Cardiovascular Disease and mortality- Is it changing in Type 1 and Type 2 Diabetes, Now ?

It is our hope that the morbidity and mortality should be much less with introduction of many antidiabetic, antihypertensive and anti lipidemic therapies in the past few decades. In one recent study published in the NEJM.org the absolute changes in the incidence rates of sentinel outcomes per 10,000 person-years were observed in the type 1 and type 2 diabetes patients 198-2012.

Patients with type 1 diabetes had roughly 40% greater reduction in cardiovascular outcomes (CVOs) than controls, and patients with type 2 diabetes had roughly 20% greater reduction than controls. Reductions in fatal outcomes were similar in patients with type 1 diabetes and controls, "whereas patients with type 2 diabetes had smaller reductions in fatal outcomes than controls".

This finding of Swedish doctors from 1998 through 2014, mortality and the incidence of cardiovascular outcomes declined substantially among persons with diabetes, although fatal outcomes declined less among those with type 2 diabetes than among controls, makes us think what could be reason for failure to reduce the fatal outcomes more significantly ? we have introduced so many new ways to treat these patients medically with drugs and interventions! Why these are adding up to reduce the fatal outcomes! in type 2 diabetes.  May be we have not understood the pathophysiology adequately and so the corrective measures are not effective too!

Reference: 

1). Aidin Rawshani,., Araz Rawshani, Stefan Franzén, Björn Eliasson,, Ann-Marie Svensson, Mervete Miftaraj, Darren K. McGuire, Naveed Sattar, Annika Rosengren, and Soffia Gudbjörnsdottir. Mortality and Cardiovascular Disease in Type 1 and Type 2 Diabetes. N Engl J Med 2017; 376:1407-1418

Is there Risk of Bleeding After Carotid Endarterectomy with dual antiplatelet therapy?

May of us are concerned about the unexpected bleeding after carotid endarterectomy. Some times suture needle puncture bleeds for a long time after endarterectomy. Some of  us assume that this could be more if the patient is on two or more anti platelet drugs preoperatively. Most of these patients might have already undergone coronary stenting procedures earlier. The cardiologist would like to  continue the antiplatelet drugs in perioperative period as there is risk of stent thrombosis in the absence of these drugs. Giulio Illuminati et al recently published their data related to the safety of using dual antiplatelet therapy in the carotid endarterectomy patients. 188 patients received dual anti platelet drugs (Aspirin 100mg, Clopidogrel 75mg) and Inj. LMWH- 2000 units B.D (till discharge) in the post operative period, started 6 hours after surgery without any complications. There were no postoperative cervical hematomas requiring surgical evacuation. There was one hypoglossal nerve palsy, which regressed within 2 weeks. There was no postoperative mortality and neurologic and cardiac morbidity.
This study is too good to believe and I am sure some surgeons will be still apprehensive to use this regimen after carotid endarterectomy in their practice.

Reference:
1) Giulio Illuminati, Fabrice Schneider, Giulia Pizzardi, Federica Masci, Francesco G. Calio', Jean-Baptiste Ricco. Dual Antiplatelet Therapy Does Not Increase the Risk of Bleeding After Carotid Endarterectomy: Results of a Prospective Study. Annals of Vascular Surgery. 2017; 40:39 - 43

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Giulio Illuminati

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Affiliations

• The Department of Surgical Sciences, University of Rome “La Sapienza”, Rome, Italy

Correspondence

• Correspondence to: Giulio Illuminati, MD, The Department of Surgical Sciences, University of Rome “La Sapienza”, Via Vincenzo Bellini 14, Rome 00198, Italy

Real-world economic burden of VTE and VTE prophylaxis in clinical practice

It is a general opinion that the treatment of VTE will be more expensive than the prevention of VTE with prophylactic measures. So, there is need to consider the thromboprophylaxis in our patients who are at high risk of VTE to reduce the overall economic burden in the world. In their study, Gussoni G et al (1) noticed that costs for VTE management (the total median) were around four-times higher than those for VTE prophylaxis (€ 1,348.68 vs € 373.03). This means if we follow the evidence-based protocols for VTE prevention, it could limit the current financial burden of VTE on our health budgets. Many clinicians may not feel this net clinical benefit in their small group of patients to get convinced about the larger role of thromboprophylaxis in the health care systems. 

Reference

1). Gussoni G, Foglia E, Frasson S, Casartelli L, Campanini M, Bonfanti M, Colombo F, Porazzi E, Ageno W, Vescovo G, Mazzone A; FADOI Permanent Study Group on Clinical Governance. A real-world economic burden of venous thromboembolism and antithrombotic prophylaxis in medical inpatients. Thromb Res. 2013 Jan;131(1):17-23