Diabetes and Coronary Artery
Disease : Making the Link
Melinda S. Thompson, BSN, RN
Alverno College MSN Student
Before we Begin…..
• This is an interactive tutorial.
Questions are embedded
throughout to evaluate your
learning. Click or hover on the
“links” as you progress in the
tutorial to view questions.
Answers will be provided.
• A pre and post test is also
provided to assess and re-assess
your knowledge on diabetes and
how it links to coronary artery
disease (CAD).
Navigation
Use this arrow to advance to the NEXT
SLIDE
Use this arrow to return to the PREVIOUS
SLIDE
Use this key to return to the HOME page
Use the key to see the LAST SLIDE VIEWED
Objectives
At the end of this tutorial you will be able to:
• Discuss the pathophysiology of diabetes.
• Discuss how other factors impact how diabetes affects the
body:
– Stress
– Inflammation
– Genetics
– Aging
• State the “link” or connection between diabetes and coronary
artery disease.
• Discuss nursing implications for diabetic patients who have
coronary artery disease.
Home Page
Pathophysiology
of Diabetes
Definitions
Pre
Test
Diabetes and
Genetics
Diabetes and
Aging
The “LINK”
between
Diabetes and
CAD
Nursing
Implications
Quick
Quiz
Diabetes and
Stress
Diabetes and
Inflammation
Case Study
Post
Test
Objectives
References
Definitions
“Hover to discover”
LDL Cholesterol
(Low density
lipoproteins)
Angina
HbA1c
Modifiable
Risk Factors
Arrhythmias
HDL Cholesterol
(High density
lipoproteins)
Atherosclerosis
Non-Modifiable
Risk Factors
Islet Cells
Foam Cells
Triglycerides
Pretest
Which of the following statements are TRUE?
Click to find the correct response:
1. As a nurse, it is not my job to educate my patient on
diabetes or coronary artery disease?
2. Low HDL levels are associated with heart disease?
False, the patient is everyone’s
responsibility; in nursing we are a
team
True
3. An acceptable blood glucose level is between 80-120?
True
4. High LDL levels are associated with coronary heart disease?
True
5. Your life is over because you have diabetes?
False, You have Diabetes, Diabetes
does NOT have you!
Mrs. Jones is a 69 y/o female who went to the emergency
room because she was having chest pressure along
with numbness and tingling in her hands and feet. She
states that her initial symptoms began 2 weeks ago
when she was just “tired”. Her pain is mid sternum and
she states it is “pressure like”. She tells you that the
pain radiates to both of her elbows but then went
away
She denies SOB, nausea, or vomiting. She had no further
episodes until 2 days ago, after eating in a restaurant
she experienced the same exact symptoms, with
pressure like sensation radiating to both of her arms.
PMH Includes: generalized anxiety, DM2, Diabetic
Peripheral neuropathy
Given the information of Mrs. Jones signs
and symptoms, what could the numbness and
tingling be associated with?
Click Here
Case Study
DM2 and/or Diabetic Peripheral neuropathy
Case Study
What labs indicate that Mrs. Jones Diabetes is not
under control?
Click Here
Patients Troponin Level in the ER was 0.014 ,
Glucose of 258
HgbA1c of 8.8
Lipid Panel Includes:
Normal
ClickLabs
to
Triglyceride of 275
HDL>40
See
HDL of 32,
LDL<100
Normal
Triglyc.<150
LDL of 35
HbA1c
<7
Labs
Glucose 80-120
Cardiac:
CK was elevated at 158
ECG was Normal Sinus Rhythm with 1st degree AV block
All of Mrs. Jones labs are abnormal and would indicate
uncontrolled DM2.
What is Diabetes?
Diabetes is a group of
diseases known for
increased blood glucose.
This is a result from
defects in insulin
production, action, or
both. This disease can
lead to serious
complications and
premature death.
Types of Diabetes Includes:
Type 1 – when the body’s immune system
mistakenly destroys pancreatic beta cells. People
with this require insulin.
Type 2 – insulin secretion is impaired and the body
cannot adequately control blood glucose levels from
one moment to the next eventually causing the long
term complications associated with diabetes.
Gestational – a form of glucose intolerance
associated with pregnancy
This tutorial focuses primarily on
Type
2 Diabetes.
Other – can be associated
with
genetics, infections,
failure of pancreas to work.
CDC, 2011
Click Here
Significance of the Disease
Fact 1
“According to WHO, diabetes is a growing
public health threat, affecting an
estimated 177 million people worldwide
in 2000, up from an estimated 30 million
in 1985”.
Fact 2
Type 2 diabetes; also known as “adult
onset diabetes” initially disease of older
adults was thought to be highly due to
obesity and sedentary lifestyles, it has
since grown at epidemic rates in recent
years and is rapidly increasingly among
young adults and even children.
Fact 3
“Diabetes is a leading cause of end-stage
kidney disease, heart attacks, strokes,
eye disease and blindness, diabetic foot
disease and other costly complications”.
Fact 4
“Research has demonstrated that clearly
expert diabetes care that keeps blood
glucose near normal can reduce the risks
of developing complications, and can
markedly slow the rate at which
complications progress”.
Diabesity & Associated Disorders in Australia 2000 – The Accelerating Epidemic – The Australian Diabetes, Obesity & Lifestyle Report
Pancreas
Negative
Feedback
Loop
Islets of
Langerhan
Alpha cell
secretes hormone
Glucagon
Beta Cell
secretes
hormone Insulin
Stimulated
by low
blood sugar
Stimulated by
high blood
sugar
Hypoglycemia and
sympathetic nervous
stimulation also result in
glucagon release.
Increasing blood glucose
levels
Brings about a
biological response, to
decrease blood glucose
levels
LBS=
HBS=
Low Blood
Sugar
High Blood
Sugar
Pathophysiology of Diabetes
The Pancreas is the major
organ involved with Type II
diabetes. Having a dual role;
the Pancreas is responsible
for:
• Exocrine Fx: is to produce
the enzymes needed to
digest food.
• Endocrine Fx: is to
produce hormones such as
insulin, which facilitates the
uptake and storage of
glucose and proteins.
http://www.nlm.nih.gov
Pathophysiology of Diabetes
Normal Pancreatic Function
After you eat, nutrients such as
carbohydrates, fats, and proteins are
broken down by the digestive system
Of these nutrients is Glucose rises in the
blood stream, allowing the pancreas
receives a signal to release insulin.
The insulin, attaches to a place on
the cell much the same way a key would
fit into a lock creating the energy needed
for the muscle to contract bringing down
glucose level
www.stemcells.nih.gov
Pathophysiology of Diabetes
Pancreatic Dysfunction also known as:
Insulin Resistance
Insulin resistance is when the cells stop
responding to insulin, meaning the door
which allows glucose to enter won't open.
The amount of glucose in the blood becomes
elevated. As long as there is too much glucose in
the blood, and too little glucose in the cell, the
pancreas will continue to produce insulin until
the glucose level goes down.
However, if the cells in the body have become
insulin resistant, the amount of glucose in blood
will never go down. As the pancreas continues
to try to lower glucose levels by producing more
insulin, it will eventually wear itself out.
www.stemcells.nih.gov
The Effects of Diabetes on the Body
With the inability of glucose to enter the cells, resulting in a
high amount of glucose build up in the bloodstream, the cells are
not able to produce energy for the body. When diabetes is not
tightly managed by keeping the amount of sugar at “just” the right
levels, the resulting high glucose amounts damage and weaken the
walls of nearly every organ; leading to scar tissue damage and
decreased healing processes.
Complications of Diabetes Include:
– Heart Disease and Stroke
– Vision Loss and Blindness ( Diabetic Retinopathy)
– Kidney Failure (Diabetic Nephropathy)
– Amputation (Diabetic Neuropathy)
True Or False
Case Study Question
• Does Mrs. Jones elevated blood glucose play a
role in the symptoms she presents with?
True
False
Why the body needs Glucose
What the
Body Needs
Why we
need glucose
The Key
• The body's cells are designed so that they function best when there is a certain
amount of glucose, or sugar, in the fluid that surrounds them. Too much glucose in
the body will turn the fluid that surrounds the body's cells into a bath of sugar that
hinders many normal functions of these cells.
• Glucose is the body's main source of energy, but glucose must get inside cells to
create the energy that the cells need to function. The problem is that cells have a
membrane or covering around the outside that won't let glucose in. This is where
insulin becomes important, because it is insulin that opens up cells to glucose.
• Maintaining a constant level of glucose is a delicate process that is controlled by the
pancreas and the insulin it produces. Glucose levels in the blood lead the pancreas
to release just the right amount of insulin to keep the amount of glucose in the
blood stream and surrounding the cells at an even level.
The Pancreatic Function in
Diabetes
•The pancreas, actually pulls double duty as a digestive organ., placed behind the
stomach, the spongy pancreas secretes both digestive enzymes and endocrine
hormones. The exocrine tissues of pancreas secrete digestive enzymes that are key
in processing carbohydrates, proteins and other nutrients.
•The liver is another key organ, that is responsible for glucose storage and
converting glucose to glycogen, then stored in the liver to be reconverted to energy.
•Together, the liver and pancreas preserve a delicate balance of blood glucose and
insulin, produced in sufficient amounts to both fuel cells and maintain glycogen
storage.
After you eat, nutrients such as
carbohydrates, fats, and
proteins are broken down by
the digestive system.
Too much glucose inside
blood, not enough inside
cell, pancreas continues to
make insulin eventually
wears out.
Of these nutrients is
Glucose rises in the blood
stream, allowing the
pancreas receives a signal to
release insulin.
Function
RECAP
Dysfunction
Insulin Hormone unable to enter
into cell, causing buildup of
glucose in bloodstream
The insulin, attaches to a place
on the cell much the same way
a key would fit into a lock
After you eat, nutrients such as
carbohydrates, fats, and
proteins are broken down by
the digestive system.
Diabetes and Stress
Stress is not a direct cause of
diabetes. However; stress can increase your
risk of developing the disease ,and it is
responsible for exacerbating your symptoms if
you already suffer from the disease.
The link between stress and diabetes is the
direct effect that stress has on the body’s
blood sugar level causing it to become
elevated
The rise in blood sugar levels, is part of the
body’s natural response to stress known as
“Fight or Flight” Response
To see “Fight or Flight” response hover over arrows
Fight or Flight
True or False
Question
• Is stress directly related to Mrs. Jones
development of diabetes?
True
False
Hover to find the correct answer
Diabetes and Inflammation
Obesity
Infection
STRESS
Activation of signaling
cascades
Inflammation
Insulin
Resistance
Diabetes
Hyperlipidemia
Atherosclerosis
According to the “Claude Bernard Lecture “Type II diabetes and
obesity are characterized by low-grade, chronic inflammation,
which could contribute to accelerated atherosclerosis”.
(DeFronzo, 2010)
Copyright © 2011, The American Society for Clinical Investigation.
Diabetes and Inflammation
• According to the (NCEPIII) Insulin
resistance NOT only contributes to
hyperinsulinemia in persons with type
2 DM, but plays a major role in
• Metabolic Abnormalities , such as:
– Obesity
– Increased levels of triglycerides
– Low levels of (HDL)
– Hypertension
– Systemic Inflammation
• Detected by (CRP) C-reactive Protein
– It has been found that people with central
trunkal obesity are at greater risk for
developing Type 2 DM and Metabolic
syndromes.
90% of Type 2 Diabetics are overweight and
are more prone to insulin resistance and
impaired suppression of glucose
production by the liver.
•Waist circumference and waist/hip
ratio have been shown to correlate
with insulin resistance
•Abdominal Obesity: Waist Circum
• >35in female
•>40 in males
Porth, 2009
Case Study Question
• The primary organ involved in diabetes is the
TRUE Or
FALSE
pancreas.
?
hover to see correct answer
Click correct answer for information re: pancreas
Diabetes and Genetics
• There are “diabetic genes” which play a
role in diabetes.
– Variations known as single nucleotide polymorphisms
(SNPs) may play a factor in diabetes.
– It is thought that two genes, calpain 10 (CAPN10) and
hepatocyte nuclear factor 4 alpha (HNF4A), have
been identified as playing a factor in diabetes.
http://www.ncbi.nlm.nih.gov/books/NBK1665
• Patients who have a family history of
diabetes are more likely to develop the
disease.
N. Americans 15.1%, A. Americans 13.3%, H. Americans 9.5%
Porth,2009
Diabetes and Genetics
Continued
• Genetics and Environmental factors can lead to insulin resistance; causing
decreased glucose uptake and increased glucose output, resulting in
hyperglycemia and type II diabetes.
•Research shows that diabetes is
effect utilization of blood glucose.
Polygenic
Hover please!
. These polymorphisms can
•Polymorphic Defects of diabetes include mutation genes related too:
•Insulin secretion
•Insulin resistance
Hover____ for more information
•obesity
(Radha et al, 2003)
Environmental Factors
The complex interactions between genes and the
environment make it difficult to identify a single factor
that leads to Diabetes Mellitus. (Radha et all, 2003)
•
•
•
•
•
Environmental Factors Include:
Central Obesity
Uncontrolled Diet
Toxins (Smoking)
Viruses
Lack of Activity
Quick Quiz
Based on her assessment Mrs. Jones should make
some changes in her health management?
This is true!
Mrs. Jones she be established
Click formedical
answer
with a primary
doctor, to
ensure a tighter control on her
blood glucose as well as her
cholesterol levels.
What are modifiable risks she can focus on to
promote wellness and assist with management
of her diabetes?
Mrs. Jones could diet and
exercise
Click for
answer more often, as these
changes are modifiable and can be managed.
True or False
Case Study Question
If Mrs. Jones is overweight, this will activate
the inflammation response; given that she
already suffers from diabetes?
True
False
Diabetes and Aging
As we age: According to the American Diabetes
Association in the United States 1in 4 people over the
age of 60 will have diabetes.
Complications Include:
Decreased Hearing loss
Decreased Muscle Mass
Physical Performance
Visual Disturbances
Facts about Coronary Heart
Disease
Coronary artery disease (CAD) is the single leading killer
of American men and women, causing approximately 500,000
deaths per year 1 of every 5 deaths.
– About 85% of people who die from CAD are 65 or older. Over half the
people who die suddenly of this disease had no previous symptoms.
– Coronary artery disease affects almost 11 million American people,
divided almost equally between men and women.
– This disease is the leading cause of premature, permanent disability in
the US labor force, accounting for 19% of disability allowance by the
Social Security Administration.
Coronary Artery Disease
• A condition in which plaque builds up inside
the coronary arteries.
Coronary
• These arteries supply your heart muscle with
Heart Disease oxygen-rich blood and become narrow.
The Plaque
• Plaque is composed of fat, cholesterol,
calcium, and other substances found in the
blood. As it builds up in arteries the vessels
become hardened.
• Narrowing of the arteries reduces blood flow
to your heart muscle.
• There is a potential for blood clots to form in
your arteries as well.
Complications
• A crack or damage in the plaque can lead to
of Plaque
heart attacks.
http://phil.cdc.gov/phil/home.asp
The Pathway
of
Diabetes Atherosclerosis
Hyperglycemia from uncontrolled
diabetes can accelerate cholesterol
plaque formation and advance
vascular disease at a rate greater
than patient's without diabetes.
"Inflammation in blood vessels is one
of the main drivers of atherosclerosis,
and diabetes makes it much worse,"
(AGEs), produced in greater levels
by patients with diabetes, interfere
with ERK5 cardio protection.
Glycation reactions cause the
release of oxidizing side products
like hydrogen peroxide (H202) that
drive free radical production,
inflammation and cell damage in
many diseases.
AGEs=
Advanced Glycation end Products
SUMO=small ubiquitin-related modifier
S
tarting with the
atherosclerotic plaques that get
deposited inside the arteries
decreasing blood flow to organs
and vital structures.
“Researchers found that AGEs and
H202 sabotage ERK5 by encouraging
the attachment to it of a small
ubiquitin-related modifier (SUMO), a
protein tag used by cells to fine-tune
their control over proteins.”
In normal function, a cell may
extend a protein's life span or send
it from one part of the cell to
another, by attaching a SUMO tag
In summary, research found that
taking away the "SUMO tag" from
ERK protects blood vessels against
diabetes," It’s believed that the
SUMOylation of ERK turns off 'good'
genes that are important in
countering atherosclerosis.”
Quick Quiz
Atherosclerotic plaque formations in the
arteries, are responsible for
microvascular complications in diabetic
patients?
True!
Decreased bloodClick
flow
to the arteries
for answer
eventually leads to the major
complications associated with diabetes.
Making the Link
Diabetes:
Fact: Increased glucose build up
inside blood stream
Fact: organs are compromised as
A result weak arteriole walls
Fact: Life threatening
Arteriole
venous damage to
To organs over period of
time
Coronary Heart Disease:
Fact: Atherosclerosis
Fact: Increase cholesterol levels
Fact: Increased arterioles creates blood
more prone to clotting
Fact: Heart attack as evidence
By blockage of blood vessels
And killing heart muscle
As many as 65% of people diagnosed with diabetes with eventually die from a heart
attack or a stroke. Having diabetes greatly increases the risk of heart attacks or stroke.
The buildup of plaque (arthrosclerosis) and hardening of the arties associated with
diabetes places this population 3x the risk as a non-diabetic person who has
previously experienced a heart attack.
www.nlm.nih.gov/medlineplus/ency/article/000313.htm
Case Study Question
• Coronary Artery Disease along with Increased
Cholesterol levels played a role in the development
of Mrs. Jones, ECG readings of NSR with 1st degree
Block ?
True
Or
False
Nursing Role
• Successful treatment of diabetes mellitus requires a combined effort
by:
– The physician having a complete understanding of the particular problems
in each case
– The nurse educator, and how well the patient has been educated with
return demonstrations required
– The patient's ability to comply with REALISTIC GOALS and instructions
• Diabetics can lead a relatively normal life if they are well informed
concerning their disease and how it should be managed.
– The Patient Should
•
Get your Blood Tested,
–
•
cholesterol increases your risk for heart disease. People at any age can
take the steps needed to manage cholesterol levels.
Eat a Healthy Diet and Exercise regularly
–
Exercise improves muscle tone, strength, and the feeling of well-being,
while reducing insulin requirements.
Nursing Role Cont….
• Monitoring blood glucose
---- is
•
•
•
•
essential in order to design a diabetic care program
and maintain good control.
• Personal Goals for Type 2 Diabetics
Learn about your disease and how it is managed
Balance diet, exercise and medication
Maintain appropriate blood sugar levels
Maintain body weight within normal range
Available Treatment Options
are: Oral and Injection
• Drugs that cause increased insulin release
– Sulfonylureas (Glyburide, Glipizide)
Click to see which medications can help insulin be released
– Sitagliptin (Januvia) *newer drug
– Exanatide (Byetta) *newer drug
• Drugs that sensitize cells to insulin
– Biguanides
(Metformin)
Click to see
what medications helps with insulin sensitivity
– Thiazolidinediones (Rosiglitazone, Pioglitazone)
• Drugs that block carbohydrate absorption
– AcarboseClick for assistance with carbohydrate absorption
Injectable Insulin's
are:
Modified to have either very short or long half
lives.
Regular Insulin, usually given for immediate reducing of
blood glucose levels, often followed by a partial long
acting dose of insulin.
Insulin Lispro (Humalog) and Insulin Aspart (Novolog)
have a quicker onset and shorter duration than
Regular Insulin.
Insulin Glargine (Lantus) is a very long acting form of
insulin.
All are administered subcutaneously.
Special Thanks to My Audience!!!
You have been
Awesome
Melinda S. Thompson
BSN,RN
Alverno College MSN Student
Prevention and reversal of diabetes can be achieved
by a strict diet, exercise, and weight loss!
References
American Diabetes Association. (2010). In Facts and figures. Retrieved
from www.diabetes.org
American Diabetes Association. (1995-2008). In Living with diabetes.
Retrieved from www.diabetes.org
American Diabetes Association. (2007). Standards of medical care for
patients with diabetes mellitus. Diabetes Care,29, 2140-2157.
De Fronzo, R. (2009). Insulin resistance, lipotoxcicity, type 2 diabetes and
atherosclerosis: The missing links. The John Claude Bernard
Lecture 2009. Diabetologia, 1270-1287.
Grundy, S.M. (2001). Third report of the national cholesterol education
program (NCEP) expert panel on detection. Evaluation and
treatment of high blood cholesterol in adults (Adult Treatment
panel III). NIH publication no. 01-360. Bethesda, MD: National
Institute of Health.
References
Khan S. E., Hull R. L., & Utzschneider K.M. (2006). Mechanisms linking obesity to insulin
resistance and type 2 diabetes. Nature, 444, 840-846.
Masharani, U. & German, M. S. (2007). Pancreatic hormones and diabetes mellitus. In
Gardner D.G., Showback D. (Eds.) Greenspan’s basic and clinical endocrinology
(8th ed., pp. 661-747). New York: Lane Medical Books/McGraw-Hill.
Nathan, D. M., Davidson M. B., DeFronzo R. A., et al. (2007). Impaired fasting glucose and
impaired glucose tolerance: Implications for care. Diabetes Care. 30, 753-759.
Porth, C. & Matfin, G. (2009). Concepts of Diabetes Mellitus and the metabolic Syndrome.
In C.M. Mattson Porth (Eds.), Pathophysiology Concepts of Diabetes States (8th
ed. pp. 1075-1077).Philadelphia, PA: Lippincott Williams & Wilkins.
Shepard, P. R. & Kahn, B. (1999). Glucose transporters and insulin action. New England
Journal of Medicine, 341, 248-256.
University of Rochester Medical Center. (2008.) How diabetes drives atherosclerosis.
ScienceDaily.Retrieved from http://www.sciencedaily.com
Resources
http://stress.lovetoknow.com/about-stress/can-stress-causediabetes
http://www.diabetes.org/living-with-diabetes/seniors/livinghealthy-with-diabetes.html
www.netplaces.com/diabetes/what-is-diabetes/the-pancreasand-liver.htm
www.patienthealthinternational.com/highcholesterol/?itemId=1
620472&nav=yes
Post Test
Which of the following statements are TRUE?
Click to find the correct response:
1. Family History is a Modifiable risk factor?
2. Proper diet and exercise is a Modifiable risk factor?
3. Low levels of HDL are associated with heart disease?
4. An acceptable blood sugar is 66 taken at 0630 before
breakfast?
5. High fat diet, exercise and medication are ways to manage
coronary heart disease?