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Volume 10, Number 10 October 2007 - National Diabetes Education ...

Professional Postgraduate Services ®Release Date: October 2007Valid Through: February 2008SponsorThis educational activity is a component of theNational Diabetes Education Initiative ® (NDEI ® ),sponsored by Professional Postgraduate Services ®(PPS).Clinicians who wish to receive CME credit forthis educational activity should do the following:(1) read the current issue; and (2) complete thepost-test and evaluation form included to concludethis CME activity. You may also complete the posttestand evaluation form on our website,www.ndei.org. To apply for CME credit, return thecompleted post-test and evaluation form to:Professional Postgraduate Services ®CME Dept. T196150 Meadowlands ParkwaySecaucus, NJ 07094-1505You may also fax the completed materials to1 (201) 430-1441. If you have any questions,please call 1 (800) 606-6106 Ext. 6014.Applicants will receive a certificate of participationfrom PPS by return mail within 6 to 8 weeks of thedate of receipt of the completed evaluation formand post-test. Online applicants will automaticallyreceive their CME credit certificate upon completionof the online post-test and evaluation form.Target AudienceThis educational activity is designed for primarycare physicians, internal medicine specialists,endocrinologists, diabetologists, cardiologists, andother healthcare professionals involved in the careand management of patients with type 2 diabetes,insulin resistance, and cardiovascular disease.Learning ObjectivesWith information from the latest evidence-basedstudies, participants should be able to:• Identify patients with insulin resistance, type 2diabetes, and/or cardiovascular disease• Select the most appropriate therapeutic regimenfor patients with type 2 diabetes and itsmacrovascular and microvascular complications• Identify risk factors for cardiovascular diseasein patients with type 2 diabetes and select anappropriate therapeutic regimenAccreditationProfessional Postgraduate Services is accredited bythe Accreditation Council for Continuing MedicalEducation to provide continuing medical educationfor physicians.Professional Postgraduate Services designates thiseducational activity for a maximum of .75 AMAPRA Category 1 Credit . Physicians should onlyclaim credit commensurate with the extent of theirparticipation in the activity.AAFP creditClinical Insights ® in Diabetes has been reviewed andis acceptable for up to 9 Prescribed credits by theAmerican Academy of Family Physicians. AAFPaccreditation begins 5/1/07. Term of approval is forone year from this date. This issue is approved for.75 Prescribed credit. Credit may be claimed for oneyear from the date of this issue.GrantorThis CME activity is supported by aneducational grant from Takeda PharmaceuticalsNorth America, Inc.Off-Label DisclosureSome of the drug treatments discussed in this issuemay note uses not approved by the Food and DrugAdministration. Articles containing such uses willbe noted at the end of the article.Professional Postgraduate Services is a business unitof KnowledgePoint360 Group, LLC, Secaucus, NJ.CLINICAL INSIGHTS ®INDiabetesMAYER B. DAVIDSON, MD,* CO-EDITOR-IN-CHIEF; SILVIO E. INZUCCHI, MD, † REVIEWER;TERRENCE F. FAGAN, ‡ MANAGING EDITOR AND CO-WRITER; CHING-LING CHEN, PhD, ‡ CO-WRITERThe Association of Nonalcoholic Fatty Liver DiseaseWith CVD Event Risk in Patients With Type 2 DiabetesRecent data suggest that the presence ofnonalcoholic fatty liver disease (NAFLD) inpatients with type 2 diabetes may lead toincreased risk of cardiovascular disease (CVD)independent of components of the metabolicsyndrome. To test this hypothesis, Targher andcolleagues assessed whether an ultrasound diagnosisof NAFLD predicted the risk of incidentCVD events in a large cohort of adults with type2 diabetes.Study subjects were outpatients with type 2diabetes (n=2,103) in the Valpolicella (Italy)Heart Diabetes Study. During 6.5 years offollow-up (range: 5 to 84 months), 384 patientsdeveloped CVD events (151 nonfatal myocardialinfarctions [MI], 68 coronary revascularizations,44 cases of nonfatal ischemic stroke, and 121cardiovascular deaths). These patients wereolder, had higher A1C levels and liver enzymes,a greater prevalence of metabolic syndrome,and a higher frequency of NAFLD than thosewithout CVD events. Diabetes duration, LDLcholesterol, sex, smoking, and treatment didnot differ between the groups.In multivariate regression analysis, NAFLDwas significantly associated with an almostdoubling of incident CVD events (hazard ratio[HR], 1.96; 95% confidence interval [CI], 1.4-2.7;P

CLINICAL INSIGHTS ®IN DIABETESYou have received thisfax because we believe itmay be of interest to you.If you would like your nameto be removed from theClinical Insights ® in Diabetesnewsletter fax list, pleasefollow these instructions:Call toll-free 1 (866) 860-3439,enter PIN 6114, followed bythe # key and fax number.VISIT OUR WEBSITEwww.ndei.org to register forType 2 Diabetes, MetabolicSyndrome, and CVD:Clinical Implicationsof Recent Pivotal Trials,A Case-Based CME/CEDinner Meeting.This unique forumwill take place on:Thursday, November 15, 2007at 6:30 PMThe Omni Los AngelesHotel at California Plaza251 South Olive StreetLos Angeles, CaliforniaNonfasting Triglycerides Associated With Increased Riskof Cardiovascular EventsAlthough the association of triglycerideswith cardiovascular disease (CVD) remainscontroversial, patients with moderate hypertriglyceridemiaand other lipid risk factors oftendevelop premature atherosclerosis. It has beensuggested that chylomicron remnants and verylow-density lipoprotein remnants in the plasmaof patients with hypertriglyceridemia penetratethe arterial intima and are trapped within thearterial wall, thereby contributing to the formationof foam cells and promoting the developmentand progression of atherosclerosis. Sinceremnant lipoproteins are present in elevatednonfasting triglycerides, atherosclerosis has beenconsidered by some a “postprandial phenomenon.”Although fasting triglycerides are routinelymonitored for lipid profile, postprandialtriglyceride levels may be an important measurefor predicting risk of CV events.Two manuscripts recently published in theJournal of the American Medical Associationprovide support for the role of nonfastingtriglyceride levels as an independent predictorfor CV events.Copenhagen City Heart StudyTo test the hypothesis that very high levelsof nonfasting triglycerides predict CV eventsincluding myocardial infarction (MI), ischemicheart disease (IHD), and death, Nordestgaardand colleagues conducted a large prospectivecohort study involving 13,981 individuals, aged20 to 93 years, drawn from the general populationof Copenhagen, Denmark. Main outcomemeasures were hazard ratios (HRs) for incidentMI, IHD, and death with increased levels of nonfastingtriglycerides, which were stratified by88.5 mg/dL increments into 5 groups vs a referentgroup of

CLINICAL INSIGHTS ®IN DIABETESNonfasting Triglycerides and CV EventsContinuedBoth studies strongly support the notionthat nonfasting triglyceride levels are associatedwith incident CV events. Nonfasting rather thanfasting triglyceride levels might therefore somedaybe employed in the risk assessment for CVevents, particularly in women. This might actuallysimplify blood sampling for lipid management.Furthermore, the findings by Nordestgaard et alof the relationship of remnant lipoproteins andnonfasting triglycerides may offer options fordesigning new trials or new agents that aim atreducing postprandial triglyceride levels or attenuatingatherogenic metabolic abnormalitiessuch as remnant lipoproteins.Nordestgaard BG et al. Nonfasting triglycerides and riskof myocardial infarction, ischemic heart disease, anddeath in men and women. JAMA. 2007;298:299-308.Bansal S et al. Fasting compared with nonfastingtriglycerides and risk of cardiovascular events in women.JAMA. 2007;298:309-316.Biology of Leg Disorders(BOLD) InitiativeCOMING TO A LOCATIONNEAR YOU!A NationwideEducational SimulcastDifferentiating Leg Disorders:Strategies for Diagnosis andTreatment in the PrimaryCare SettingBroadcast simultaneously toexclusive sites across the country,this certified activity will include anin-depth review of the multiplepathways involved in dozens ofleg disorders, focusing on thechallenge of differential diagnosis,often complicated by primary andsecondary symptoms and comorbiddisease, and a critical examinationof treatment options.Saturday, November 3, 2007 –3.0 CME/CE CreditsRegister on LegDisorders.orgHigher Mortality in Diabetes Following AcuteCoronary SyndromesThe rise in worldwide prevalence of type 2diabetes raises the burden of cardiovasculardisease (CVD) as well. The Framingham HeartStudy reported a 3-fold increase in age-adjustedCV mortality in patients with diabetes. Approximatelytwo thirds of patients with diabetes inthe United States die from CVD. Moreover,diabetes is considered as a risk equivalent ofcoronary artery disease for myocardial infarction(MI) and CV mortality. It is not clear, however,whether diabetes is an independent predictorfor mortality following acute coronary syndromes(ACS).In this report, Donahoe and colleagues assessedthe independent effect of diabetes onmortality following ACS from a large clinical trialdatabase covering the full spectrum of ACS andtheir medical therapies. Patients with ACS werepooled from 11 independent Thrombolysis inMyocardial Infarction (TIMI) Study Group clinicaltrials from 1997 to 2006. A total of 62,036 patients,which included 46,577 with ST-segmentelevation myocardial infarction (STEMI) and15,459 with unstable angina/non-STEMI(UA/NSTEMI), were evaluated. Among this group,10,613 (17.1%) had self-reported diabetes.The primary outcome measures were shortterm(30 days) and long-term (1 year) mortalityfollowing ACS. Mortality rates were comparedamong patients with and without diabetes in3 populations, including all patients with ACS,patients with UA/NSTEMI, and patients withSTEMI. A multivariable model was generated toadjust for baseline characteristics, ACS clinicalpresentations, and ACS medical therapies used.Compared with patients without diabetes,those with the disease at ACS presentation wereolder, more often women, had a higher bodymass index, and were more likely to have a historyof hypertension, hyperlipidemia, previousMI, and coronary artery bypass graft surgery.These patients also had a higher TIMI risk scoreand a higher risk of heart failure. Patients withUA/NSTEMI had a higher prevalence of diabetesthan those with STEMI (22.4% vs 15.4%;P

CLINICAL INSIGHTS ®IN DIABETESClinical Insights ® in Diabetes Post-Test October 20071) Two recent studies examining the impact of nonfasting triglyceride levels on cardiovascular (CV)events showed all but one of the following:a. Nonfasting triglyceride levels are associated with incident CV eventsb. Nonfasting triglyceride levels showed greater predictive ability in women than in menc. Fasting triglyceride levels showed stronger association with CV events than nonfastingtriglyceride levels in models adjusted for multiple variablesd. Risk of CV events was greater at higher nonfasting triglyceride levels2) In a study of patients with type 2 diabetes, the presence of nonalcoholic fatty liver disease wassignificantly associated with increased risk of cardiovascular disease except after adjusting for whichof the followinga. Metabolic syndromeb. Diabetes durationc. LDL cholesterold. None of the above3) In a study of patients following acute coronary syndromes, diabetes was an independent risk factorfor mortality at 30 days and 1 year in patients with ST-segment elevation myocardial infarction(STEMI), but not with unstable angina/non-STEMI.a. Trueb. FalseANSWER KEY1. c. Fasting triglyceride levels showed stronger association with CV events than nonfasting triglyceride levelsin models adjusted for multiple variables. After adjusting for age, blood pressure, smoking, and use ofhormone therapy, both fasting and nonfasting triglyceride levels were strongly associated with CV events.Among fasting participants, further adjustment for total and high-density lipoprotein cholesterol and forindicators of insulin resistance substantially weakened this association, making it nonsignificant. In contrast,nonfasting triglyceride levels maintained a strong and significant association with CV events in fullyadjusted models.2. d. None of the above. In multivariate regression analysis, nonalcoholic fatty liver disease was significantlyassociated with incident CVD events after adjusting for age, A1C, diabetes duration, smoking, sex,LDL cholesterol, and medications. Further adjustment for metabolic syndrome had little effect onthe association.3. b. False. Diabetes was an independent risk factor for mortality at 30 days and 1 year in patients withST-segment elevation myocardial infarction (STEMI) as well as patients with unstable angina/non-STEMI.NDEI MISSION STATEMENTThe National Diabetes EducationInitiative ® (NDEI ® ) is a multicomponenteducational program on type 2 diabetesdesigned for endocrinologists, diabetologists,cardiologists, primary carephysicians, and other healthcareprofessionals involved in the care andmanagement of patients with type 2diabetes and insulin resistance. NDEIprograms address issues concerninginsulin resistance and type 2 diabetes,from the epidemiology and pathophysiologyof the disease and its associatedcomplications to the therapeuticoptions for treatment and prevention.National Diabetes Education Initiative,NDEI, and Clinical Insights are trademarksused herein under license.Copyright © 2007 ProfessionalPostgraduate Services ® .All rights reserved.Clinical Insights ® in Diabetes is co-edited by NDEI faculty members Mayer B. Davidson, MD, and Silvio E. Inzucchi, MD.You have received this email because we believe it may be of interest to you. If you would like yourname to be removed from the Clinical Insights ® newsletter email list, please click on the following linkwww.pps-sso.com.If you have any colleagues who are not receiving this free, CME e-newsletter via email, please fill in theirinformation on the lines below and fax this page back to us at 1 (800) 471-7716 and we will add them toour subscriber list.PLEASE PRINT CLEARLY:Name:Address:City:Phone:For more information about upcoming NDEI CME and CE activities, visit us at www.ndei.org or call1 (800) 606-6106, ext. 6014. Visit www.ppscme.org for information on other CME or CE activities.Email Address: State: ZIP Code: - - Fax: - - Professional Classification: MD DO PharmD RN NPSpecialty: Endocrinology Cardiology Internal medicine Family medicineOther ___________________________________________________________________________EM-T196-7-PHYCME-10074

CLINICAL INSIGHTS ®IN DIABETESActivity Code: T196-7Issue Date: October 2007CME Credit Availability: Through February 2008CME Activity Evaluation/Registration FormParticipants who wish to obtain CME credit for this educational activity, please complete the contact information below, sign thisform, and fax it with the completed post-test to 1 (201) 430-1441 or mail to: Professional Postgraduate Services ® , CME Dept. T196,150 Meadowlands Parkway, Secaucus, NJ 07094-1505. You may download previous issues of Clinical Insights ® in Diabetes e-newslettersby visiting us online at www.ndei.org.I have completed this activity as designed: ________________________________________________________________________________(Signature)(Date)PLEASE PRINT CLEARLY:Name:Address:City:Phone:Email Address: State: ZIP Code: - - Fax: - - Professional Classification: MD DO PharmD RN NPOther ____________________________________________________________________________________Specialty: Endocrinology Cardiology Internal medicine Family medicineOther ______________________________________________________________________________________________________1. The activity met the stated objectives in such a way that I am better able to:StronglyDisagree Disagree AgreeStronglyAgreea. Identify patients with insulin resistance, type 2 diabetes, and/orcardiovascular disease1 2 3 4 5 6b. Select the most appropriate therapeutic regimen for patients with type 2diabetes and its macrovascular and microvascular complications1 2 3 4 5 6c. Identify risk factors for cardiovascular disease in patients with type 2 diabetesand select an appropriate therapeutic regimen1 2 3 4 5 62. Overall, the activity was presented in a fair-balanced manner. Yes No** If you checked “No,” please explain.3. Overall, the activity was free from commercial bias. Yes No** If you checked “No,” please explain.4. In reflecting on your practice, what type of impact will this educational activity have?This program has validated my practice in the treatment of type 2 diabetes and its cardiovascular complications.Need more information before making a change.(Please specify what information you would require.)5. What is the largest challenge or unmet educational need in your practice?6. What other clinical issues are you and your colleagues challenged by that could be addressed in a CME activity? (Please specify.)Thank you for your participation.5

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