants, small dense LDL particles These components are not isolated abnormalities but are metabolically linked Overproduction of large VLDL particles with increased secretion of both TGs and Apo B ### leads to the generation of small, dense LDL particles and lowering of HDL-C As the dyslipidaemia is characterized by elevation of the Apo B concentration Therefore, the malignant nature of dyslipidaemia in T#DM is between the hepatic import and export of lipids results in excess flux of FFA comes from both the systemic FFA pools and de novo lipogenesis in the setting of <PERSOON> the content of liver fat and hepatic IR seem to be driving the overproduction of large VLDL particles in people with T#DM Impaired clearance of large VLDL particles, linked to increased concentration of Apo C, contributes to a more robust hypertriglyceridaemia ### Thus dual metabolic defects contribute to the hypertriglyceridaemia in people with T#DM Recent data suggest that part of the lipid oversupply to the liver in the presence of obesity may be FFAs, leading to ectopic fat deposition and lipotoxicity that underlies survey of ## ### patients with T#DM in the National Diabetes register in Sweden reported that ##% of patients did not receive statins were used, highlighting the need for intensification of therapy wealth of data from case-control, mechanistic, genetic and large observational studies indicate that a causal association exists between Type # diabetes mellitus Comprehensive and consistent data exist.
| 594 | nvvc |
remnants, small dense LDL particles These components are not isolated abnormalities but are metabolically linked Overproduction of large VLDL particles with increased secretion of both TGs and Apo B ### leads to the generation of small, dense LDL particles and lowering of HDL-C As the dyslipidaemia is characterized by elevation of the Apo B concentration Therefore, the malignant nature of dyslipidaemia in T#DM is between the hepatic import and export of lipids results in excess flux of FFA comes from both the systemic FFA pools and de novo lipogenesis in the setting of <PERSOON> the content of liver fat and hepatic IR seem to be driving the overproduction of large VLDL particles in people with T#DM Impaired clearance of large VLDL particles, linked to increased concentration of Apo C, contributes to a more robust hypertriglyceridaemia ### Thus dual metabolic defects contribute to the hypertriglyceridaemia in people with T#DM Recent data suggest that part of the lipid oversupply to the liver in the presence of obesity may be FFAs, leading to ectopic fat deposition and lipotoxicity that underlies survey of ## ### patients with T#DM in the National Diabetes register in Sweden reported that ##% of patients did not receive statins were used, highlighting the need for intensification of therapy wealth of data from case-control, mechanistic, genetic and large observational studies indicate that a causal association exists between Type # diabetes mellitus Comprehensive and consistent data exist of CVD events in <PERSOON> benefits of statin therapy in lowering LDL-C and reducing CVD events are seen in all subgroup analyses of major RCTs ### In a meta-analysis of ## RCTs covering reduction in all-cause mortality and a ##% reduction in the incidence of major vascular outcomes per mmol/L of LDL-C lowering non-<PERSOON> magnitude of the benefit was associated with the absolute reduction in LDL-C, highlighting a positive relationship a subgroup of patients with ACS, intensive statin therapy reduced by statins had a beneficial effect on progression of atheroma in Intensification of LDL-C lowering can also be achieved by adding however, under way <PERSOON> analysis of pooled safety data comparing the efficacy and safety profile of combination therapy with ezetimibe/statin vs statin monotherapy in DM and non-DM (n ¼ effects on all major lipid measures <PERSOON> Study of Heart and Renal Protection (SHARP) trial reported a ##% reduction of major atherosclerotic events in chronic kidney disease treated with simvastatin plus ezetimibe daily vs placebo ### In this context it should be emphasized that, although relative reduction of events may be similar for people with and without DM, the absolute benefit is greater in (CTT) analysis included ### T#DM patients with an average age of ## years and a majority with prior CVD events This analysis # ## â<DATUM> to that seen in T#DM and with a P value for interaction of # #, verifying the result despite only a borderline significance in the subgroup ### It should be recognized that no trial data exist on.
| 601 | nvvc |
in lowering LDL-C and reducing CVD events are seen in all subgroup analyses of major RCTs ### In a meta-analysis of ## RCTs covering reduction in all-cause mortality and a ##% reduction in the incidence of major vascular outcomes per mmol/L of LDL-C lowering non-<PERSOON> magnitude of the benefit was associated with the absolute reduction in LDL-C, highlighting a positive relationship a subgroup of patients with ACS, intensive statin therapy reduced by statins had a beneficial effect on progression of atheroma in Intensification of LDL-C lowering can also be achieved by adding however, under way <PERSOON> analysis of pooled safety data comparing the efficacy and safety profile of combination therapy with ezetimibe/statin vs statin monotherapy in DM and non-DM (n ¼ effects on all major lipid measures <PERSOON> Study of Heart and Renal Protection (SHARP) trial reported a ##% reduction of major atherosclerotic events in chronic kidney disease treated with simvastatin plus ezetimibe daily vs placebo ### In this context it should be emphasized that, although relative reduction of events may be similar for people with and without DM, the absolute benefit is greater in (CTT) analysis included ### T#DM patients with an average age of ## years and a majority with prior CVD events This analysis # ## â<DATUM> to that seen in T#DM and with a P value for interaction of # #, verifying the result despite only a borderline significance in the subgroup ### It should be recognized that no trial data exist on However, in T#DM, statin therapy should be considered on an individual basis in those at high risk for CVD events, irrespective of Study (CARDS) evaluated the benefits of a statin in patients with Study (HPS) recruited ### patients (mainly T#DM) without preexisting CVD Simvastatin (## mg/day) reduced the composite reduced the rate of major CVD events and procedures by ##% Safety of statin therapy Reports from major RCTs demonstrate that statins are safe and well-tolerated ### <PERSOON> frequency of adverse events, except for muscle symptoms, is rare In the majority of cases of myopathy or rhabdomyolysis there are drug interactions with a higher-than-standard dose of statin ### <PERSOON> combination of gemfibrozil and statins should be avoided due to pharmacokinetic interaction, but there are no safety issues with fenofibrate and event rates were significantly higher in those with dyslipidaemia â¤# ## mmol/L) ###,### In FIELD,### the baseline variables best predicting CVD events over a #-year follow-up were lipid ratios CVD events was attenuated by adjustment for <PERSOON> results were unexpected, since the dyslipidaemia in DM is a cluster very similar association with coronary heart disease irrespective of the presence of <PERSOON> study reported that an increase of associated with a ##% reduction in risk of coronary heart disease the risk associated with elevation of triglyceride rich proteins in clinical practice <PERSOON> use of Apo B and Apo BâApo A are also advocated HDL-C One explanation for these findings may relate to abnormal.
| 635 | nvvc |
However, in T#DM, statin therapy should be considered on an individual basis in those at high risk for CVD events, irrespective of Study (CARDS) evaluated the benefits of a statin in patients with Study (HPS) recruited ### patients (mainly T#DM) without preexisting CVD Simvastatin (## mg/day) reduced the composite reduced the rate of major CVD events and procedures by ##% Safety of statin therapy Reports from major RCTs demonstrate that statins are safe and well-tolerated ### <PERSOON> frequency of adverse events, except for muscle symptoms, is rare In the majority of cases of myopathy or rhabdomyolysis there are drug interactions with a higher-than-standard dose of statin ### <PERSOON> combination of gemfibrozil and statins should be avoided due to pharmacokinetic interaction, but there are no safety issues with fenofibrate and event rates were significantly higher in those with dyslipidaemia â¤# ## mmol/L) ###,### In FIELD,### the baseline variables best predicting CVD events over a #-year follow-up were lipid ratios CVD events was attenuated by adjustment for <PERSOON> results were unexpected, since the dyslipidaemia in DM is a cluster very similar association with coronary heart disease irrespective of the presence of <PERSOON> study reported that an increase of associated with a ##% reduction in risk of coronary heart disease the risk associated with elevation of triglyceride rich proteins in clinical practice <PERSOON> use of Apo B and Apo BâApo A are also advocated HDL-C One explanation for these findings may relate to abnormal If this is true, merely increasing the number of such particles without any improvement of DM patients remain limited Fenofibrate has trivial efficacy in this regard, while niacin (N-ER) has potentially useful properties, increasing HDL-C by ## â##%, with an associated increase in Apo on reduction of carotid wall area quantified with magnetic resonance imaging after one year of therapy,### two recent clinical prevention <PERSOON> Atherothrombosis Intervention in Metabolic Syndrome with Low HDL/High Triglycerides Impact on Global Heart Protection Study # Treatment of HDL to Reduce the Incidence of Vascular Events (HPS-# THRIVE) trial, <DATUM> patients with known vascular disease were randomized to placebo or therapy <PERSOON> trial was stopped prematurely after a median follow stroke, or coronary revascularization Moreover, there was a significant <DATUM> absolute excess risk of DM complications and a significant In patients with high TG ( <DATUM> mmol/L) lifestyle advice (with a focus glucose control are the main targets Risks associated with TG are acute pancreatitis and polyneuropathy In a pooled analysis of randomized trial data, use of statins was associated with a lower risk of pancreatitis in patients with normal or mildly elevated triglyceride levels Fibrates were not protective and may even have enhanced the in people with high levels ### There is, however, no evidence that such â <PERSOON> role of HDL particles in the regulation of insulin secretion in â Efficiency and safety of drugs increasing or improving HDL-C particles is unclear.
| 625 | nvvc |
true, merely increasing the number of such particles without any improvement of DM patients remain limited Fenofibrate has trivial efficacy in this regard, while niacin (N-ER) has potentially useful properties, increasing HDL-C by ## â##%, with an associated increase in Apo on reduction of carotid wall area quantified with magnetic resonance imaging after one year of therapy,### two recent clinical prevention <PERSOON> Atherothrombosis Intervention in Metabolic Syndrome with Low HDL/High Triglycerides Impact on Global Heart Protection Study # Treatment of HDL to Reduce the Incidence of Vascular Events (HPS-# THRIVE) trial, <DATUM> patients with known vascular disease were randomized to placebo or therapy <PERSOON> trial was stopped prematurely after a median follow stroke, or coronary revascularization Moreover, there was a significant <DATUM> absolute excess risk of DM complications and a significant In patients with high TG ( <DATUM> mmol/L) lifestyle advice (with a focus glucose control are the main targets Risks associated with TG are acute pancreatitis and polyneuropathy In a pooled analysis of randomized trial data, use of statins was associated with a lower risk of pancreatitis in patients with normal or mildly elevated triglyceride levels Fibrates were not protective and may even have enhanced the in people with high levels ### There is, however, no evidence that such â <PERSOON> role of HDL particles in the regulation of insulin secretion in â Efficiency and safety of drugs increasing or improving HDL-C particles is unclear translate to one case of T#DM when ### patients have been treated for # years Over the same time, statins would prevent <DATUM> CVD statin trials reported that the risk of new onset DM increased with intensive statin (atorvastatin or simvastatin ## mg daily) therapy (OR <DATUM> ##% Cl <DATUM> â# ##; I# ¼ #%), compared with moderate (simvastatin ## mg or pravastatin ## mg) doses ### In the intensive group, observed, whereas the number of CVD events was <DATUM> cases fewer approved label changes on increases of blood glucose and HbA#c small risk of developing DM is clearly outweighed by the reduction demonstrated that, in individuals with a five-year risk of major vascular events lower than ##%, each # mmol/L reduction in LDL-C produced an absolute reduction in major vascular events of about ## per ### over five years, without an increase in incidence of cancer or deaths from other causes This benefit greatly exceeds any and this residual risk is linked to many factors including elevation of FIELD study, fenofibrate therapy did not reduce the primary endpoint (CAD-related death and non-fatal MI), but total CVD events any additional effect on the primary endpoint In a pre-specified subgroup analysis of people with TG <DATUM> mmol/L ( ### mg/dL) and reduced by ##% in the fenofibrate-plus-simvastatin group (for interaction between patients with this lipid profile vs those without, P ¼ a ##% reduction in CVD risk ### In both FIELD and ACCORD, fenofibrate therapy was associated with robust reduction of TG (##%),.
| 659 | nvvc |
### patients have been treated for # years Over the same time, statins would prevent <DATUM> CVD statin trials reported that the risk of new onset DM increased with intensive statin (atorvastatin or simvastatin ## mg daily) therapy (OR <DATUM> ##% Cl <DATUM> â# ##; I# ¼ #%), compared with moderate (simvastatin ## mg or pravastatin ## mg) doses ### In the intensive group, observed, whereas the number of CVD events was <DATUM> cases fewer approved label changes on increases of blood glucose and HbA#c small risk of developing DM is clearly outweighed by the reduction demonstrated that, in individuals with a five-year risk of major vascular events lower than ##%, each # mmol/L reduction in LDL-C produced an absolute reduction in major vascular events of about ## per ### over five years, without an increase in incidence of cancer or deaths from other causes This benefit greatly exceeds any and this residual risk is linked to many factors including elevation of FIELD study, fenofibrate therapy did not reduce the primary endpoint (CAD-related death and non-fatal MI), but total CVD events any additional effect on the primary endpoint In a pre-specified subgroup analysis of people with TG <DATUM> mmol/L ( ### mg/dL) and reduced by ##% in the fenofibrate-plus-simvastatin group (for interaction between patients with this lipid profile vs those without, P ¼ a ##% reduction in CVD risk ### In both FIELD and ACCORD, fenofibrate therapy was associated with robust reduction of TG (##%), associated with increased levels of triglycerides and are often seen <DATUM> # Recommendations on management of dyslipidaemia in diabetes Statin therapy is recommended in patients with T#DM and T#DM at very high-risk (i e if combined with documented CVD, severe CKD or with one or more CV risk factors and/or target organ damage) with an LDL-C target of (<DATUM> mmol/L ((## mg/dL) or at least a â¥##% LDL-C reduction if this target goal cannot be reached Statin therapy is recommended in patients with T#DM at high risk (without any other CV risk factor and free of target Statins may be considered in T#DM patients at high risk for cardiovascular events irrespective of the basal LDL-C It may be considered to have a secondary goal of nonâHDL-C (<DATUM> mmol/L ((### mg/dL) in patients with DM at very <PERSOON> use of drugs that increase HDL-C to prevent CVD in T#DM is not recommended CV ¼ cardiovascular; CVD ¼ cardiovascular disease; DM ¼ diabetes mellitus; HDL-C ¼ high density lipoprotein cholesterol; LDL-C ¼ low-density lipoprotein cholesterol; T#DM ¼ type # diabetes mellitus, T#DM ¼ type # diabetes mellitus Platelet activation plays a pivotal role in the initiation and progression in DM ex vivo have been described by numerous groups,### and both major determinants of in vivo platelet activation in the early and late cyclo-oxygenase # (COX-#) activity ### No formal studies have specifically examined the dose- and time-dependence of its antiplatelet effect.
| 669 | nvvc |
associated with increased levels of triglycerides and are often seen <DATUM> # Recommendations on management of dyslipidaemia in diabetes Statin therapy is recommended in patients with T#DM and T#DM at very high-risk (i e if combined with documented CVD, severe CKD or with one or more CV risk factors and/or target organ damage) with an LDL-C target of (<DATUM> mmol/L ((## mg/dL) or at least a â¥##% LDL-C reduction if this target goal cannot be reached Statin therapy is recommended in patients with T#DM at high risk (without any other CV risk factor and free of target Statins may be considered in T#DM patients at high risk for cardiovascular events irrespective of the basal LDL-C It may be considered to have a secondary goal of nonâHDL-C (<DATUM> mmol/L ((### mg/dL) in patients with DM at very <PERSOON> use of drugs that increase HDL-C to prevent CVD in T#DM is not recommended CV ¼ cardiovascular; CVD ¼ cardiovascular disease; DM ¼ diabetes mellitus; HDL-C ¼ high density lipoprotein cholesterol; LDL-C ¼ low-density lipoprotein cholesterol; T#DM ¼ type # diabetes mellitus, T#DM ¼ type # diabetes mellitus Platelet activation plays a pivotal role in the initiation and progression in DM ex vivo have been described by numerous groups,### and both major determinants of in vivo platelet activation in the early and late cyclo-oxygenase # (COX-#) activity ### No formal studies have specifically examined the dose- and time-dependence of its antiplatelet effect ### mg once daily, i e at the same dose and dosing interval used in low-dose aspirin may be associated with incomplete inhibition of platelet COX-# activity and TXA#-dependent platelet function,### â ### support this view indicates the potentially beneficial effects of sustained eventsâ (non-fatal MI, non-fatal stroke or vascular death) from approximately ### patients with DM in the randomized trials and is no apparent reason to treat patients with DM and CVD differently from non-DM patients and low-dose aspirin is uniformly recommended for both the acute treatment of ischaemic syndromes North American organizations for the primary prevention of cardiovascular events in adults with DM ###,### However, direct evidence of its conducted specifically in patients with DM and six other trials in which such patients represent a subgroup within a broader population, aspirin risk of coronary events (RR # ##; ##% CI # ## â <DATUM> and a nonsignificant ##% reduction in the risk of stroke (RR # ##; ##% CI patients with DM enrolled in these nine trials was <DATUM> with as <DATUM> to as high as #<DATUM> ### These results have been interpreted as suggesting that aspirin probably produces a modest reduction in the risk of cardiovascular events, but the limited amount of available data precludes a precise estimate of the effect size Consistent with this uncertainty, antiplatelet therapy with aspirin in adults at a low CVD risk is not recommended by the Fifth Joint Task Force of.
| 645 | nvvc |
dose and dosing interval used in low-dose aspirin may be associated with incomplete inhibition of platelet COX-# activity and TXA#-dependent platelet function,### â ### support this view indicates the potentially beneficial effects of sustained eventsâ (non-fatal MI, non-fatal stroke or vascular death) from approximately ### patients with DM in the randomized trials and is no apparent reason to treat patients with DM and CVD differently from non-DM patients and low-dose aspirin is uniformly recommended for both the acute treatment of ischaemic syndromes North American organizations for the primary prevention of cardiovascular events in adults with DM ###,### However, direct evidence of its conducted specifically in patients with DM and six other trials in which such patients represent a subgroup within a broader population, aspirin risk of coronary events (RR # ##; ##% CI # ## â <DATUM> and a nonsignificant ##% reduction in the risk of stroke (RR # ##; ##% CI patients with DM enrolled in these nine trials was <DATUM> with as <DATUM> to as high as #<DATUM> ### These results have been interpreted as suggesting that aspirin probably produces a modest reduction in the risk of cardiovascular events, but the limited amount of available data precludes a precise estimate of the effect size Consistent with this uncertainty, antiplatelet therapy with aspirin in adults at a low CVD risk is not recommended by the Fifth Joint Task Force of (ADP) receptor P#Y##, provides a valid alternative for patients who once daily) produced additive cardio-protective effects when combined with low-dose aspirin (##â### mg once daily) in patients (PCI) ### There is, however, evidence from the Clopidogrel for High the general cohort, this benefit carried a risk of increased thrombolysis in myocardial infarction (TIMI) major bleeding ### In a DM substudy, a similar reduction in recurrent ischaemic events was seen, be superior to clopidogrel in ACS patients with renal impairment ### There is no convincing evidence that either clopidogrel or the newer drugs are any more or less effective in people with DM than in those Patients with glucose perturbations are in need of early risk assessment This includes evaluation of (i) risk factors (e g lifestyle habits including testing, stress echocardiography, or myocardial scintigraphy is of a particular concern in the detection of ischaemia in DM Confounders are a and subsequent hyperglycaemia but also the accumulation of cardiovascular risk factors Accordingly, successful risk prevention depends and hazard of aspirin in primary prevention, these results probably represent a best-case scenario, as people at increased risk of gastrointestinal bleeding were excluded and elderly people were underrepresented ### In the same analyses, the presence of DM at baseline also with a ##% increased risk of major extracranial bleeds during ##% ###,### However, relatively little emphasis is placed in either statement on the need to evaluate the variable bleeding risk of the <PERSOON> the annual risk of cardiovascular events can vary approximately ##-fold in DM,### the annual risk of upper gastro-intestinal # ## (##% CI # #â# #; P , # ##).
| 676 | nvvc |
aspirin (##â### mg once daily) in patients (PCI) ### There is, however, evidence from the Clopidogrel for High the general cohort, this benefit carried a risk of increased thrombolysis in myocardial infarction (TIMI) major bleeding ### In a DM substudy, a similar reduction in recurrent ischaemic events was seen, be superior to clopidogrel in ACS patients with renal impairment ### There is no convincing evidence that either clopidogrel or the newer drugs are any more or less effective in people with DM than in those Patients with glucose perturbations are in need of early risk assessment This includes evaluation of (i) risk factors (e g lifestyle habits including testing, stress echocardiography, or myocardial scintigraphy is of a particular concern in the detection of ischaemia in DM Confounders are a and subsequent hyperglycaemia but also the accumulation of cardiovascular risk factors Accordingly, successful risk prevention depends and hazard of aspirin in primary prevention, these results probably represent a best-case scenario, as people at increased risk of gastrointestinal bleeding were excluded and elderly people were underrepresented ### In the same analyses, the presence of DM at baseline also with a ##% increased risk of major extracranial bleeds during ##% ###,### However, relatively little emphasis is placed in either statement on the need to evaluate the variable bleeding risk of the <PERSOON> the annual risk of cardiovascular events can vary approximately ##-fold in DM,### the annual risk of upper gastro-intestinal # ## (##% CI # #â# #; P , # ##) In addition, there was a substantial reduction was reported as more cost-effective than conventional care Since increased expenses relating to intensive care were driven by pharmacy and consultation costs, such treatment would be dominant (i e costand life-saving with the use of generic drugs in a primary care Data from the Euro Heart Survey on Diabetes and the Heart support a multifactorial approach as a cornerstone of patient management Among ### patients with known T#DM and CAD, ##% received evidence-based pharmacological therapy, defined as a combination of aspirin, beta-blockade, RAAS inhibitors and statins in the after one year of follow up, compared with those who did not use of evidence-based treatment in T#DM had an independent protective effect (HR for death # #) <PERSOON> example of the inadequacy of a single drug approach to decrease the incidence of CVD originates Table ## Summary of treatment targets for managing patients with diabetes mellitus or impaired glucose tolerance Very high risk patients (<DATUM> mmol/L ((## mg/dL) or reduced by at least ##% Aim for weight stabilization in the overweight or obese DM patients based on calorie balance, and weight reduction in subjects with IGT to prevent development of T#DM CVD ¼ cardiovascular disease; DM ¼ diabetes mellitus; HbA#c ¼ glycated haemoglobin A#c; IGT ¼ impaired glucose tolerance; LDL ¼ low density lipoprotein; with T#DM in general practice was studied in the AngloDanish-Dutch Study of Intensive Treatment in People With Screen # ##â# ##).
| 647 | nvvc |
In addition, there was a substantial reduction was reported as more cost-effective than conventional care Since increased expenses relating to intensive care were driven by pharmacy and consultation costs, such treatment would be dominant (i e costand life-saving with the use of generic drugs in a primary care Data from the Euro Heart Survey on Diabetes and the Heart support a multifactorial approach as a cornerstone of patient management Among ### patients with known T#DM and CAD, ##% received evidence-based pharmacological therapy, defined as a combination of aspirin, beta-blockade, RAAS inhibitors and statins in the after one year of follow up, compared with those who did not use of evidence-based treatment in T#DM had an independent protective effect (HR for death # #) <PERSOON> example of the inadequacy of a single drug approach to decrease the incidence of CVD originates Table ## Summary of treatment targets for managing patients with diabetes mellitus or impaired glucose tolerance Very high risk patients (<DATUM> mmol/L ((## mg/dL) or reduced by at least ##% Aim for weight stabilization in the overweight or obese DM patients based on calorie balance, and weight reduction in subjects with IGT to prevent development of T#DM CVD ¼ cardiovascular disease; DM ¼ diabetes mellitus; HbA#c ¼ glycated haemoglobin A#c; IGT ¼ impaired glucose tolerance; LDL ¼ low density lipoprotein; with T#DM in general practice was studied in the AngloDanish-Dutch Study of Intensive Treatment in People With Screen # ##â# ##) only slightly better control of important cardiovascular risk factors (HbA#c, cholesterol concentrations and blood pressure) in the intensive group In contrast, the value of a multifactorial intervention in by the STENO # study which, in a highly specialized setting, randomized ### participants to an intensive, target-driven multifactorial group, their overall management was considerably better than in routinely handled patients This resulted in a reduction in microvascular and macrovascular events of about ##% after <DATUM> years of follow-up <PERSOON> target most successfully attained was that for cholesterol, probably making crucial the role of statins in the overall prevention strategy ###,### Subsequently, target-driven therapy was recommended to patients in both groups They were followed for ## years after randomization By that time, patients originally allocated to the intensively â Pleiotropic effects of glucose-lowering therapies on CVD outcomes are not fully understood DM is associated with a poorer prognosis in patients with acute and stable CAD ### â ### This is apparent in patients with newly All patients with CAD, without previously known glucose perturbations, should, for the purpose of risk stratification and adapted but a normal value does not exclude glucose abnormalities Accordingly, and as detailed in Section <DATUM> the appropriate screening not be performed earlier than #â# days after an acute coronary outcome is still poor amongst patients with <PERSOON> reasons are partially unexplained but a higher prevalence of complications, in As outlined in current European guidelines on patients with CAD, different levels of recommendations and different levels of evidence.
| 627 | nvvc |
(HbA#c, cholesterol concentrations and blood pressure) in the intensive group In contrast, the value of a multifactorial intervention in by the STENO # study which, in a highly specialized setting, randomized ### participants to an intensive, target-driven multifactorial group, their overall management was considerably better than in routinely handled patients This resulted in a reduction in microvascular and macrovascular events of about ##% after <DATUM> years of follow-up <PERSOON> target most successfully attained was that for cholesterol, probably making crucial the role of statins in the overall prevention strategy ###,### Subsequently, target-driven therapy was recommended to patients in both groups They were followed for ## years after randomization By that time, patients originally allocated to the intensively â Pleiotropic effects of glucose-lowering therapies on CVD outcomes are not fully understood DM is associated with a poorer prognosis in patients with acute and stable CAD ### â ### This is apparent in patients with newly All patients with CAD, without previously known glucose perturbations, should, for the purpose of risk stratification and adapted but a normal value does not exclude glucose abnormalities Accordingly, and as detailed in Section <DATUM> the appropriate screening not be performed earlier than #â# days after an acute coronary outcome is still poor amongst patients with <PERSOON> reasons are partially unexplained but a higher prevalence of complications, in As outlined in current European guidelines on patients with CAD, different levels of recommendations and different levels of evidence and ventricular arrhythmias ###,### Beta-blockers may have negative metabolic effectsâfor example, by increasing IR and masking with modulation synthesis of NO, nebivolol), with the latter advocated as having a better glucometabolic profile ### Overall the positive effects of beta-blockade on prognosis outweigh the negative Treatment with ACE-I or ARB should be started during hospitalization for ACS and continued thereafter in patients with DM and left are also recommended an <PERSOON>) study showed a ##% reduction in MI, DM ### A proportionately similar trend to benefit was observed in the subgroup of patients with DM in the EUropean trial on Reduction Of cardiac events with Perindopril in stable coronary Artery disease (EUROPA) trial, recruiting a population at lower similar to that in HOPE In this head-to-head comparison, telmisartan was found to be equivalent to ramipril as regards the primary Since very few pharmacological trials have been directed towards patients with DM, information on treatment efficacy is frequently the risk of looking at groups of patients with DM considered suitable for the trial but in which the DM phenotypes are not well defined favours a proportionately similar efficacy of cardiovascular risk management in DM and non-DM patients Considering the higher risk for of the two drugs caused adverse events without any increase in <PERSOON> specific, heart-rate lowering, anti-anginal drug ivabradine inhibits the If currentâthe primary modulator of spontaneous diastolic depolarization in the sinus node.
| 590 | nvvc |
may have negative metabolic effectsâfor example, by increasing IR and masking with modulation synthesis of NO, nebivolol), with the latter advocated as having a better glucometabolic profile ### Overall the positive effects of beta-blockade on prognosis outweigh the negative Treatment with ACE-I or ARB should be started during hospitalization for ACS and continued thereafter in patients with DM and left are also recommended an <PERSOON>) study showed a ##% reduction in MI, DM ### A proportionately similar trend to benefit was observed in the subgroup of patients with DM in the EUropean trial on Reduction Of cardiac events with Perindopril in stable coronary Artery disease (EUROPA) trial, recruiting a population at lower similar to that in HOPE In this head-to-head comparison, telmisartan was found to be equivalent to ramipril as regards the primary Since very few pharmacological trials have been directed towards patients with DM, information on treatment efficacy is frequently the risk of looking at groups of patients with DM considered suitable for the trial but in which the DM phenotypes are not well defined favours a proportionately similar efficacy of cardiovascular risk management in DM and non-DM patients Considering the higher risk for of the two drugs caused adverse events without any increase in <PERSOON> specific, heart-rate lowering, anti-anginal drug ivabradine inhibits the If currentâthe primary modulator of spontaneous diastolic depolarization in the sinus node heart rate ## bpm, especially if there is also left ventricular (LV) dysfunction It can be used in selected patients with non-ST elevation ACS in the event of beta-blocker intolerance, or insufficient dose ###,### High heart rate is associated with a worse outcome in patients with DM,### and ivabradine is effective in preventing angina in these patients without any safety concerns or adverse reduces the risk of stroke, MI or vascular death, although the benefits Other antiplatelet drugs, such as thienopyridines (ticlopidine, clopidogrel, prasugrel and ticagrelor) reduce the risk of cardiovascular events when added to aspirin in patients with <PERSOON> incidence of cardiovascular death, MI or stroke decreased from <DATUM> to patients with DM ### In the Clopidogrel vs Aspirin in Patients at those randomized to clopidogrel and <DATUM> in those who received event rates in patients with DM, the absolute benefit of clopidogrel is amplified in this clinical setting ### In a subgroup analysis of the TRITON trial, patients with DM tended to have a greater major bleeding, with prasugrel than with clopidogrel ### It is important to acknowledge that many trials do not separately are based on available evidence from trials including patients Hyperglycaemia may relate to previously undetected glucose perturbations, but also to stress-induced catecholamine release increasing FFA concentrations, decreased insulin production and increasing IR and glycogenolysis,### with a negative impact on myocardial metabolism and function (for details see Section #) Two strategies have been tested in an attempt to improve the prognosis.
| 575 | nvvc |
in selected patients with non-ST elevation ACS in the event of beta-blocker intolerance, or insufficient dose ###,### High heart rate is associated with a worse outcome in patients with DM,### and ivabradine is effective in preventing angina in these patients without any safety concerns or adverse reduces the risk of stroke, MI or vascular death, although the benefits Other antiplatelet drugs, such as thienopyridines (ticlopidine, clopidogrel, prasugrel and ticagrelor) reduce the risk of cardiovascular events when added to aspirin in patients with <PERSOON> incidence of cardiovascular death, MI or stroke decreased from <DATUM> to patients with DM ### In the Clopidogrel vs Aspirin in Patients at those randomized to clopidogrel and <DATUM> in those who received event rates in patients with DM, the absolute benefit of clopidogrel is amplified in this clinical setting ### In a subgroup analysis of the TRITON trial, patients with DM tended to have a greater major bleeding, with prasugrel than with clopidogrel ### It is important to acknowledge that many trials do not separately are based on available evidence from trials including patients Hyperglycaemia may relate to previously undetected glucose perturbations, but also to stress-induced catecholamine release increasing FFA concentrations, decreased insulin production and increasing IR and glycogenolysis,### with a negative impact on myocardial metabolism and function (for details see Section #) Two strategies have been tested in an attempt to improve the prognosis ### improved use of glucose for energy production and improved endothelial function and fibrinolysis ### RCTs failed to show mortality or of effect may be due to increased PG or negative effects of the fluid load induced by the GIK-infusion <PERSOON> Immediate Myocardial Metabolic Enhancement During Initial Assessment and Treatment in (DIGAMI)###,#<DATUM> and # and âHyperglycaemia Intensive Insulin Infusion in <PERSOON> first DIGAMI trial randomized ### patients with DM and acute MI to a â¥##-h insulin â glucose infusion, followed by multi-dose insulin, or to routine glucoselowering therapy ### Mortality after <DATUM> years was ##% in the There is no evidence for a prognostic impact of nitrates but they may be used for symptomatic relief ###,###,### Calcium channel blockers conduction disturbances or compromised LV function <PERSOON> alternative is the use of a dihydropyridine calcium channel blocker, such as â <PERSOON> role and optimum level of glycaemic control in the outcome in â Is it possible to reduce final infarct size by means of very early GIK A quarter of myocardial revascularization procedures are performed in patients with DM Revascularization in these patients is challenged admission HbA#c decreased more (<DATUM> ), from a higher level (<DATUM> ), compared with # #% from <DATUM> in DIGAMI <DATUM> In addition, the use of beta-blockade, statins and revascularization was <PERSOON> difference in glucose levels between the control and insulin groups in the HI-# study was small and there was no reduction in from the three studies confirmed that insulin â glucose infusion P ¼ # ###) ###.
| 641 | nvvc |
of effect may be due to increased PG or negative effects of the fluid load induced by the GIK-infusion <PERSOON> Immediate Myocardial Metabolic Enhancement During Initial Assessment and Treatment in (DIGAMI)###,#<DATUM> and # and âHyperglycaemia Intensive Insulin Infusion in <PERSOON> first DIGAMI trial randomized ### patients with DM and acute MI to a â¥##-h insulin â glucose infusion, followed by multi-dose insulin, or to routine glucoselowering therapy ### Mortality after <DATUM> years was ##% in the There is no evidence for a prognostic impact of nitrates but they may be used for symptomatic relief ###,###,### Calcium channel blockers conduction disturbances or compromised LV function <PERSOON> alternative is the use of a dihydropyridine calcium channel blocker, such as â <PERSOON> role and optimum level of glycaemic control in the outcome in â Is it possible to reduce final infarct size by means of very early GIK A quarter of myocardial revascularization procedures are performed in patients with DM Revascularization in these patients is challenged admission HbA#c decreased more (<DATUM> ), from a higher level (<DATUM> ), compared with # #% from <DATUM> in DIGAMI <DATUM> In addition, the use of beta-blockade, statins and revascularization was <PERSOON> difference in glucose levels between the control and insulin groups in the HI-# study was small and there was no reduction in from the three studies confirmed that insulin â glucose infusion <PERSOON>#D compared the effects of prandial (pre-meal insulin release, may aggravate myocardial ischaemia and provoke arrhythmias ###,### Recent data indicate that hypoglycaemic episodes identify patients at risk for other reasons (e g heart failure, renal remain as an independent risk factor when correcting for such variables ###,### acute MI will benefit from glycaemic control if hyperglycaemia is significant ( ## mmol/L or ### mg/dL) <PERSOON> approximation achieve rapid glucose control Glucose management in the longterm perspective is presented elsewhere in these guidelines higher propensity to develop re-stenosis after PCI and saphenous graft occlusion after coronary artery bypass graft surgery (CABG) This results in a higher risk, including long-term mortality, than seen in in patients with DM has been obtained in the shifting context of a continued development of PCI, CABG and pharmacological treatments, bypass graft or percutaneous coronary intervention by diabetes status in an analysis of ## randomized trials Reproduced with permission from Hlatky et al ### Stable coronary artery disease A randomized comparison of myocardial revascularization, either with CABG or PCI, vs optimal PCI or CABG had been chosen as the most adequate potential revascularization technique, patients were randomized to OMT alone or to revascularization plus OMT After five years, no significant differences were noted in the combined endpoint of death, MI or stroke surgical group, freedom from major adverse cardiac and cerebrovascular events (MACCE) was significantly higher with CABG (##%) than with OMT alone (##%, P ¼ # ##), but there was no difference stratum, there were no significant differences in MACCE or survival.
| 654 | nvvc |
ischaemia and provoke arrhythmias ###,### Recent data indicate that hypoglycaemic episodes identify patients at risk for other reasons (e g heart failure, renal remain as an independent risk factor when correcting for such variables ###,### acute MI will benefit from glycaemic control if hyperglycaemia is significant ( ## mmol/L or ### mg/dL) <PERSOON> approximation achieve rapid glucose control Glucose management in the longterm perspective is presented elsewhere in these guidelines higher propensity to develop re-stenosis after PCI and saphenous graft occlusion after coronary artery bypass graft surgery (CABG) This results in a higher risk, including long-term mortality, than seen in in patients with DM has been obtained in the shifting context of a continued development of PCI, CABG and pharmacological treatments, bypass graft or percutaneous coronary intervention by diabetes status in an analysis of ## randomized trials Reproduced with permission from Hlatky et al ### Stable coronary artery disease A randomized comparison of myocardial revascularization, either with CABG or PCI, vs optimal PCI or CABG had been chosen as the most adequate potential revascularization technique, patients were randomized to OMT alone or to revascularization plus OMT After five years, no significant differences were noted in the combined endpoint of death, MI or stroke surgical group, freedom from major adverse cardiac and cerebrovascular events (MACCE) was significantly higher with CABG (##%) than with OMT alone (##%, P ¼ # ##), but there was no difference stratum, there were no significant differences in MACCE or survival for symptomatic reasons, compared with ##% in the revascularization stratum, showing that an initial conservative strategy with Higher repeat revascularization rates after PCI have been consistently found in DM patients included in RCTs comparing CABG and PCI A meta-analysis based on individual data from ## RCTs (### patients) comparing both types of revascularizations suggests a distinct survival advantage for CABG in DM patients (Figure <DATUM> ### Fiveyear mortality was ##% with PCI, compared with ##% with CABG (odds ratio # #; ##% CI # # â# #), whereas no difference was found DM and type of revascularization was significant A specific comparison of the efficacy and safety of PCI and CABG in patients with DM was performed in the Coronary Artery Revascularization in Diabetes coincided with the enrolment period, leading to a mixed use of baremetal stents (BMS) (##%) and DES (##%) After one year there was a (driven by a higher rate of MI) and significantly higher rates of repeat revascularization in the PCI group (# vs ##%, <PERSOON> conclusions of the study were hampered by the limited size of the study Overall, except in specific situations such as left main coronary artery stenosis â¥##%, proximal LAD stenosis or triple vessel patients with DM did not improve survival when compared with practice, it should be kept in mind that the results were obtained in a selected population Patients were excluded if they required immediate revascularization or had left main coronary disease, a creatinine.
| 642 | nvvc |
compared with ##% in the revascularization stratum, showing that an initial conservative strategy with Higher repeat revascularization rates after PCI have been consistently found in DM patients included in RCTs comparing CABG and PCI A meta-analysis based on individual data from ## RCTs (### patients) comparing both types of revascularizations suggests a distinct survival advantage for CABG in DM patients (Figure <DATUM> ### Fiveyear mortality was ##% with PCI, compared with ##% with CABG (odds ratio # #; ##% CI # # â# #), whereas no difference was found DM and type of revascularization was significant A specific comparison of the efficacy and safety of PCI and CABG in patients with DM was performed in the Coronary Artery Revascularization in Diabetes coincided with the enrolment period, leading to a mixed use of baremetal stents (BMS) (##%) and DES (##%) After one year there was a (driven by a higher rate of MI) and significantly higher rates of repeat revascularization in the PCI group (# vs ##%, <PERSOON> conclusions of the study were hampered by the limited size of the study Overall, except in specific situations such as left main coronary artery stenosis â¥##%, proximal LAD stenosis or triple vessel patients with DM did not improve survival when compared with practice, it should be kept in mind that the results were obtained in a selected population Patients were excluded if they required immediate revascularization or had left main coronary disease, a creatinine myocardial revascularization and the presence of DM has been documented in trials on non-ST-elevation ACS management ### â ### <PERSOON> of these studies,###,###,### with a greater benefit in patients with DM in the Treat angina with Aggrastat and determine Cost of Therapy with an Invasive or Conservative Strategy-Thrombolysis In Myocardial Infarction (TACTICS-TIMI ##) trial ### In STEMI patients, a pooled analysis of individual patient data (n ¼ ###) from ## RCTs comparing primary PCI with fibrinolysis showed that patients with DM (n ¼ ###; ##%) treated with reperfusion had an increased mortality, compared with those without <PERSOON> benefits of a primary PCI, compared with fibrinolysis were, however, consistent in patients initiation of reperfusion treatments and longer ischaemic times, probably related to atypical symptoms causing significant delays in the time Owing to a higher absolute risk, the NNT to <INSTELLING> one life at ## days DM patients included in the Occluded Artery Trial (OAT) confirmed #<DATUM> patients undergoing PCI from ### to ###, four-year survival was significantly higher with surgery and the association of study reported on the long-term outcome of ### patients with unprotected left main stenosis, treated with DES or CABG In this specific setting, there was a similar rate of the composite endpoint death, without DM did not reveal significant interactions between treatment outcomes and the presence or absence of DM after adjustment Newer-generation stents could be used as long as the FDA approved MI or stroke After a median of #.
| 651 | nvvc |
presence of DM has been documented in trials on non-ST-elevation ACS management ### â ### <PERSOON> of these studies,###,###,### with a greater benefit in patients with DM in the Treat angina with Aggrastat and determine Cost of Therapy with an Invasive or Conservative Strategy-Thrombolysis In Myocardial Infarction (TACTICS-TIMI ##) trial ### In STEMI patients, a pooled analysis of individual patient data (n ¼ ###) from ## RCTs comparing primary PCI with fibrinolysis showed that patients with DM (n ¼ ###; ##%) treated with reperfusion had an increased mortality, compared with those without <PERSOON> benefits of a primary PCI, compared with fibrinolysis were, however, consistent in patients initiation of reperfusion treatments and longer ischaemic times, probably related to atypical symptoms causing significant delays in the time Owing to a higher absolute risk, the NNT to <INSTELLING> one life at ## days DM patients included in the Occluded Artery Trial (OAT) confirmed #<DATUM> patients undergoing PCI from ### to ###, four-year survival was significantly higher with surgery and the association of study reported on the long-term outcome of ### patients with unprotected left main stenosis, treated with DES or CABG In this specific setting, there was a similar rate of the composite endpoint death, without DM did not reveal significant interactions between treatment outcomes and the presence or absence of DM after adjustment Newer-generation stents could be used as long as the FDA approved MI or stroke After a median of # ###), with a five-year of CABG was driven by differences in both MI (P , # ###) and mortality (<PERSOON> estimates of the primary outcome and death A rates of the composite primary outcome of death, myocardial infarction or stroke and B death from any cause truncated at five years after randomization <PERSOON> P-value was calculated by means of the log-rank test on the basis of all available follow-up data Reproduced by permission from Farkouh et al ### <PERSOON> literature on CABG vs PCI is confused by confounder bias in Future REvascularization Evaluation in patients with Diabetes mellitus Optimal management of Multivessel disease (FREEDOM) trial, a lack of prospective <PERSOON> implication is that much of the available information has to be derived from subgroup analyses in trials in populations in which patients with DM may be relatively few or selected As a consequence of increased repeat revascularization in the SYNTAX the rate of MACCE after one year was twice as high with PCI as it risk for repeat revascularization after one year was even higher (RR lesions, i e high SYNergy between percutaneous coronary intervention with TAXus and cardiac surgery (SYNTAX) scores, one-year #%; <PERSOON> five years of follow-up, the rates of MACCE Extremely Serious Operative Mortality Evaluation (AWESOME) randomized trial and registry, which included high-risk patients for balloon pump treatment), showed no significant difference in threeyear mortality between revascularization techniques ### Data.
| 625 | nvvc |
both MI (P , # ###) and mortality (<PERSOON> estimates of the primary outcome and death A rates of the composite primary outcome of death, myocardial infarction or stroke and B death from any cause truncated at five years after randomization <PERSOON> P-value was calculated by means of the log-rank test on the basis of all available follow-up data Reproduced by permission from Farkouh et al ### <PERSOON> literature on CABG vs PCI is confused by confounder bias in Future REvascularization Evaluation in patients with Diabetes mellitus Optimal management of Multivessel disease (FREEDOM) trial, a lack of prospective <PERSOON> implication is that much of the available information has to be derived from subgroup analyses in trials in populations in which patients with DM may be relatively few or selected As a consequence of increased repeat revascularization in the SYNTAX the rate of MACCE after one year was twice as high with PCI as it risk for repeat revascularization after one year was even higher (RR lesions, i e high SYNergy between percutaneous coronary intervention with TAXus and cardiac surgery (SYNTAX) scores, one-year #%; <PERSOON> five years of follow-up, the rates of MACCE Extremely Serious Operative Mortality Evaluation (AWESOME) randomized trial and registry, which included high-risk patients for balloon pump treatment), showed no significant difference in threeyear mortality between revascularization techniques ### Data with DM treated with CABG, compared with DES, even in terms It was concluded that CABG is superior to PCI for patients with DM and advanced CAD There was no significant interaction based on SYNTAX score, since the absolute difference in the primary end points between PCI and CABG were similar in patients with low, intermediate and high SYNTAX scores Given the wide variability of the patients enrolled in FREEDOM, the trial represents realworld practice Further analysis revealed that CABG was a costeffective strategy, compared with PCI ###,### It can be concluded Although hypoglycaemic medications may influence the safety of coronary angiography, as well as early and late outcomes of revascularization with PCI or CABG, few trials have addressed interactions with <PERSOON> plasma half-life of metformin is <DATUM> h There is no adequate scientific support for the frequent practice of stopping metformin ## to ## h prior to angiography or PCI because of a potential risk of lactic recommendations are less restrictive ### Rather than stopping metformin treatment in all patients, a reasonable approach is to carefully monitor renal function after the procedure and to withhold metformin for ## h if it deteriorates and until renal function has resumed its Observational data reported concern over the use of sulphonylureas in patients treated with primary PCI for acute MI this has not been might be associated with lower re-stenosis rates after PCI with BMS,### but carry an increased risk of heart failure due to water retention in the kidney (see also Section <DATUM> #).
| 580 | nvvc |
with DES, even in terms It was concluded that CABG is superior to PCI for patients with DM and advanced CAD There was no significant interaction based on SYNTAX score, since the absolute difference in the primary end points between PCI and CABG were similar in patients with low, intermediate and high SYNTAX scores Given the wide variability of the patients enrolled in FREEDOM, the trial represents realworld practice Further analysis revealed that CABG was a costeffective strategy, compared with PCI ###,### It can be concluded Although hypoglycaemic medications may influence the safety of coronary angiography, as well as early and late outcomes of revascularization with PCI or CABG, few trials have addressed interactions with <PERSOON> plasma half-life of metformin is <DATUM> h There is no adequate scientific support for the frequent practice of stopping metformin ## to ## h prior to angiography or PCI because of a potential risk of lactic recommendations are less restrictive ### Rather than stopping metformin treatment in all patients, a reasonable approach is to carefully monitor renal function after the procedure and to withhold metformin for ## h if it deteriorates and until renal function has resumed its Observational data reported concern over the use of sulphonylureas in patients treated with primary PCI for acute MI this has not been might be associated with lower re-stenosis rates after PCI with BMS,### but carry an increased risk of heart failure due to water retention in the kidney (see also Section <DATUM> #) insulin infusion to achieve moderately tight glycaemic control (<DATUM> lower mortality and major complications than that observed after #D trial, outcomes were similar in patients receiving insulin sensitization vs insulin provision to control blood glucose In the CABG stratum, administration of insulin was associated with more cardiovascular events than insulin-sensitization medications ###,### â <PERSOON> role and optimum level of glycaemic control in the outcome <PERSOON> DIABETES trial demonstrated a ##% reduction in target vessel for paclitaxel), provided that dual antiplatelet therapy after DES implantation was continued for # months <PERSOON> risk of death associated with sirolimus-eluting stents was more than twice that associated with BMS in eight trials employing dual antiplatelet therapy for period of less more than six months <PERSOON> analysis of registry data from the National Heart, Lung and Blood Institute Dynamic Registry revealed that, compared with BMS, DES were associated with fewer repeat revascularizationsâto a similar extent in insulin-treated or non-insulin-treated not superior in terms of target lesion failure after one year of follow-up those without DM ###,###,### Initial trials in glycoprotein IIb/IIIa inhibitors reported an interaction with DM, but this was not confirmed in performed in the clopidogrel era ### Prasugrel is superior to clopidogrel in reducing the composite endpoint of cardiovascular death or MI or stroke without excess major bleeding Similarly ticagrelor, in comparison with clopidogrel in the PLATelet inhibition and <PERSOON>) trial, reduced the rate of ischaemic events in ACS.
| 598 | nvvc |
infusion to achieve moderately tight glycaemic control (<DATUM> lower mortality and major complications than that observed after #D trial, outcomes were similar in patients receiving insulin sensitization vs insulin provision to control blood glucose In the CABG stratum, administration of insulin was associated with more cardiovascular events than insulin-sensitization medications ###,### â <PERSOON> role and optimum level of glycaemic control in the outcome <PERSOON> DIABETES trial demonstrated a ##% reduction in target vessel for paclitaxel), provided that dual antiplatelet therapy after DES implantation was continued for # months <PERSOON> risk of death associated with sirolimus-eluting stents was more than twice that associated with BMS in eight trials employing dual antiplatelet therapy for period of less more than six months <PERSOON> analysis of registry data from the National Heart, Lung and Blood Institute Dynamic Registry revealed that, compared with BMS, DES were associated with fewer repeat revascularizationsâto a similar extent in insulin-treated or non-insulin-treated not superior in terms of target lesion failure after one year of follow-up those without DM ###,###,### Initial trials in glycoprotein IIb/IIIa inhibitors reported an interaction with DM, but this was not confirmed in performed in the clopidogrel era ### Prasugrel is superior to clopidogrel in reducing the composite endpoint of cardiovascular death or MI or stroke without excess major bleeding Similarly ticagrelor, in comparison with clopidogrel in the PLATelet inhibition and <PERSOON>) trial, reduced the rate of ischaemic events in ACS ###,### Patients with DM who undergo CABG usually have extensive regarding the use of one vs two internal thoracic artery (ITA) conduits in DM Although observational evidence suggests that using bilateral ITA conduits improves patient outcome without compromising sternal stability, their use is still under debate, given DM ### A recent meta-analysis has shown that ITA harvesting by skeletonization (without the satellite veins and fascia) reduces the risk of sternal wound infection, in particular in DM patients undergoing bilateral ITA grafting,### although there are no randomized studies on CABG with bilateral ITA and PCI in DM reported improved outcomes (freedom from angina, re-intervention, or composite major after cardiac surgery may not have been diagnosed as having DM <DATUM> # Recommendations for coronary revascularization of patients with diabetes CABG is recommended in patients with DM and multivessel or complex (SYNTAX Score )##) CAD to improve PCI for symptom control may be considered as an alternative to CABG in patients with DM and less complex In DM patients subjected to PCI, DES rather than BMS are recommended to reduce risk of target vessel Renal function should be carefully monitored after coronary angiography/PCI in all patients on metformin If renal function deteriorates in patients on metformin undergoing coronary angiography/PCI it is recommended to withhold treatment for ## h or until renal function has returned to its initial level Optimal medical treatment should be considered as preferred treatment in patients with stable CAD and DM.
| 589 | nvvc |
use of one vs two internal thoracic artery (ITA) conduits in DM Although observational evidence suggests that using bilateral ITA conduits improves patient outcome without compromising sternal stability, their use is still under debate, given DM ### A recent meta-analysis has shown that ITA harvesting by skeletonization (without the satellite veins and fascia) reduces the risk of sternal wound infection, in particular in DM patients undergoing bilateral ITA grafting,### although there are no randomized studies on CABG with bilateral ITA and PCI in DM reported improved outcomes (freedom from angina, re-intervention, or composite major after cardiac surgery may not have been diagnosed as having DM <DATUM> # Recommendations for coronary revascularization of patients with diabetes CABG is recommended in patients with DM and multivessel or complex (SYNTAX Score )##) CAD to improve PCI for symptom control may be considered as an alternative to CABG in patients with DM and less complex In DM patients subjected to PCI, DES rather than BMS are recommended to reduce risk of target vessel Renal function should be carefully monitored after coronary angiography/PCI in all patients on metformin If renal function deteriorates in patients on metformin undergoing coronary angiography/PCI it is recommended to withhold treatment for ## h or until renal function has returned to its initial level Optimal medical treatment should be considered as preferred treatment in patients with stable CAD and DM descending coronary artery; PCI ¼ percutaneous coronary intervention; STEMI ¼ ST-elevation myocardial infarction Heart failure and T#DM frequently co-exist, each adversely affecting heart failure is common in patients with DM, among which CAD has led to recognition of a clinical entity labelled as DM cardiomyopathy, in which compromised diastolic function is an early feature <PERSOON> analysis of ### patients with heart failure and preserved LVEF, enrolled in the Digitalis Investigation Group (DIG) ancillary study,### revealed that T#DM was associated with significantly increased risk to cardiomyopathy includes echocardiographic assessment of LV diastolic dysfunction, which can worsen during physical exercise ### Insulin resistance, which characterizes the heart failure syndrome, regardless of aetiology, seems to be an important factor behind the elevated risk of DM development among heart failure patients Despite of these co-existing conditions is still not fully evidence-based owing to a lack of clinical trials specifically addressing such patient populations Studies in heart failure populations reveal a prevalence of T#DM risk factor for the development of heart failure In the Framingham study, the relative risk of heart failure in patients with T#DM (age unknown heart failure; #% with reduced LVEF and ##% with preserved <PERSOON> prevalence increased rapidly with age, and heart failure with preserved LVEF was more common in women than This underlines the importance of looking for signs and symptoms Several clinical correlates are independent risk factors for the development of heart failure in T#DM, including high HbA#c, increased and duration of T#DM were associated with heart failure and its reviewed by McDonald et al , it is higher in people with symptomatic.
| 585 | nvvc |
affecting heart failure is common in patients with DM, among which CAD has led to recognition of a clinical entity labelled as DM cardiomyopathy, in which compromised diastolic function is an early feature <PERSOON> analysis of ### patients with heart failure and preserved LVEF, enrolled in the Digitalis Investigation Group (DIG) ancillary study,### revealed that T#DM was associated with significantly increased risk to cardiomyopathy includes echocardiographic assessment of LV diastolic dysfunction, which can worsen during physical exercise ### Insulin resistance, which characterizes the heart failure syndrome, regardless of aetiology, seems to be an important factor behind the elevated risk of DM development among heart failure patients Despite of these co-existing conditions is still not fully evidence-based owing to a lack of clinical trials specifically addressing such patient populations Studies in heart failure populations reveal a prevalence of T#DM risk factor for the development of heart failure In the Framingham study, the relative risk of heart failure in patients with T#DM (age unknown heart failure; #% with reduced LVEF and ##% with preserved <PERSOON> prevalence increased rapidly with age, and heart failure with preserved LVEF was more common in women than This underlines the importance of looking for signs and symptoms Several clinical correlates are independent risk factors for the development of heart failure in T#DM, including high HbA#c, increased and duration of T#DM were associated with heart failure and its reviewed by McDonald et al , it is higher in people with symptomatic T#DM in the Hypertension, Microalbuminuria or Proteinuria, Cardiovascular Events and Ramipril (DIABHYCAR) trial, investigating T#DM increased the risk of hospitalization in patients with heart patients with heart failure and T#DM had one-year hospitalization T#DM resulted in a ##-fold higher annual mortality than among patients with T#DM but without heart failure (## vs #%) ### BEST and Studies Of Left Ventricular Dysfunction (SOLVD) reported ON Dofetilide (DIAMOND) and Candesartan in Heart Failure Assessment of Reduction in Mortality and Morbidity (CHARM) trials Three neurohormonal antagonistsâan ACE-I or ARB, a betablocker and a mineralocorticoid receptor antagonist (MRA)â of all patients with systolic heart failure, including those with DM They are usually combined with a diuretic for relieving congestion trial, using enalapril, showed a significant mortality reduction in DM the Assessment of Treatment with Lisinopril And Survival (ATLAS) Subgroup analyses of clinical trials indicate that the beneficial ACE-I and ARBs should not be combined in patients with an LVEF ESC heart failure Guidelines, such patients should be prescribed an MRA (see below), which causes a larger morbidity and mortality reduction than that following addition of an ARB ### When ACE-I and ARBs are used in patients with DM, surveillance ARB) a beta-blocker should be given to all patients with an LVEF failure trials indicate that the RR of mortality in patients with DM receiving a beta-blocker was significantly improved (# ## vs with T#DM are less likely to be discharged from hospital on a betablocker (OR # ##; ##% CI # ##â# ##) than non-DM with heart.
| 626 | nvvc |
Cardiovascular Events and Ramipril (DIABHYCAR) trial, investigating T#DM increased the risk of hospitalization in patients with heart patients with heart failure and T#DM had one-year hospitalization T#DM resulted in a ##-fold higher annual mortality than among patients with T#DM but without heart failure (## vs #%) ### BEST and Studies Of Left Ventricular Dysfunction (SOLVD) reported ON Dofetilide (DIAMOND) and Candesartan in Heart Failure Assessment of Reduction in Mortality and Morbidity (CHARM) trials Three neurohormonal antagonistsâan ACE-I or ARB, a betablocker and a mineralocorticoid receptor antagonist (MRA)â of all patients with systolic heart failure, including those with DM They are usually combined with a diuretic for relieving congestion trial, using enalapril, showed a significant mortality reduction in DM the Assessment of Treatment with Lisinopril And Survival (ATLAS) Subgroup analyses of clinical trials indicate that the beneficial ACE-I and ARBs should not be combined in patients with an LVEF ESC heart failure Guidelines, such patients should be prescribed an MRA (see below), which causes a larger morbidity and mortality reduction than that following addition of an ARB ### When ACE-I and ARBs are used in patients with DM, surveillance ARB) a beta-blocker should be given to all patients with an LVEF failure trials indicate that the RR of mortality in patients with DM receiving a beta-blocker was significantly improved (# ## vs with T#DM are less likely to be discharged from hospital on a betablocker (OR # ##; ##% CI # ##â# ##) than non-DM with heart the general population It should be noted that the prevalence of DM patients is lower in heart failure trials, indicating a selection the incidence of DM in heart failure populations is sparse but, in an heart failure ### When people with two or more visits in the Reykjavik did not predict each other independently, although fasting glucose and BMI were significant risk factors, both for glucose disturbances mayâeven in the absence of other risk factors such as CAD, valvular and DM makes the contribution of the glucometabolic state to the diastolic dysfunction difficult to isolate <PERSOON> pathogenic mechanisms involve interstitial fibrosis, leading to impaired calcium homeostasis and impaired myocardial insulin signalling (See Section # for further details and references) These perturbations increase myocardial stiffness and reduce transmitral inflow of blood and tissue Doppler imaging of the mitral annulus Deteriorating diastolic dysfunction is associated with a progressive increase in LV filling pressure which, in turn, has an impact on the transmitral flow pattern ### It has been claimedâbut not verified in longitudinal studiesâthat myocardial dysfunction may progress in a timedependent fashion after the onset of diastolic dysfunction, leading to systolic dysfunction and the classical features of heart failure Due to the frequent co-existence of DM, hypertension and CAD, it has been debated whether the myocardial dysfunction is primarily triggered by the glucometabolic disorder itself, rather than by the synergistic action of these factors From a clinical perspective, prevention of the development of LV systolic dysfunction and subsequent heart failure is currently focussed on pharmacological treatment of the co-morbidities.
| 621 | nvvc |
noted that the prevalence of DM patients is lower in heart failure trials, indicating a selection the incidence of DM in heart failure populations is sparse but, in an heart failure ### When people with two or more visits in the Reykjavik did not predict each other independently, although fasting glucose and BMI were significant risk factors, both for glucose disturbances mayâeven in the absence of other risk factors such as CAD, valvular and DM makes the contribution of the glucometabolic state to the diastolic dysfunction difficult to isolate <PERSOON> pathogenic mechanisms involve interstitial fibrosis, leading to impaired calcium homeostasis and impaired myocardial insulin signalling (See Section # for further details and references) These perturbations increase myocardial stiffness and reduce transmitral inflow of blood and tissue Doppler imaging of the mitral annulus Deteriorating diastolic dysfunction is associated with a progressive increase in LV filling pressure which, in turn, has an impact on the transmitral flow pattern ### It has been claimedâbut not verified in longitudinal studiesâthat myocardial dysfunction may progress in a timedependent fashion after the onset of diastolic dysfunction, leading to systolic dysfunction and the classical features of heart failure Due to the frequent co-existence of DM, hypertension and CAD, it has been debated whether the myocardial dysfunction is primarily triggered by the glucometabolic disorder itself, rather than by the synergistic action of these factors From a clinical perspective, prevention of the development of LV systolic dysfunction and subsequent heart failure is currently focussed on pharmacological treatment of the co-morbidities also explain why meticulous blood pressure-lowering seems to be particularly effective in people with DM Cardiac resynchronization therapy and implantable cardioverter defibrillators Cardiac resynchronization therapy is a mortality in patients in NYHA function class III â IV, an LVEF and with a prolonged QRS duration (â¥### â### ms) ### Despite a lack of subgroup analyses, there is no reason to believe that the effect of resynchronization therapy should be any different in patients with or without DM Also, there is no additional benefit from implantable cardioverter defibrillators in a subgroup of patients with T#DM and heart failure, compared with patients free from this disease ### contra-indicate heart transplantation more often in patients withthan in those without DM ### DM was an independent risk factor for decreased ##-year survival in a large registry study of patients <PERSOON> impact of various glucose-lowering drugs on T#DM patients with heart failure was systematically reviewed by Gitt et al ### They noted that the only drugs addressed in RCTs were thiazolidinediones, while of larger intervention studies in systolic heart failure, observational <PERSOON> use of metformin, the recommended first-hand glucose lowering treatment, has previously been contra-indicated in patients with heart failure because of concerns regarding lactic acidosis This drug a study by Masoudi et al , who reported that <DATUM> of metformin users had metabolic acidosis, in comparison with <DATUM> in those not treated with newly diagnosed heart failure and DM, who were either exposed oral glucose-lowering agents or insulin were neutral in this respect.
| 602 | nvvc |
also explain why meticulous blood pressure-lowering seems to be particularly effective in people with DM Cardiac resynchronization therapy and implantable cardioverter defibrillators Cardiac resynchronization therapy is a mortality in patients in NYHA function class III â IV, an LVEF and with a prolonged QRS duration (â¥### â### ms) ### Despite a lack of subgroup analyses, there is no reason to believe that the effect of resynchronization therapy should be any different in patients with or without DM Also, there is no additional benefit from implantable cardioverter defibrillators in a subgroup of patients with T#DM and heart failure, compared with patients free from this disease ### contra-indicate heart transplantation more often in patients withthan in those without DM ### DM was an independent risk factor for decreased ##-year survival in a large registry study of patients <PERSOON> impact of various glucose-lowering drugs on T#DM patients with heart failure was systematically reviewed by Gitt et al ### They noted that the only drugs addressed in RCTs were thiazolidinediones, while of larger intervention studies in systolic heart failure, observational <PERSOON> use of metformin, the recommended first-hand glucose lowering treatment, has previously been contra-indicated in patients with heart failure because of concerns regarding lactic acidosis This drug a study by Masoudi et al , who reported that <DATUM> of metformin users had metabolic acidosis, in comparison with <DATUM> in those not treated with newly diagnosed heart failure and DM, who were either exposed oral glucose-lowering agents or insulin were neutral in this respect on observational data No relationship was seen between sulphonylurea and heart failure mortality in UKPDS,### but in a large number of patients treated with sulphonylureas than with metformin during an average of <DATUM> years of follow-up ### A similar difference, to the disadvantage of sulphonylureas, was not confirmed in a study on Medicare beneficiaries, concluding that there was no association with such provoke or worsen heart failure and cause increased numbers of hospitalizations ###,###,### In the review by Gitt et al ,### it was stated that thiazolidinediones should not be used because of an increased event rate in patients with T#DM and established heart failure and a large increase in There is a lack of information on the impact of GLP-# analogues or DPP-# inhibitors in patients with heart failure, although experimental and early clinical observations indicate favourable effects on did not reveal any association between the use of insulin and mortality tremor and palpitations but increased sweating ### Prolonged hypoglycaemia has been described with non-cardio-selective beta-blockade (propranolol), but not with beta-#-selective agents or with carvedilol ###,### Elderly DM patients on insulin (n ¼ <DATUM> , without heart failure, experienced an increased risk of serious hypoglycaemia with heart failure, different beta-blockers may have varying effects on glycaemic indices, decreasing insulin sensitivity and increasing the risk of with DM and heart failure outweigh the risks of hypoglycaemia and all patients with persisting symptoms [New York Heart Association (NYHA) Class IIâ IV] and an LVEF â¤##%, despite treatment with.
| 635 | nvvc |
on observational data No relationship was seen between sulphonylurea and heart failure mortality in UKPDS,### but in a large number of patients treated with sulphonylureas than with metformin during an average of <DATUM> years of follow-up ### A similar difference, to the disadvantage of sulphonylureas, was not confirmed in a study on Medicare beneficiaries, concluding that there was no association with such provoke or worsen heart failure and cause increased numbers of hospitalizations ###,###,### In the review by Gitt et al ,### it was stated that thiazolidinediones should not be used because of an increased event rate in patients with T#DM and established heart failure and a large increase in There is a lack of information on the impact of GLP-# analogues or DPP-# inhibitors in patients with heart failure, although experimental and early clinical observations indicate favourable effects on did not reveal any association between the use of insulin and mortality tremor and palpitations but increased sweating ### Prolonged hypoglycaemia has been described with non-cardio-selective beta-blockade (propranolol), but not with beta-#-selective agents or with carvedilol ###,### Elderly DM patients on insulin (n ¼ <DATUM> , without heart failure, experienced an increased risk of serious hypoglycaemia with heart failure, different beta-blockers may have varying effects on glycaemic indices, decreasing insulin sensitivity and increasing the risk of with DM and heart failure outweigh the risks of hypoglycaemia and all patients with persisting symptoms [New York Heart Association (NYHA) Class IIâ IV] and an LVEF â¤##%, despite treatment with Surveillance of kidney function and potassium is mandatory, considering the increased risk of nephropathy in patients with <PERSOON> effect of diuretics on mortality and morbidity has not been investigated, but these drugs are useful for the relief of dyspnoea and oedema in heart failure with fluid overload, irrespective of Ivabradine In a large, randomized, double-blind, placebocontrolled trial involving ### patients with heart failure in sinus T#DM), ivabradine demonstrated a significant reduction in composite endpoints of cardiovascular death and hospital admission for worsening heart failure <PERSOON> beneficial difference was similar in a risk of stroke and have twice the mortality rate from CVD as those in sinus rhythm ###,### Diabetes mellitus is frequent in patients with as hypertension, atherosclerosis and obesity however, the independent role of DM as a risk factor for AF has not been established <PERSOON> Manitoba Follow-up Study estimated the age-specific incidence of AF in ### men ### DM was significantly associated with multivariable model, the association with DM was insignificant, suggesting that the increased risk may relate to ischaemic heart that AF is relatively common in T#DM and demonstrated that when mortality, cardiovascular death, stroke and heart failure ### These findings suggest that AF identifies DM patients who are likely to obtain risk factors Because AF is asymptomaticâor only mildly symptomaticâin a substantial proportion of patients (about ##%), screening for AF can be recommended in selected patient groups with T#DM with any suspicion of paroxysmal or permanent AF by pulse palpation, Diabetes and risk of stroke in atrial fibrillation.
| 637 | nvvc |
is mandatory, considering the increased risk of nephropathy in patients with <PERSOON> effect of diuretics on mortality and morbidity has not been investigated, but these drugs are useful for the relief of dyspnoea and oedema in heart failure with fluid overload, irrespective of Ivabradine In a large, randomized, double-blind, placebocontrolled trial involving ### patients with heart failure in sinus T#DM), ivabradine demonstrated a significant reduction in composite endpoints of cardiovascular death and hospital admission for worsening heart failure <PERSOON> beneficial difference was similar in a risk of stroke and have twice the mortality rate from CVD as those in sinus rhythm ###,### Diabetes mellitus is frequent in patients with as hypertension, atherosclerosis and obesity however, the independent role of DM as a risk factor for AF has not been established <PERSOON> Manitoba Follow-up Study estimated the age-specific incidence of AF in ### men ### DM was significantly associated with multivariable model, the association with DM was insignificant, suggesting that the increased risk may relate to ischaemic heart that AF is relatively common in T#DM and demonstrated that when mortality, cardiovascular death, stroke and heart failure ### These findings suggest that AF identifies DM patients who are likely to obtain risk factors Because AF is asymptomaticâor only mildly symptomaticâin a substantial proportion of patients (about ##%), screening for AF can be recommended in selected patient groups with T#DM with any suspicion of paroxysmal or permanent AF by pulse palpation, Diabetes and risk of stroke in atrial fibrillation factors in AF and concluded that prior stroke/TIA/thromboembolism, age, hypertension, DM and structural heart disease are important risk factors ###,### stroke (doubled)] risk index <PERSOON> ### ESC Guidelines for the management of AF, updated ###, proposed a new scheme <PERSOON> use of sex category (female)] It is based on a points system in which two points are assigned for history of stroke or TIA, or age â¥## years and one point for the other variables Heart failure is defined either as clinical heart failure or LV systolic dysfunction (EF ,##%) and vascular disease as a history of MI, complex aortic plaque, or PAD of ## RCTs in ### patients was performed to characterize the efficacy of anticoagulant and antiplatelet agents for the prevention of blocker; LVEF ¼ left ventricular ejection fraction; MRA ¼ mineralocorticoid receptor antagonist; NYHA ¼ New York Heart Association; T#DM ¼ type (AVERROES) study was stopped early, due to clear evidence of a reduction in stroke and systemic embolism with apixaban # mg b i d , apixaban in patients with AF with a median CHADS# score of <DATUM> showed that apixaban # mg b i d was superior to warfarin in preventing stroke or systemic embolism, caused less bleeding and resulted in Rivaroxaban Once Daily Oral Direct Factor Xa Inhibition Compared with <PERSOON> for Prevention of Stroke and Embolism in preventing stroke, systemic embolism or major bleeding among <DATUM> .
| 618 | nvvc |
in AF and concluded that prior stroke/TIA/thromboembolism, age, hypertension, DM and structural heart disease are important risk factors ###,### stroke (doubled)] risk index <PERSOON> ### ESC Guidelines for the management of AF, updated ###, proposed a new scheme <PERSOON> use of sex category (female)] It is based on a points system in which two points are assigned for history of stroke or TIA, or age â¥## years and one point for the other variables Heart failure is defined either as clinical heart failure or LV systolic dysfunction (EF ,##%) and vascular disease as a history of MI, complex aortic plaque, or PAD of ## RCTs in ### patients was performed to characterize the efficacy of anticoagulant and antiplatelet agents for the prevention of blocker; LVEF ¼ left ventricular ejection fraction; MRA ¼ mineralocorticoid receptor antagonist; NYHA ¼ New York Heart Association; T#DM ¼ type (AVERROES) study was stopped early, due to clear evidence of a reduction in stroke and systemic embolism with apixaban # mg b i d , apixaban in patients with AF with a median CHADS# score of <DATUM> showed that apixaban # mg b i d was superior to warfarin in preventing stroke or systemic embolism, caused less bleeding and resulted in Rivaroxaban Once Daily Oral Direct Factor Xa Inhibition Compared with <PERSOON> for Prevention of Stroke and Embolism in preventing stroke, systemic embolism or major bleeding among <DATUM> <PERSOON> assessment of bleeding risk should carried out before starting anticoagulation Using a real-world cohort of ### European patients with AF from the Euro Heart Survey, a new simple bleeding score alcohol, as risk factors of bleeding A score â¥# indicates high risk and some caution and regular review of the patients is needed following the initiation of antithrombotic therapy Clinical studies of sudden cardiac death in diabetes mellitus Sudden cardiac death accounts for approximately ##% of all cardiovascular deaths <PERSOON> majority are caused by ventricular tachyarrhythmia, often triggered by an ACS, which may occur without known samples have shown that people with DM are at higher risk of with an increased risk of sudden cardiac death in all ages (almost fourfold) and was consistently greater in women than in men ### <PERSOON> ## years, followed for ## years, reported that sudden cardiac death report from the ARIC investigators demonstrated that the magnitude of the relative increase in risk associated with DM was similar for secondary prevention of stroke in studies comprising ### patients, Aspirin reduced risk of stroke by only ##% (##% CI # â##), with an and <DATUM> per year for secondary prevention In five trials comparing anticoagulant therapy with antiplatelet agents in ### patients, warfarin was more effective than aspirin, with an RRR of ##% (##% CI ## â ##) These responses were observed in both permanent and paroxysmal AF Supported by the results of several trials and the ### and in ###.
| 641 | nvvc |
real-world cohort of ### European patients with AF from the Euro Heart Survey, a new simple bleeding score alcohol, as risk factors of bleeding A score â¥# indicates high risk and some caution and regular review of the patients is needed following the initiation of antithrombotic therapy Clinical studies of sudden cardiac death in diabetes mellitus Sudden cardiac death accounts for approximately ##% of all cardiovascular deaths <PERSOON> majority are caused by ventricular tachyarrhythmia, often triggered by an ACS, which may occur without known samples have shown that people with DM are at higher risk of with an increased risk of sudden cardiac death in all ages (almost fourfold) and was consistently greater in women than in men ### <PERSOON> ## years, followed for ## years, reported that sudden cardiac death report from the ARIC investigators demonstrated that the magnitude of the relative increase in risk associated with DM was similar for secondary prevention of stroke in studies comprising ### patients, Aspirin reduced risk of stroke by only ##% (##% CI # â##), with an and <DATUM> per year for secondary prevention In five trials comparing anticoagulant therapy with antiplatelet agents in ### patients, warfarin was more effective than aspirin, with an RRR of ##% (##% CI ## â ##) These responses were observed in both permanent and paroxysmal AF Supported by the results of several trials and the ### and in ### anticoagulants (NOAC; for further details see below)âare recommended in patients with AF <PERSOON> choice of antithrombotic therapy and bleeding and the net clinical benefit for a given <PERSOON> to use either VKAs or NOAC, the combination of aspirin and clopidogrel should be considered ### VKA or NOAC should be used if ratio and an appreciation of the patientâs values and preferences ###,### It can be concluded that VKA or NOAC should be accepted by the <PERSOON> the use of VKA, an international normalized ratio (INR) of # # â# # is the optimal range for prevention of stroke and systemic embolism in patients with DM A lower In the ACTIVE W warfarin was superior to clopidogrel plus aspirin <PERSOON> aspirin arm ACTIVE A aspirin found that major vascular events were reduced in patients receiving aspirin plus clopidogrel, compared vascular events and lead to more bleeding events,### and such combinations should be avoided Two new classes of anticoagulants have been developed oral was non-inferior to VKA for stroke prevention and systemic embolism with lower rates of major bleedings Dabigatran ### mg b i d was associated with lower rates of stroke and systemic embolism with with lower heart rate variability ### Similar findings were reported by the ARIC study,### which showed that even patients with prediabetes have abnormalities of autonomic cardiac function and heart rate variability These studies further confirm that glucose levels should be considered as a continuous variable influencing not designed to answer the question of whether reduced heart cardiac death.
| 627 | nvvc |
of antithrombotic therapy and bleeding and the net clinical benefit for a given <PERSOON> to use either VKAs or NOAC, the combination of aspirin and clopidogrel should be considered ### VKA or NOAC should be used if ratio and an appreciation of the patientâs values and preferences ###,### It can be concluded that VKA or NOAC should be accepted by the <PERSOON> the use of VKA, an international normalized ratio (INR) of # # â# # is the optimal range for prevention of stroke and systemic embolism in patients with DM A lower In the ACTIVE W warfarin was superior to clopidogrel plus aspirin <PERSOON> aspirin arm ACTIVE A aspirin found that major vascular events were reduced in patients receiving aspirin plus clopidogrel, compared vascular events and lead to more bleeding events,### and such combinations should be avoided Two new classes of anticoagulants have been developed oral was non-inferior to VKA for stroke prevention and systemic embolism with lower rates of major bleedings Dabigatran ### mg b i d was associated with lower rates of stroke and systemic embolism with with lower heart rate variability ### Similar findings were reported by the ARIC study,### which showed that even patients with prediabetes have abnormalities of autonomic cardiac function and heart rate variability These studies further confirm that glucose levels should be considered as a continuous variable influencing not designed to answer the question of whether reduced heart cardiac death cardiac death and sudden cardiac death among T#DM patients to define the risk factors for sudden cardiac death and the role of DM autonomic neuropathy in a population of ### DM patients followed for ## years ### These data suggested that kidney dysfunction and atherosclerotic heart disease are the most important determinants of the risk of sudden cardiac death, whereas neither autonomic not include heart rate variability or other risk variables among the results of the MONICA/KORA study reported that QTc was an independent predictor of sudden death, associated with a three-fold increase in patients with DM and a two-fold increase in those become valuable as predictors of sudden cardiac death in DM On the basis of available evidence, it seems that all levels of of a variety of abnormalities that adversely affect survival and predispose to sudden cardiac death <PERSOON> identification of independent stage where it is possible to devise a risk stratification scheme for Conclusions Sudden cardiac death is a major cause of mortality in DM patients While there are some risk factors for sudden cardiac death that may be specifically related to DM, such as microvascular prevention of DM, atherosclerosis and CAD and secondary prevention of the cardiovascular consequences of these common â Information is lacking on the long-term impact of glycaemic â What is the role of hypoglycaemia and other predictors in sudden DM attenuated the gender difference in absolute risk of sudden DM increases the cardiovascular mortality in patients with heart failure and in survivors of MI.
| 569 | nvvc |
patients to define the risk factors for sudden cardiac death and the role of DM autonomic neuropathy in a population of ### DM patients followed for ## years ### These data suggested that kidney dysfunction and atherosclerotic heart disease are the most important determinants of the risk of sudden cardiac death, whereas neither autonomic not include heart rate variability or other risk variables among the results of the MONICA/KORA study reported that QTc was an independent predictor of sudden death, associated with a three-fold increase in patients with DM and a two-fold increase in those become valuable as predictors of sudden cardiac death in DM On the basis of available evidence, it seems that all levels of of a variety of abnormalities that adversely affect survival and predispose to sudden cardiac death <PERSOON> identification of independent stage where it is possible to devise a risk stratification scheme for Conclusions Sudden cardiac death is a major cause of mortality in DM patients While there are some risk factors for sudden cardiac death that may be specifically related to DM, such as microvascular prevention of DM, atherosclerosis and CAD and secondary prevention of the cardiovascular consequences of these common â Information is lacking on the long-term impact of glycaemic â What is the role of hypoglycaemia and other predictors in sudden DM attenuated the gender difference in absolute risk of sudden DM increases the cardiovascular mortality in patients with heart failure and in survivors of MI sudden cardiac deathâ in patients with heart failure independent of EF ### In a series of ### post-infarction patients from Germany and Finland, the incidence of sudden cardiac death was higher in T#DM with an HR of <DATUM> (##% <PERSOON> incidence of sudden cardiac death in post-infarction patients with DM and a LVEF ##% was equal to that of non-DM patients with an <PERSOON> incidence of sudden cardiac death was substantially should be used in all symptomatic (NYHA Class IIâIV) DM patients with an LVEF ,##% unless contra-indicated T#DM patients with congestive heart failure or post MI should have their LVEF measured, to identify candidates for prophylactic implantable cardioverter defibrillator therapy Similarly, secondary prophylaxis with implantable cardioverter defibrillator therapy is indicated in DM patients resuscitated heart failure should also be treated with beta-blocking drugs, which electrical substrate in DM are unclear and are likely to be consequent neuropathy; (v) abnormalities in electrical propagation in the myocardium reflected in ECG re-polarization and de-polarization abnormalities and (vi) obstructive sleep apnoea ### â ### Experimentally induced hypoglycaemia can also cause changes in cardiac electrophysiological properties âDead in bedâ syndrome is a term used to describe the unexpected death of young individuals with T#DM while sleeping, suggesting that hypoglycaemia may contribute to sudden Jouven et al ,### studied the RR of sudden cardiac death in groups of patients with different degrees of dysglycaemia and showed that higher values of glycaemia led to higher risk Following adjustment.
| 584 | nvvc |
of EF ### In a series of ### post-infarction patients from Germany and Finland, the incidence of sudden cardiac death was higher in T#DM with an HR of <DATUM> (##% <PERSOON> incidence of sudden cardiac death in post-infarction patients with DM and a LVEF ##% was equal to that of non-DM patients with an <PERSOON> incidence of sudden cardiac death was substantially should be used in all symptomatic (NYHA Class IIâIV) DM patients with an LVEF ,##% unless contra-indicated T#DM patients with congestive heart failure or post MI should have their LVEF measured, to identify candidates for prophylactic implantable cardioverter defibrillator therapy Similarly, secondary prophylaxis with implantable cardioverter defibrillator therapy is indicated in DM patients resuscitated heart failure should also be treated with beta-blocking drugs, which electrical substrate in DM are unclear and are likely to be consequent neuropathy; (v) abnormalities in electrical propagation in the myocardium reflected in ECG re-polarization and de-polarization abnormalities and (vi) obstructive sleep apnoea ### â ### Experimentally induced hypoglycaemia can also cause changes in cardiac electrophysiological properties âDead in bedâ syndrome is a term used to describe the unexpected death of young individuals with T#DM while sleeping, suggesting that hypoglycaemia may contribute to sudden Jouven et al ,### studied the RR of sudden cardiac death in groups of patients with different degrees of dysglycaemia and showed that higher values of glycaemia led to higher risk Following adjustment study emphasizes that glucose intolerance seems to be a continuous variable directly related to the risk of sudden cardiac death, rather than supporting the previous view of risk being related to a specific threshold of glucose intolerance This fits with the present concept that cardiovascular risk increases below present thresholds for DM already at glucose levels that have been considered fairly normal - Exertional pain in the upper extremities particularly if associated - Unusual or post-prandial abdominal pain particularly if related to - Any pain at rest localized to the lower legs or feet and its association AF ¼ atrial fibrillation; DM ¼ diabetes mellitus; EF ¼ ejection fraction; LV ¼ left <PERSOON> definition of PAD used by the current ESC Guidelines includes same definition will be used in the present document Although abdominal aortic aneurysm is frequent in patients with DM, it is not included in the current PAD definition Moreover, diagnosis and management of abdominal aortic aneurysm are carried out independent Diabetes mellitus is a risk factor for the development of atherosclerosis at any vascular site, but particularly for lower extremity artery for carotid artery disease In LEAD, cigarette smoking, DM and hypertension are important risk factors Although the association of DM with LEAD is inconsistent on multivariable analysis, it appears that the duration and severity of DM particularly influence the risk of gangrene and ulceration ###,### In population studies, the presence of presence of PAD at different vascular sites.
| 575 | nvvc |
intolerance seems to be a continuous variable directly related to the risk of sudden cardiac death, rather than supporting the previous view of risk being related to a specific threshold of glucose intolerance This fits with the present concept that cardiovascular risk increases below present thresholds for DM already at glucose levels that have been considered fairly normal - Exertional pain in the upper extremities particularly if associated - Unusual or post-prandial abdominal pain particularly if related to - Any pain at rest localized to the lower legs or feet and its association AF ¼ atrial fibrillation; DM ¼ diabetes mellitus; EF ¼ ejection fraction; LV ¼ left <PERSOON> definition of PAD used by the current ESC Guidelines includes same definition will be used in the present document Although abdominal aortic aneurysm is frequent in patients with DM, it is not included in the current PAD definition Moreover, diagnosis and management of abdominal aortic aneurysm are carried out independent Diabetes mellitus is a risk factor for the development of atherosclerosis at any vascular site, but particularly for lower extremity artery for carotid artery disease In LEAD, cigarette smoking, DM and hypertension are important risk factors Although the association of DM with LEAD is inconsistent on multivariable analysis, it appears that the duration and severity of DM particularly influence the risk of gangrene and ulceration ###,### In population studies, the presence of presence of PAD at different vascular sites all DM patients, clinical screening to detect PAD should be performed annually and beneficial lifestyle changes encouraged ### All patients with PAD should receive adequate lipid-lowering, antihypertensive and antiplatelet treatment,###,###,###,### with optimal glycaemic control ###,###,### Vascular obstructions are often located distally in patients with DM and typical lesions occur in the popliteal artery or in the vessels of the lower leg In a cohort of ### patients over ## years, one in <PERSOON> incidence and prevalence of LEAD increase with age and - Measurement of blood pressure in both arms and notation of - Auscultation and palpation of the carotid and cervical areas - Abdominal palpation and auscultation at different levels including the those aged ##â## years ### In many older patients, LEAD is already present at the time of diagnosis of DM Progression of LEAD may result in foot ulceration, gangrene and ultimate amputation of part all non-traumatic amputations in the United States and a second amputation is common Mortality is increased in patients with LEAD and three-year survival after an amputation is less than ##% ### Early diagnosis of LEAD in patients with DM is important for the prevention of Diagnosis Symptoms suggestive of claudication are walking impairment, e g fatigue, aching, cramping, or pain with localization to relieved at rest Palpation of pulses and visual inspection of the feet delayed hyperaemia when the foot is lowered, absence of hair growth and dystrophic toenails are signs of limb ischaemia <PERSOON> objective measure of LEAD is the ABI, calculated by dividing the systolic.
| 603 | nvvc |
and beneficial lifestyle changes encouraged ### All patients with PAD should receive adequate lipid-lowering, antihypertensive and antiplatelet treatment,###,###,###,### with optimal glycaemic control ###,###,### Vascular obstructions are often located distally in patients with DM and typical lesions occur in the popliteal artery or in the vessels of the lower leg In a cohort of ### patients over ## years, one in <PERSOON> incidence and prevalence of LEAD increase with age and - Measurement of blood pressure in both arms and notation of - Auscultation and palpation of the carotid and cervical areas - Abdominal palpation and auscultation at different levels including the those aged ##â## years ### In many older patients, LEAD is already present at the time of diagnosis of DM Progression of LEAD may result in foot ulceration, gangrene and ultimate amputation of part all non-traumatic amputations in the United States and a second amputation is common Mortality is increased in patients with LEAD and three-year survival after an amputation is less than ##% ### Early diagnosis of LEAD in patients with DM is important for the prevention of Diagnosis Symptoms suggestive of claudication are walking impairment, e g fatigue, aching, cramping, or pain with localization to relieved at rest Palpation of pulses and visual inspection of the feet delayed hyperaemia when the foot is lowered, absence of hair growth and dystrophic toenails are signs of limb ischaemia <PERSOON> objective measure of LEAD is the ABI, calculated by dividing the systolic the brachial systolic blood pressure <PERSOON> index of ,# # is suggestive of LEAD, particularly in the presence of symptoms or clinical findings such as bruits or absent pulses <PERSOON> ABI ,# # indicates PAD, regardless of symptoms Sensitivity of ABI measurement may be increased poorly compressible vessels as a result of stiff arterial walls (medial calcinosis) that can impede the correct estimation of pressure in - ABI, calculated by dividing the systolic blood pressure at the tibial or dorsalis pedal level with the brachial pressure <PERSOON> index of (# # is exercise) and control of risk factors, including hyperglycaemia, hyperlipidaemia and hypertension Treatment In a systematic review of RCTs of exercise programmes in symptomatic claudication, supervised exercise therapy was effective in increasing walking time, compared with standard care ### Combination therapy including drugs and exercise is often used Although several drugs such as cilostazol, naftidrofuryl and pentoxifylline increase walking distance in patients with intermittent claudication, their role remains uncertain In addition, statin therapy has been reported to be of benefit by increasing walking distance in patients with PAD ###,### If conservative therapy is unsuccessful, revascularization should be considered In case of disabling claudication with the first choice, along with management of risk factors ### <PERSOON> algorithm for the treatment of intermittent claudication is shown in Figure # Critical limb ischaemia (CLI) is defined by the presence of ischaemic pain at rest and ischaemic lesions or gangrene attributable to arterial occlusive disease that is chronic and distinguishable from acute limb ischaemia.
| 632 | nvvc |
<PERSOON> index of ,# # is suggestive of LEAD, particularly in the presence of symptoms or clinical findings such as bruits or absent pulses <PERSOON> ABI ,# # indicates PAD, regardless of symptoms Sensitivity of ABI measurement may be increased poorly compressible vessels as a result of stiff arterial walls (medial calcinosis) that can impede the correct estimation of pressure in - ABI, calculated by dividing the systolic blood pressure at the tibial or dorsalis pedal level with the brachial pressure <PERSOON> index of (# # is exercise) and control of risk factors, including hyperglycaemia, hyperlipidaemia and hypertension Treatment In a systematic review of RCTs of exercise programmes in symptomatic claudication, supervised exercise therapy was effective in increasing walking time, compared with standard care ### Combination therapy including drugs and exercise is often used Although several drugs such as cilostazol, naftidrofuryl and pentoxifylline increase walking distance in patients with intermittent claudication, their role remains uncertain In addition, statin therapy has been reported to be of benefit by increasing walking distance in patients with PAD ###,### If conservative therapy is unsuccessful, revascularization should be considered In case of disabling claudication with the first choice, along with management of risk factors ### <PERSOON> algorithm for the treatment of intermittent claudication is shown in Figure # Critical limb ischaemia (CLI) is defined by the presence of ischaemic pain at rest and ischaemic lesions or gangrene attributable to arterial occlusive disease that is chronic and distinguishable from acute limb ischaemia Figure # Algorithm for the management of critical limb ischaemia (from Tendera et al ### with permission) CVD ¼ cardiovascular disease with LEAD and DM A meta-analysis of ## RCTs found that betablockers do not adversely affect walking capacity or symptoms of At ##-month follow-up of ### patients with PAD and prior MI, betablockers caused a ##% significant and independent decrease in new where possible, optimization of wound care, wearing of appropriate of management is arterial reconstruction and limb salvage, which should be attempted without delay in all patients with critical limb ischaemia (CLI) when technically possible <PERSOON> screening forâor assessment ofâcoronary or cerebrovascular diseases should not delay management of patients with CLI if clinically stable Medical be initiated according to principles outlined elsewhere in this the anatomy of the arterial lesion Outcomes of endovascular iliac artery repair in DM have been reported as similar to or worse than those without DM, and long-term patency is lower ### Longterm patency rates of intravascular interventions in the tibioperoneal region are low in patients with and without DM, but may be sufficient in the short term to facilitate healing of foot <PERSOON> diabetic foot is a specific clinical entity that may involve LEAD is diffuse and particularly severe in distal vessels When to a heavily calcified arterial wall, the ABI is inconclusive, toe pressure, distal Doppler waveform analyses, or transcutaneous oxygen can assess the arterial status When ischaemia is present, imaging stroke with an incidence <DATUM> #.
| 609 | nvvc |
Figure # Algorithm for the management of critical limb ischaemia (from Tendera et al ### with permission) CVD ¼ cardiovascular disease with LEAD and DM A meta-analysis of ## RCTs found that betablockers do not adversely affect walking capacity or symptoms of At ##-month follow-up of ### patients with PAD and prior MI, betablockers caused a ##% significant and independent decrease in new where possible, optimization of wound care, wearing of appropriate of management is arterial reconstruction and limb salvage, which should be attempted without delay in all patients with critical limb ischaemia (CLI) when technically possible <PERSOON> screening forâor assessment ofâcoronary or cerebrovascular diseases should not delay management of patients with CLI if clinically stable Medical be initiated according to principles outlined elsewhere in this the anatomy of the arterial lesion Outcomes of endovascular iliac artery repair in DM have been reported as similar to or worse than those without DM, and long-term patency is lower ### Longterm patency rates of intravascular interventions in the tibioperoneal region are low in patients with and without DM, but may be sufficient in the short term to facilitate healing of foot <PERSOON> diabetic foot is a specific clinical entity that may involve LEAD is diffuse and particularly severe in distal vessels When to a heavily calcified arterial wall, the ABI is inconclusive, toe pressure, distal Doppler waveform analyses, or transcutaneous oxygen can assess the arterial status When ischaemia is present, imaging stroke with an incidence <DATUM> # aspects related to carotid artery disease It should be noted that carotid artery stenosis ### Although the presence of DM increases <PERSOON> management of symptomatic carotid artery disease should be decided as Figure ## Algorithm for the management of extra cranial carotid artery disease (from Tendera et al ,### with permission) BMT ¼ best medical therapy; CTA ¼ computed tomography angiography; MRA ¼ magnetic resonance angiography; TIA ¼ transient ischaemic Diagnosis Carotid bruits are common in patients with carotid lesion severity Although the spectrum of symptoms is wide, only those who have suffered a stroke or TIA within the past six months imaging of the brain and supra-aortic vessels is mandatory in patients tomography angiography and magnetic resonance imaging are indicated to evaluate carotid artery stenosis Whilst carotid endarterectomy seems to offer a clear advantage remains less clear ### It needs to be emphasized that most data in patients with no symptoms were collected before statins and antiplatelet agents became standard therapy On the other hand, the results of both endarterectomy and carotid stenting have improved over time and the role of revascularization in this cohort needs to be flow to the foot to improve healing of ulcerations Sufficient amputation is necessary in order to achieve adequate perfusion which, in combination with revascularization, will contain the ischaemic, inflammatory and infective process Follow-up should include patient education, smoking cessation, protective shoes, periodic foot care and reconstructive foot surgery as needed <PERSOON> management of risk factors.
| 588 | nvvc |
related to carotid artery disease It should be noted that carotid artery stenosis ### Although the presence of DM increases <PERSOON> management of symptomatic carotid artery disease should be decided as Figure ## Algorithm for the management of extra cranial carotid artery disease (from Tendera et al ,### with permission) BMT ¼ best medical therapy; CTA ¼ computed tomography angiography; MRA ¼ magnetic resonance angiography; TIA ¼ transient ischaemic Diagnosis Carotid bruits are common in patients with carotid lesion severity Although the spectrum of symptoms is wide, only those who have suffered a stroke or TIA within the past six months imaging of the brain and supra-aortic vessels is mandatory in patients tomography angiography and magnetic resonance imaging are indicated to evaluate carotid artery stenosis Whilst carotid endarterectomy seems to offer a clear advantage remains less clear ### It needs to be emphasized that most data in patients with no symptoms were collected before statins and antiplatelet agents became standard therapy On the other hand, the results of both endarterectomy and carotid stenting have improved over time and the role of revascularization in this cohort needs to be flow to the foot to improve healing of ulcerations Sufficient amputation is necessary in order to achieve adequate perfusion which, in combination with revascularization, will contain the ischaemic, inflammatory and infective process Follow-up should include patient education, smoking cessation, protective shoes, periodic foot care and reconstructive foot surgery as needed <PERSOON> management of risk factors cholesterol; LEAD ¼ lower extremity artery disease; PAD ¼ peripheral artery disease Diabetes mellitus is an important risk factor for both renal and cardiovascular outcomes and renal impairmentâin the form of elevated urinary albumin excretion and/or impaired GFRâis itself an independent predictor of cardiovascular outcomes ###,###,### Urinary albumin excretion and loss of glomerular filtration rate (GFR) are to some extent beneficially modifiable by interventions that lower DM Although the incidence has declined slowly following the implementation of intensive treatment regimens, vision-threatening proliferative retinopathy affects ##% of people with T#DM and ##% with the combination of retinopathy and nephropathy predicts excess some pathophysiological mechanisms that also affect the macrovascular endothelium Chronic hyperglycaemia induces biochemical abnormalities causing protein glycation and overproduction of ROS, leading to vascular damage and responsive activation of tissuespecific growth/repair systems ### <PERSOON> phenotypic characteristics and increased vascular permeability In the retina, progressive vascular occlusion promotes aberrant responsive neovascularization, any stage of progressive vasoregression, increased vascular permeability causes retinal thickening, which is clinically significant when In the kidney, endothelial dysfunction and increased vascular permeability are clinically represented by microalbuminuria, and vascular occlusion corresponds to a progressive decline in renal function as Lifestyle intervention There are no trials proving that lifestyle interventions alone have an effect on the prevention of nephropathy, strict glycaemic control prevents both microvascular and cardiovascular outcomes with a long-term beneficial effect, both in <PERSOON> level of retinal damage, euglycaemia no longer provides a benefit against progression of retinopathy For T#DM, this level of damage is precisely defined (i e.
| 595 | nvvc |
extremity artery disease; PAD ¼ peripheral artery disease Diabetes mellitus is an important risk factor for both renal and cardiovascular outcomes and renal impairmentâin the form of elevated urinary albumin excretion and/or impaired GFRâis itself an independent predictor of cardiovascular outcomes ###,###,### Urinary albumin excretion and loss of glomerular filtration rate (GFR) are to some extent beneficially modifiable by interventions that lower DM Although the incidence has declined slowly following the implementation of intensive treatment regimens, vision-threatening proliferative retinopathy affects ##% of people with T#DM and ##% with the combination of retinopathy and nephropathy predicts excess some pathophysiological mechanisms that also affect the macrovascular endothelium Chronic hyperglycaemia induces biochemical abnormalities causing protein glycation and overproduction of ROS, leading to vascular damage and responsive activation of tissuespecific growth/repair systems ### <PERSOON> phenotypic characteristics and increased vascular permeability In the retina, progressive vascular occlusion promotes aberrant responsive neovascularization, any stage of progressive vasoregression, increased vascular permeability causes retinal thickening, which is clinically significant when In the kidney, endothelial dysfunction and increased vascular permeability are clinically represented by microalbuminuria, and vascular occlusion corresponds to a progressive decline in renal function as Lifestyle intervention There are no trials proving that lifestyle interventions alone have an effect on the prevention of nephropathy, strict glycaemic control prevents both microvascular and cardiovascular outcomes with a long-term beneficial effect, both in <PERSOON> level of retinal damage, euglycaemia no longer provides a benefit against progression of retinopathy For T#DM, this level of damage is precisely defined (i e while in T#DM the point of no return is unknown ### In T#DM, transient Blood pressure â nephropathy As a primary intervention, intensified blood pressure control using RAAS blockers prevents the onset of microalbuminuria in T#DM,###,### but not in T#DM ### â ### As a secondary intervention, intensified blood pressure control using ACE-I to block the RAAS slowed progression of kidney disease in T#DM cardiovascular events was not demonstrated in these young patients, although it should be expected, considering the renal effects of ACE-I In T#DM, high doses of ramipril prevented both renal and cardiovascular events ### ARBs reduced progression from microalbuminuria to proteinuria and prevented renal events but not cardiovascular cardiovascular morbidity and mortality In T#DM, advanced retinopathy more than doubles the risk of cardiovascular outcomes ### monotherapy or combined with laser versus laser monotherapy for diabetic macular edema (RESTORE), Ranibizumab Injection in Subjects With Clinically Significant Macular Edema (ME) With Center Involvement Secondary to Diabetes Mellitus (RIDE) and Ranibizumab Injection in Subjects With Clinically Significant Macular Edema (ME) With Center of treatment with ranibizumab was more effective than sham or focal/ grid laser therapy in improving best corrected visual acuity and reducing central retinal thickness in patients with visual impairment associated â <PERSOON> balance between the benefit to microvascular risk associated with tightening of glycaemic control and the risk of adverse CV BP ¼ blood pressure; DM ¼ diabetes mellitus; HbA#c ¼ glycated haemoglobin.
| 606 | nvvc |
in T#DM the point of no return is unknown ### In T#DM, transient Blood pressure â nephropathy As a primary intervention, intensified blood pressure control using RAAS blockers prevents the onset of microalbuminuria in T#DM,###,### but not in T#DM ### â ### As a secondary intervention, intensified blood pressure control using ACE-I to block the RAAS slowed progression of kidney disease in T#DM cardiovascular events was not demonstrated in these young patients, although it should be expected, considering the renal effects of ACE-I In T#DM, high doses of ramipril prevented both renal and cardiovascular events ### ARBs reduced progression from microalbuminuria to proteinuria and prevented renal events but not cardiovascular cardiovascular morbidity and mortality In T#DM, advanced retinopathy more than doubles the risk of cardiovascular outcomes ### monotherapy or combined with laser versus laser monotherapy for diabetic macular edema (RESTORE), Ranibizumab Injection in Subjects With Clinically Significant Macular Edema (ME) With Center Involvement Secondary to Diabetes Mellitus (RIDE) and Ranibizumab Injection in Subjects With Clinically Significant Macular Edema (ME) With Center of treatment with ranibizumab was more effective than sham or focal/ grid laser therapy in improving best corrected visual acuity and reducing central retinal thickness in patients with visual impairment associated â <PERSOON> balance between the benefit to microvascular risk associated with tightening of glycaemic control and the risk of adverse CV BP ¼ blood pressure; DM ¼ diabetes mellitus; HbA#c ¼ glycated haemoglobin <DATUM> ### Blood pressure â retinopathy Blood pressure control has beneficial effects on the progression of retinopathy <PERSOON> recommended to this target does not adversely affect retinopathy <PERSOON> DIabetic effects of blood pressure-lowering with candesartan on the development and progression of retinopathy There was a non-significant trend towards reduced progression of retinopathy, both in T#DM been documented as altering renal disease in DM Fibrates and filtration rate (eGFR) loss over # years, despite initially and reversibly protection in people with reduced kidney function including those reported that fenofibrate was associated with a reduction in requirement for laser therapy, although this effect appeared to be independent of effects on lipid levels <PERSOON> ACCORD trial tested the outcome of lipid Study severity scale, assessed by fundus photography from baseline, (photocoagulation or vitrectomy) <PERSOON> OR for reduction in progression of retinopathy by lipid treatment was # ## (##% <PERSOON> # years the rates of progression of retinopathy were <DATUM> with intensive glycaemia treatment, against <DATUM> with Patients with T#DM require antiplatelet agents for secondary prevention of CVD There is no specific contra-indication against the use of aspirin or other antiplatelet agents, as they do not increase the incidence of intravitreal haemorrhages ### At doses given for secondary prevention of CVD, aspirin is unlikely to improve retinopathy may also be indicated Selected cases of macular oedema with subfoveal oedema and vision impairment ,##/## may benefit from intravitreal administration of ranibizumab, aninhibitorof vascularendothelial growth factor (VEGF) In four RCTs [Safety and Efficacy of Ranibizumab multidisciplinary teams.
| 624 | nvvc |
retinopathy <PERSOON> recommended to this target does not adversely affect retinopathy <PERSOON> DIabetic effects of blood pressure-lowering with candesartan on the development and progression of retinopathy There was a non-significant trend towards reduced progression of retinopathy, both in T#DM been documented as altering renal disease in DM Fibrates and filtration rate (eGFR) loss over # years, despite initially and reversibly protection in people with reduced kidney function including those reported that fenofibrate was associated with a reduction in requirement for laser therapy, although this effect appeared to be independent of effects on lipid levels <PERSOON> ACCORD trial tested the outcome of lipid Study severity scale, assessed by fundus photography from baseline, (photocoagulation or vitrectomy) <PERSOON> OR for reduction in progression of retinopathy by lipid treatment was # ## (##% <PERSOON> # years the rates of progression of retinopathy were <DATUM> with intensive glycaemia treatment, against <DATUM> with Patients with T#DM require antiplatelet agents for secondary prevention of CVD There is no specific contra-indication against the use of aspirin or other antiplatelet agents, as they do not increase the incidence of intravitreal haemorrhages ### At doses given for secondary prevention of CVD, aspirin is unlikely to improve retinopathy may also be indicated Selected cases of macular oedema with subfoveal oedema and vision impairment ,##/## may benefit from intravitreal administration of ranibizumab, aninhibitorof vascularendothelial growth factor (VEGF) In four RCTs [Safety and Efficacy of Ranibizumab multidisciplinary teams and such teams are essential components of successful diseasemanagement programmes for CVD ### Nurse-led multidisciplinary programmes, including nurse case-management, have been effective in improving multiple cardiovascular risk factors and adherence in patients priorities and goals in managing various conditions, and the partnership between providers and patients When this approach is used by a there will be increased success in supporting patients in achieving lifestyle changes and effectively self-managing their conditions It is also important to recognise that single or limited interventions or sessions on behavioural change are not sufficient to maintain lifestyle changes and that ongoing support and booster sessions will be necessary for sustained change â Effects of patient-centred interventions on outcome measures, including micro- and macrovascular complications, are not known Patient-centred cognitive behavioural strategies are recommended to help patients achieve <PERSOON> importance of multifactorial risk assessment and lifestyle management, including diet and exercise, in the prevention and treatment supporting patients in achieving and maintaining lifestyle changes on successfully in clinical trials to prevent and treat DM and CVD is difficult to replicate in practice Once intensive intervention stops, positive changes in lifestyle and risk factors may end, although ongoing Effective strategies for supporting patients in achieving positive lifestyle changes and improving self-management can be recommended Patient-centred care is an approach that facilitates shared control and on the whole person and their experiences of illness within social contexts, rather than a single disease or organ system, and it develops a therapeutic alliance between patient and provider.
| 580 | nvvc |
such teams are essential components of successful diseasemanagement programmes for CVD ### Nurse-led multidisciplinary programmes, including nurse case-management, have been effective in improving multiple cardiovascular risk factors and adherence in patients priorities and goals in managing various conditions, and the partnership between providers and patients When this approach is used by a there will be increased success in supporting patients in achieving lifestyle changes and effectively self-managing their conditions It is also important to recognise that single or limited interventions or sessions on behavioural change are not sufficient to maintain lifestyle changes and that ongoing support and booster sessions will be necessary for sustained change â Effects of patient-centred interventions on outcome measures, including micro- and macrovascular complications, are not known Patient-centred cognitive behavioural strategies are recommended to help patients achieve <PERSOON> importance of multifactorial risk assessment and lifestyle management, including diet and exercise, in the prevention and treatment supporting patients in achieving and maintaining lifestyle changes on successfully in clinical trials to prevent and treat DM and CVD is difficult to replicate in practice Once intensive intervention stops, positive changes in lifestyle and risk factors may end, although ongoing Effective strategies for supporting patients in achieving positive lifestyle changes and improving self-management can be recommended Patient-centred care is an approach that facilitates shared control and on the whole person and their experiences of illness within social contexts, rather than a single disease or organ system, and it develops a therapeutic alliance between patient and provider changes and treatments to be adapted and implemented within cultural beliefs and behaviours Providers should take into account age, ethnic providers and patients to jointly develop realistic and acceptable improvements in glycaemic control, DM knowledge, triglyceride concentrations, blood pressure, medication reduction and selfmanagement for ##â## months Benefits for #â# years, including group-based sessions are effective in facilitating behavioural change, especially when multiple strategies are used ### â ### However, a systematic review of studies on increasing physical activity found the positive thereafter;### this may simply indicate the need for subsequent booster sessions beginning around six months Similar patient-centred cognitive educational strategies, along with simplification of dosing regimens adherence ### â ### Research is still needed regarding the most effective For patients with greater reluctance or resistance towards making counselling with the purpose of working through ambivalence and effective in helping patients to decrease body mass index and systolic blood pressure and increase physical activity and fruit and vegetable <PERSOON> CME text â### ESC Guidelines on diabetes, pre-diabetes, and cardiovascular diseasesâ is accredited by the European Board for Accreditation in Cardiology (EBAC) EBAC works according to the quality standards of the European Accreditation Council for Continuing Medical Education (EACCME), which is an institution of the European Union of Medical Specialists (UEMS) In compliance with EBAC/EACCME Guidelines, all authors participating in this programme have disclosed any potential conflicts of interest that might cause a bias in the article.
| 583 | nvvc |
be adapted and implemented within cultural beliefs and behaviours Providers should take into account age, ethnic providers and patients to jointly develop realistic and acceptable improvements in glycaemic control, DM knowledge, triglyceride concentrations, blood pressure, medication reduction and selfmanagement for ##â## months Benefits for #â# years, including group-based sessions are effective in facilitating behavioural change, especially when multiple strategies are used ### â ### However, a systematic review of studies on increasing physical activity found the positive thereafter;### this may simply indicate the need for subsequent booster sessions beginning around six months Similar patient-centred cognitive educational strategies, along with simplification of dosing regimens adherence ### â ### Research is still needed regarding the most effective For patients with greater reluctance or resistance towards making counselling with the purpose of working through ambivalence and effective in helping patients to decrease body mass index and systolic blood pressure and increase physical activity and fruit and vegetable <PERSOON> CME text â### ESC Guidelines on diabetes, pre-diabetes, and cardiovascular diseasesâ is accredited by the European Board for Accreditation in Cardiology (EBAC) EBAC works according to the quality standards of the European Accreditation Council for Continuing Medical Education (EACCME), which is an institution of the European Union of Medical Specialists (UEMS) In compliance with EBAC/EACCME Guidelines, all authors participating in this programme have disclosed any potential conflicts of interest that might cause a bias in the article CME questions for this article are available at European Heart Journal (WEBLINK) and European Society of Cardiology (WEBLINK) ## Colagiuri S, <PERSOON> JE, <PERSOON> RB, <PERSOON> DM Effect of aging on A#C levels in individuals without diabetes evidence from the Framingham Offspring Study and the National Health and ## Saaristo TE, <PERSOON> prevalence of ## <PERSOON> KM Prevention of type # diabetes issues and strategies for identifying persons for interventions Diabetes Technol Ther ###;<DATUM> â### ## <PERSOON> GE, <PERSOON> NJ, Lauritzen T Effect of early intensive multifactorial therapy on #-year cardiovascular outcomes in individuals with type # ## <PERSOON> of type # diabetes mellitus by changes in lifestyle among ## Knowler WC, Barrett-<PERSOON-##> EA, <PERSOON> DM Reduction in the incidence of type # diabetes with lifestyle intervention or metformin <PERSOON-##> J Med ###;##<DATUM> â### ##.
| 541 | nvvc |
Cardiology (WEBLINK) ## Colagiuri S, <PERSOON> JE, <PERSOON> RB, <PERSOON> DM Effect of aging on A#C levels in individuals without diabetes evidence from the Framingham Offspring Study and the National Health and ## Saaristo TE, <PERSOON> prevalence of ## <PERSOON> KM Prevention of type # diabetes issues and strategies for identifying persons for interventions Diabetes Technol Ther ###;<DATUM> â### ## <PERSOON> GE, <PERSOON> NJ, Lauritzen T Effect of early intensive multifactorial therapy on #-year cardiovascular outcomes in individuals with type # ## <PERSOON> of type # diabetes mellitus by changes in lifestyle among ## Knowler WC, Barrett-<PERSOON> EA, <PERSOON> DM Reduction in the incidence of type # diabetes with lifestyle intervention or metformin <PERSOON-##> J Med ###;##<DATUM> â### ## Impact of ## <PERSOON-##> KG, Mathers JC Prevention of type # diabetes in adults with impaired glucose tolerance the European Diabetes Prevention RCT in Newcastle upon Tyne, UK BMC Public Health ###;<DATUM> ## Gillies CL, Abrams KR, <PERSOON-##> and lifestyle interventions to prevent or delay type # diabetes in ## Hare MJ, Shaw JE, Zimmet PZ Current controversies in the use of haemoglobin ## <PERSOON-##> of glucose metabolism in polycystic ovary syndrome HbA#c or fasting glucose compared with the oral glucose tolerance test as a screening method <PERSOON-##> Z, Gao W, <PERSOON-##> of an A#C and fasting capillary blood glucose test for screening newly diagnosed diabetes and pre-diabetes defined by an oral glucose tolerance test in <PERSOON-##> AM, van der <PERSOON-##> SJ, Beulens JW Prediction models for risk of developing type # diabetes systematic literature search and independent external validation study BMJ ###;### e### ## <PERSOON-##> diabetes risk score a practical tool to predict type # ## <PERSOON-##> PE, <PERSOON-##> for predicting the risk of type # ##.
| 504 | nvvc |
<PERSOON> KG, Mathers JC Prevention of type # diabetes in adults with impaired glucose tolerance the European Diabetes Prevention RCT in Newcastle upon Tyne, UK BMC Public Health ###;<DATUM> ## Gillies CL, Abrams KR, <PERSOON> and lifestyle interventions to prevent or delay type # diabetes in ## Hare MJ, Shaw JE, Zimmet PZ Current controversies in the use of haemoglobin ## <PERSOON> of glucose metabolism in polycystic ovary syndrome HbA#c or fasting glucose compared with the oral glucose tolerance test as a screening method <PERSOON> Z, Gao W, <PERSOON> of an A#C and fasting capillary blood glucose test for screening newly diagnosed diabetes and pre-diabetes defined by an oral glucose tolerance test in <PERSOON> AM, van der <PERSOON> SJ, Beulens JW Prediction models for risk of developing type # diabetes systematic literature search and independent external validation study BMJ ###;### e### ## <PERSOON> diabetes risk score a practical tool to predict type # ## <PERSOON> PE, <PERSOON-##> for predicting the risk of type # ## <PERSOON-##> glucose tolerance test is needed for appropriate classification of glucose regulation in patients with coronary artery disease a report from the <PERSOON-##> glucose, HbA#c, or oral glucose tolerance testing for the detection of glucose abnormalities in patients with acute coronary syndromes <PERSOON-##> VA Comparison of diagnostic criteria to detect undiagnosed diabetes in hyperglycaemic patients ## <PERSOON-##> glucose tolerance test and HbA(#)c for diagnosis of # International Diabetes Federation ### Global Burden Prevalence and Projections, ### and ### Available from (WEBLINK) its complications Part # diagnosis and classification of diabetes mellitus <PERSOON-##> (WHO) Consultation Definition and diagnosis of diabetes and intermediate hyperglycaemia ### (WEBLINK) # Report of the Expert Committee on the Diagnosis and Classification of <PERSOON-##> KG, Bennett P, <PERSOON-##> A, <PERSOON-##> M, <PERSOON-##>-up report on the diagnosis of diabetes mellitus Diabetes Care ###;## ### â###.
| 500 | nvvc |
<PERSOON> glucose tolerance test is needed for appropriate classification of glucose regulation in patients with coronary artery disease a report from the <PERSOON> glucose, HbA#c, or oral glucose tolerance testing for the detection of glucose abnormalities in patients with acute coronary syndromes <PERSOON> VA Comparison of diagnostic criteria to detect undiagnosed diabetes in hyperglycaemic patients ## <PERSOON> glucose tolerance test and HbA(#)c for diagnosis of # International Diabetes Federation ### Global Burden Prevalence and Projections, ### and ### Available from (WEBLINK) its complications Part # diagnosis and classification of diabetes mellitus <PERSOON> (WHO) Consultation Definition and diagnosis of diabetes and intermediate hyperglycaemia ### (WEBLINK) # Report of the Expert Committee on the Diagnosis and Classification of <PERSOON> KG, Bennett P, <PERSOON> A, <PERSOON> M, <PERSOON>-up report on the diagnosis of diabetes mellitus Diabetes Care ###;## ### â### Diagnosis and classification of diabetes mellitus Diabetes Care ###;## Suppl # Use of glycated hemoglobin (HbA#c) in the diagnosis if diabetes mellitus ### http // # Diagnosis and classification of diabetes mellitus <PERSOON-##> from glucose diagnostic criteria to the new HbA(#c) criteria would have a profound impact on prevalence of diabetes ## <PERSOON-##> J HbA(#c) in diagnosing and predicting Type # diabetes in impaired glucose tolerance the <PERSOON-##> K <PERSOON-##> of onset and type of diabetes <PERSOON-##>-cell function in relation to islet cell antibodies during the first # yr after clinical diagnosis of diabetes in type II diabetic patients <PERSOON-##> MJ Antibodies to glutamic acid decarboxylase as predictors of insulin-dependent diabetes mellitus before ## Incidence and trends of childhood Type # diabetes worldwide ### â### <PERSOON-##> relative contributions of insulin resistance and beta-cell dysfunction ##.
| 449 | nvvc |
Diagnosis and classification of diabetes mellitus Diabetes Care ###;## Suppl # Use of glycated hemoglobin (HbA#c) in the diagnosis if diabetes mellitus ### http // # Diagnosis and classification of diabetes mellitus <PERSOON> from glucose diagnostic criteria to the new HbA(#c) criteria would have a profound impact on prevalence of diabetes ## <PERSOON> J HbA(#c) in diagnosing and predicting Type # diabetes in impaired glucose tolerance the <PERSOON> K <PERSOON> of onset and type of diabetes <PERSOON>-cell function in relation to islet cell antibodies during the first # yr after clinical diagnosis of diabetes in type II diabetic patients <PERSOON> MJ Antibodies to glutamic acid decarboxylase as predictors of insulin-dependent diabetes mellitus before ## Incidence and trends of childhood Type # diabetes worldwide ### â### <PERSOON> relative contributions of insulin resistance and beta-cell dysfunction ## <PERSOON> beta cell glucose sensitivity rather than inadequate compensation for insulin resistance is the dominant defect in glucose intolerance <PERSOON> # diabetes mellitus after gestational diabetes a systematic review and meta-analysis Lancet ###;### ## Feig <PERSOON-##> B, <PERSOON-##> X, Hux JE Risk of development of diabetes mellitus after diagnosis of gestational diabetes CMAJ Canadian Medical Association journal¼<PERSOON-##> of blood glucose comparison between different types of specimens <PERSOON-##> ## <PERSOON>- and sex-specific prevalences of diabetes and impaired glucose regulation in ## ## <PERSOON-##> ME, <PERSOON-##> JE, <PERSOON-##> to an A#C-based diagnosis of diabetes has a different impact on prevalence in different ethnic groups Diabetes Care European evidence-based guideline for the prevention of type # diabetes <PERSOON-##> M, <PERSOON-##> N,.
| 420 | nvvc |
cell glucose sensitivity rather than inadequate compensation for insulin resistance is the dominant defect in glucose intolerance <PERSOON> # diabetes mellitus after gestational diabetes a systematic review and meta-analysis Lancet ###;### ## Feig <PERSOON> B, <PERSOON> X, Hux JE Risk of development of diabetes mellitus after diagnosis of gestational diabetes CMAJ Canadian Medical Association journal¼<PERSOON> of blood glucose comparison between different types of specimens <PERSOON> ## <PERSOON>- and sex-specific prevalences of diabetes and impaired glucose regulation in ## ## <PERSOON> ME, <PERSOON> JE, <PERSOON> to an A#C-based diagnosis of diabetes has a different impact on prevalence in different ethnic groups Diabetes Care European evidence-based guideline for the prevention of type # diabetes <PERSOON-##> M, <PERSOON-##> T, <PERSOON-##> R, Wens J, <PERSOON-##> T <PERSOON-##> action to prevent diabetes the IMAGE toolkit for the prevention of type # diabetes in Europe Horm Metab Res Eriksson KF, Lindgarde F No excess ##-year mortality in men with impaired glucose tolerance who participated in the Malmo Preventive Trial with diet and exercise <PERSOON-##> P, <PERSOON-##> EW, <PERSOON-##> Q, <PERSOON-##> Y, <PERSOON-##> longterm effect of lifestyle interventions to prevent diabetes in the China Da Qing Diabetes Prevention Study a ##-year follow-up study <PERSOON-##> EW, <PERSOON> J, <PERSOON-##> P, <PERSOON> W, <PERSOON-##> Y, <PERSOON-##> PH Long-term effects of a randomised trial of a #-year lifestyle intervention in impaired glucose tolerance on diabetes-related microvascular complications the China Da Qing Diabetes Prevention Outcome Study Diabetologia ###;#<DATUM> â###.
| 422 | nvvc |
Subsets and Splits
No community queries yet
The top public SQL queries from the community will appear here once available.