XI. STRATEGIES FOR IMPROVING DIABETES CARE D iabetes is a chronic illness that requires continuing medical care and patient self-management education to prevent acute complications and to reduce the risk of long-term complications. Diabetes care is complex and requires that many issues, beyond glycemic control, be addressed. A large body of evidence exists that supports a range of interventions to improve diabetes outcomes. These standards of care are intended to provide clinicians, patients, researchers, payors, and other interested individuals with the components of diabetes care, treatment goals, and tools to evaluate the quality of care. While individual preferences, comorbidities, and other patient factors may require modification of goals, targets that are desirable for most patients with diabetes are provided. These standards are not intended to preclude more extensive evaluation and management of the patient by other specialists as needed. For more detailed information, refer to Bode (Ed.): Medical Management of Type 1 Diabetes (1), Burant (Ed): Medical Management of Type 2 Diabetes (2), and Klingensmith (Ed): Intensive Diabetes Management (3). The recommendations included are diagnostic and therapeutic actions that are known or believed to favorably affect health outcomes of patients with diabetes. A grading system (Table 1), developed by the American Diabetes Association (ADA) and modeled after existing methods, was utilized to clarify and codify the evidence that forms the basis for the recommendations. The level of evidence that supports each recommendation is listed after each recommendation using the letters A, B, C, or E.

Standards of Medical Care in Diabetes

Table of contents Preamble Scope of the document 1256 Method 1257 Part 1. Classification, epidemiology and prognosis Definition 1258 Brief overview of pathophysiology of syncope 1258 Classification 1259 Epidemiological considerations 1259 Prognostic stratification: identification of factors predictive of adverse outcome 1260 Part 2. Diagnosis Strategy of evaluation (flow chart) 1262 Initial evaluation (history, physical examination, baseline electrocardiogram) 1264 Echocardiogram 1266 Carotid sinus massage 1266 Tilt testing 1268 Electrocardiographic monitoring (non-invasive and invasive) 1271 Electrophysiological testing 1273 ATP test 1277 Ventricular signal-averaged electrocardiogram 1278 Exercise testing 1278 Cardiac catheterization and angiography 1279 Neurological and psychiatric evaluation 1279 Diagnostic yield and prevalence of causes of syncope 1282

Guidelines on management (diagnosis and treatment) of syncope

Background Little is known about the epidemiology and prognosis of syncope in the general population. Methods We evaluated the incidence, specific causes, and prognosis of syncope among women and men participating in the Framingham Heart Study from 1971 to 1998. Results Of 7814 study participants followed for an average of 17 years, 822 reported syncope. The incidence of a first report of syncope was 6.2 per 1000 person-years. The most frequently identified causes were vasovagal (21.2 percent), cardiac (9.5 percent), and orthostatic (9.4 percent); for 36.6 percent the cause was unknown. The multivariable-adjusted hazard ratios among participants with syncope from any cause, as compared with those who did not have syncope, were 1.31 (95 percent confidence interval, 1.14 to 1.51) for death from any cause, 1.27 (95 percent confidence interval, 0.99 to 1.64) for myocardial infarction or death from coronary heart disease, and 1.06 (95 percent confidence interval, 0.77 to 1.45) for fatal or nonfatal stroke. The...

Incidence and prognosis of syncope

Clinical trials of 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors or statin therapy have demonstrated that baseline or treated low-density lipoprotein (LDL) cholesterol levels are only weakly associated with net coronary angiographic change or cardiovascular events. The beneficial effects of statins on clinical events may involve nonlipid mechanisms that modify endothelial function, inflammatory responses, plaque stability, and thrombus formation. Experimental animal models suggest that statins may foster stability through a reduction in macrophages and cholesterol ester content and an increase in volume of collagen and smooth muscle cells. The thrombotic sequelae caused by plaque disruption is mitigated by statins through inhibition of platelet aggregation and maintenance of a favorable balance between prothrombotic and fibrinolytic mechanisms. These nonlipid properties of statins may help to explain the early and significant cardiovascular event reduction reported in several clinical trials of statin therapy.

https://jamanetwork.com/journals/jama/articlepdf/187556/JCC80006.pdf

Antiatherothrombotic Properties of Statins Implications for Cardiovascular Event Reduction

Renal artery stenosis (RAS) can accelerate or generate progressive hypertension and renal dysfunction. The goals for treating patients with RAS are to reduce cardiovascu-lar morbidity and mortality attributable to elevated arterial pressure and to preserve renal function beyond critical stenosis. Recent, randomized trials with current anti-hypertensive agents indicate that many patients with RAS can be managed for years without renal artery revascularization. As it does elsewhere, atherosclerotic disease can progress to more severe occlusion in the renal arteries. Rapid advances in endo-vascular techniques, including stenting, make restoration of renal blood flow possible in more patients than before. Therapeutic goals are achieved by 1) avoidance of tobacco, 2) reducing arterial pressure with antihypertensive drug therapy, particularly those agents capable of blocking the renin-angiotensin system, and 3) renal revascu-larization, using balloon angioplasty and stent placement, surgical bypass, or endart-erectomy. The major clinical challenges are to identify progressive occlusive disease and to determine appropriate timing for vascular intervention.

Renal-Artery Stenosis

Objective The objective of this study was to examine the prevalence and correlates of postural hypotension (defined as a drop in systolic blood pressure of greater than or equal to 20 mm Hg) in a cohort of elderly persons with isolated systolic hypertension (ISH). Design Baseline cross-sectional analysis of the 4,736 persons randomized in the Systolic Hypertension in the Elderly Program (SHEP). Setting A randomized multi-center double-blind outpatient clinical trial of the impact of treating ISH. Participants Men and women age greater than or equal to 60 years with the systolic blood pressure (SBP) greater than or equal to 160 mm Hg and diastolic blood pressure (DBP) less than 90 mm Hg. Measures Medical histories were obtained using interviewer-administered, standardized clinical history forms. At entry into the study, seated and standing BP was measured by certified BP technicians using a random zero sphygmomanometer. Postural hypotension (PH) was assessed at 1 and 3 minutes after the participant arose from a seated position. Main results PH was found in 10.4% of participants at 1 minute and in 12.0% of participants at 3 minutes. 5.3% of participants demonstrated PH at both time intervals while 17.3% demonstrated PH at either or both of the time intervals. Factors significantly (P less than 0.05) associated with the presence of PH were higher mean SBP and a lower mean body mass index. Conclusions Somewhat different persons were defined as having PH based upon the 1 minute and 3 minute standing measures of BP, and prevalence estimates of PH can vary depending on whether one or more intervals of measurement are used. Cross-sectional data analysis indicated that PH, in healthy community-dwelling older persons with ISH, may not be associated with a history of disorders or problems usually thought to be related to PH. However, prospective data are needed to determine the prognostic significance of PH, and whether one or multiple measurements carry more significance.

Prevalence of postural hypotension at baseline in the Systolic Hypertension in the Elderly Program (SHEP) cohort.

https://www.amjmed.com/article/0002-9343(85)90032-4/pdf

Evaluation of prognostic classifications for patients with syncope.

To improve the diagnosis and forecast the response to surgery or renal angioplasty in patients with hypertension and renal artery stenosis, we employed a simplified captopril renography protocol in conjunction with renal arteriography in 94 clinically selected patients. Fifty hypertensive patients (group 1) with a high clinical likelihood of renovascular hypertension were evaluated using a simplified captopril renography protocol and renal angiography on the arterial side. Criteria for normal captopril renal scintigrams were established based on this original cohort and validated in an additional 44 clinically comparable patients (group 2). Renal revascularization or nephrectomy was performed in 39 patients, and success of the procedure was determined in the 34 patients for whom 3-month follow-up was available. In the 94 patients, 44 (47%) had renal artery stenosis. Simplified captopril renography was 91% sensitive and 94% specific in identifying or excluding renal artery stenosis in the combined group, with no difference in the diagnostic utility between groups 1 and 2, or in those with renal insufficiency (n = 38) or those with bilateral disease (n = 17). Scintigraphic abnormalities induced by captopril were strongly associated with cure or improvement in blood pressure control following revascularization or nephrectomy (15 of 18), while the lack of captopril-induced changes was associated with failure of such intervention (13 of 16) (p = 0.0004). We conclude that simplified captopril renography is highly sensitive and specific in the diagnosis of renal artery stenosis in a clinically selected high-risk population and that the test accurately predicts the success or failure of therapeutic intervention.

Simplified captopril renography in diagnosis and treatment of renal artery stenosis.

https://www.amjmed.com/article/0002-9343(86)90303-7/pdf

Racial differences in serum creatine kinase levels

We reviewed the charts of 100 patients admitted to the hospital for evaluation of syncope. The charts were examined with special attention given to the causes of syncope, the frequency and benefit of diagnostic tests, and the relative cost of these tests. In 39 patients no etiology for syncope was found, and another 18 were felt to have had a vasovagal episode. Twelve patients had arrhythmias as the cause for syncope. Most of the patients underwent a variety of diagnostic tests including cardiac enzyme determinations, brain scans, electroencephalograms, head CAT scans, and Holter monitoring. In most instances, these tests added little useful information to the initial history and physical exam and were done at great expense to the patient. Our data suggest that extensive neurologic testing in patients with "routine" syncope is not warranted and that the focus of hospitalization should be to rule out potentially life-threatening arrhythmias.

Henry R. Black

Papers

Prevalence of postural hypotension at baseline in the Systolic Hypertension in the Elderly Program (SHEP) cohort.

Evaluation of prognostic classifications for patients with syncope.

Simplified captopril renography in diagnosis and treatment of renal artery stenosis.

Racial differences in serum creatine kinase levels

The impact of diagnostic tests in evaluating patients with syncope.