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14 Kareem Mahmoud

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I’m going to discuss this patient from the cardiologists perspective let’s summarize our patient he has an established cardiovascular disease who is newly diagnosed diabetes mellitus and multiple cardiovascular risk factors he has also target organ damage in the form of left ventricular hypertrophy and some other risk factors such as overweight family history and

Lack of exercise so the first step is to determine his risk and he’s actually as a very high risk as mentioned by dr. maja because he has established cardiovascular disease the target target work and damage and three or more major risk factors so based on that we will discuss this patient in three aspects the diabetes mellitus management the control of risk factor

And management of carotid disease first of all we’ll go to the core of our session which is diabetes mellitus this patient had this double profile that corrected over eight months to reach and acceptable remarkable human see of 7.1% so the question the question now which drug to start with of course i died semuc target is an appropriate target and we all need our

Patient to have an fm equivalency around seven percent however to reach this target we can use a multiple drugs some of them are very very good such as a metformin with a very good a good data good previous data however there is no large study that discussing the cardiovascular outcome in the mid form in some of these drugs has a neutral cardiovascular outcomes

Such as dd before most was most actually of dd before and some of these drugs may be harmful to the cardiac patient such as the d cds saxagliptin as a dd before and some generation of sulfonylurea and recently two classes were introduced into the lobby smartkey market which are glp-1 receptor agonist and sglt2 inhibitors and we’ll talk about them we will talk about

The trial of these two classes of drugs from this point of view the three point means which which are the cardiovascular deaths non-fatal myocardial infarction and non-fatal stroke so talking about j lb j lb one receptor agonist they have some difficulty and start to reach statistical significance of improving the cardiovascular outcome however the liraglutide the

Leader trial showed a significant reduction of a 3-point maze with a reduction of cardiovascular deaths and non-fatal myocardial infarction the c magnetite which is which given once-weekly through the injection should also a reduction of three point means mainly through the reduction of a non-fatal stroke and the orosi magnetite also show a reduction of three point

Means mainly through the reduction of a non-fatal stroke as well as the unit i ain’t you went to trial that showed a reduction of three point means and non-fatal bhaskar stroke so going to a second class and this is the three major trial of the classes that the drugs of sodium-glucose cotransport are two inhibitors which are which are mm barek for the impact of

Flows in the clear damien 58 for double flows in and canvas for chemically flossing if you appreciate the mpeg studied the patient was a current stablish cardiovascular disease however in the studies and the declare came in 58 the starvation to either establish cardiovascular disease or a multiple cardiovascular risk factors so what are the results in the america

There was a reduction of the three point means mainly through the reduction of the cardiovascular death and the canvas to a reduction of three appointments but with non significant reduction of the cardiovascular death however we have other beneficial effects such as and groove meant of the renal outcome and reduction of hospitalization of the heart failure this

Result was confirmed in the declared damien 58 that the flows in show the reduction of hospitalization of the heart failure in the cardiac patient and very high-risk patient so we have these two important classes for the management of diabetes now and according to the urban society of cardiology if we have our basis naively with established cardiovascular disease or

Very high risk or high cardiovascular risk we should start with one of these two tracks these two classes jd one or sglt2 inhibitors and if we didn’t reach the target we should we should go to the metformin and if we didn’t reach the target we should go to other drug with beneficial cardiovascular effect dd before if the patient was not in the glp-1 agonist basal

Insulin and maybe in some cases this deserves not a rare however it should be used in cope with cautious in the patient wastes established cardiovascular disease if the patient was already in metformin this is good so we add one of these two drugs observation for the patient with established cardiovascular disease or is a very high-risk and if he is not achieving

The goal we should add any other drug and this is the recommendation of the guideline every patient is established cardiovascular disease or a very high or high cardiovascular risk we mentioned this before and if the patient is a moderate risk we can start with metformin so if we look to the g will be one it can be it has a beneficial effect regarding the reduction

Of arteriosclerotic event actually the are beneficial reduction of an fatal mi and returns true and the sodium glucose transport sodium-glucose cotransport are 2 inhibitor showed a reduction of the heart failure related related endpoints and actually the body frozen was studied in the deb hf recently and showed a marvelous outcome regarding the patient’s heart

Failure even in the non diabetic patient so it can actually be used as a heart failure medication in the future okay going to the risk factors if we mentioned the lifestyle is very important the patient should stop smoking she should reduce his weight and reduce calorie intake and he should exercise regularly the blood pressure target he has a blood pressure or

150 over 90 this is not acceptable the blood pressure should should be lower than that with a target less than 130 but not less than 120 and a stolid pressure less than 80 but not less than 70 and the drug used here is the arb diuretics which is a good a very good drug actually but being the patient is not achieving the blood pressure target we should add a calcium

Channel blockers to for this what about his david profile actually this patient has a very poor lipid profile with and he is not achieving neither the energy target h delta none hdl target nor the triglyceride and for the ldl target this patient being a very high risk he should have ldl less than 55 milligram per liter with more than 50% reduction in ldl and

Non hdl called 0 less than 85 milligram per deciliter and to do that we should start i do statin i the reserve a certain 20 to 40 milligram per day or to verse 13 – 80 milligram per day and if we note reaching the target we should add is it a mile then if we not reaches the target we should add pcsk9 inhibitor what about the tribalist right the first line for the

Management of tracker scientists in the state and the state and should be given as a triglyceride as more than 200 milligram per deciliter but if the patient is not achieving this target and still having a triglyceride between 135 250 500 milligram per deciliter – so we should add the new drug which is a kosovan tsi in a high dose before gram per day this is based

On the reduce at trial the reduced trial showed intubation twith establish cardiovascular disease or a high cardiovascular risk adding this drug showed a very favorable cardiovascular outcome reduction regarding the reduction of the primary and the secondary cardiovascular outcome so this drug is the future and should be added for the patient with a high bar at

Least reggie mia the pheno vibrate actually has a class to be to be added to this patient so it should be reserved with if if we have a very high triglyceride and a quiz event is i should be the first line of the management of this patient what about the preneur disease the chronological zzz this patient have a macarthur a function from six months so he should

Continue on the rasp locker and the statin for the reduction of the cardiovascular death he should continue on the aspirin for life and regarding the be two by twelve inhibitor preferably the ticket roll or brass rm plus one to continue on these drugs for one year and we may continue this drug up to three years if the patient has no increased the bleeding risk

The beta blocker should be in the diabetic patient should not be prolonged because it might be associated with adverse outcome – so to conclude i think irish my identity’s my time dr. nabil so to conclude we have now a prescription we can add some drugs and we can prescribed a more drugged with beneficial effect for our cardiac patient with a very high risk this

Include the new anti-diabetic drugs with a proven cardiovascular outcome this includes the new distributing a drugs such as micro cement inside and the pcsk9 if the patient is not achieving the ldl and triglyceride pools in addition to the current medication of course this will come on the expense of the cost and the patient patient may suffer from the increased

Cost of the cost of this medication however i think we have an answer now if our patient start to ask how can i improve my cardiovascular outcome and prevent a future cardiovascular effect and thank you so much

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14 Kareem Mahmoud By WebCast Streamer