Pathophysiology, Assessment, And Management Of Macrovascular Complications In Diabetes

Pathophysiology of Macrovascular Complications in Diabetes

Diabetes Mellitus (DM) is a metabolic disorder. It is characterized by hyperglycemia that generates due to disequilibrium in insulin secretion and/or insulin action. The pathological hallmark of DM encompasses vasculature leading to microvascular and macrovascular complications. The microvascular complications like nephropathy and retinopathy accelerates the chance of developing macrovascular complications, which promotes atherosclerosis and eventually leads to the development of cardiovascular disease, peripheral vascular disease and stroke (Marieb & Hoehn, 2015). The following essay aims to highlight the pathophysiology associated with macrovascular complications of diabetes followed by assessment and diagnostic criteria. At the end, the essay will explore common treatment and management principles underlying macrovascular complications of diabetes.

According to Chilelli, Burlina and Lapolla (2013), the main pathological mechanism in macrovascular complications in DM mainly involves atherosclerosis. Atherosclerosis results from chronic injury or inflammation of the wall of arteries present in the coronary or peripheral vascular system. Inflammation the walls of the arteries cause oxidation of the lipids from low-density-lipoprotein particles under the action of angiotensin II. The oxidized lipid particles accumulate in the endothelial walls leading to narrowing (Bullock & Hales, 2016). The activation of the inflammatory pathway causes stimulation and proliferation of macrophage and attraction of T-lymphocyte at the site of inflammation. The activated T-lymphocyte induces proliferation of smooth muscle in the arterial walls and simultaneous collagen accumulation leading to thickening of arteries. The arterial inflammation leads to narrowing of the arterial walls throughout the body and thereby increasing the chance of cardiovascular accident (Chilelli, Burlina & Lapolla, 2013).

Chawla, Chawla and Jaggi (2016) highlighted the pathophysiology underlying the inflammation in diabetes and subsequent development of macrovascular complications in details. According to Chawla, Chawla and Jaggi (2016), hyperglycemia provokes monocyte adhesion to the arterial cells. These monocyte adhserion triggers type 1 hypersensitivity reaction, promoting the accumulation of the primary mediators of hypersentivity and thereby causing thickening of the arteries. Increase blood glucose level activates matrix-degrading enzyme metalloproteinase, which cause plaque rupture and arterial remodelling leading toe thickening of the arteries. Diabetes also increases the secretion of the primary inflammatory mediators like C-reactive protein, plasminogen activator inhibitor and interleukine-6 that cause activation of macrophage and thereby leading to the development of inflammatory reaction under the influence of protein kinase C (PKC) pathway.

Another underlying pathophysiology behind the development of the macrovascular complications include increased rate of platelet adhesion and hypercoagulability (Zhang et al., 2014). Impaired nitric oxide generation, free radical formation in the platelets and altered calcium regulation promote platelet aggregation cause hypercoagulability. Increased levels of plasminogen activator inhibitor type 1 impair fibrinolysis in patients with diabetes. The combination of these cause increased level of platelet coagulability which in turn cause vascular occlusion and cardiovascular events in type 2 diabetes (Zhang et al., 2014).

Assessment and Diagnostics of Macrovascular Complications in Diabetes

Chawla, Chawla and Jaggi (2016) stated that hyperglycemia and insulin resistance are main reasons behind the development of macrovascular complications of diabetes. Development of diabetes is inherently associated with hyperglycemia. However, insulin resistance develops years before hyperglycemia and during the course of time becomes clinically significant. Obesity plays an important role in the development of insulin resistance (common among the people with type 2 diabetes). The release of free-fatty acids, inflammatory mediators and reactive oxygen species increases the chance of systemic inflammation and thereby leading to the development of atherosclerosis.  

The study conducted by Donaghue et al. (2014) highlighted that assessment of macrovascular complication of diabetes should start after the age of 10. The main screening methods that are used to highlight the marcrovascular complications include testing the lipid profile of the individual after every 5 years along with the annual tabulation of blood pressure. Truong, Maahs and Daniels (2012) highlighted that for type 1 diabetes (T1D) individuals, with no significant family history of early cardiovascular disease or individuals who are over 12 years of age, should undergo proper screening of glycemic level after every 5 years. If T1D have family history of cardio-vascular disease then fasting lipid profile must be used as screening tool for the detection of macrovascular complications. If lipid screening is found to be abnormal, annual screening is recommended. For type 2 diabetes (T2D), lipid profile must be done after every 2 years if lipid content of the blood is found within the permissible range (Truong, Maahs & Daniels, 2012). Other hallmarks apart from blood lipid concentration, which can be used to detect the tendency of developing macrovascular complication, include microalbuminuria. Donaghue et al. (2014) stated that microalbuminuria is confirmed via analysis of two or three samples for a period of three to six months. Persistent microalbuminuria is found to predict the end stage of the renal failure, which in turn increases the chance of developing macrovascular disease. Donaghue et al. (2014) highlighted that loss of nocturnal dipping on round the clock blood pressure monitoring is regarded as the early marker for the assessment diabetic renal disease which simultaneously precedes towards microalbuminuria leading the renal hypertrophy and subsequent development of macrovascular complications.

In the domain of selection of the proper assessment and diagnostic tool for the detection of macrovascular diseases (MVD) in diabetes, Papa et al. (2013) conducted a population based study. 1199 diabetic cohort from outpatient department were selected on the basis of their cardiovascular history and other medical and hospital records (cardiac index, brachial index, duplex ultrasonography of the carotid and lower limbs, computed tomography angiography and peripheral arteriography). Over the selected group of individuals, Papa et al. (2013) conducted standardized procedure for the assessment of macrovascular complications. The analysis of the results indicated that the phenotypic heterogeneity is associated with different types of macrovascular complications among type 2 diabetes patients. They are also found to have different metabolic syndrome. Depending on this phenotypic heterogeneity, the development of the diagnostic tools and therapeutic strategies for MVD must be selected (Papa et al., 2013).

Treatment and Management of Macrovascular Complications in Diabetes

Park et al. (2015) highlighted that the diagnostic method that can be used for the detection of MVD include bronchial artery ultrasound for the detection of flow-mediated dilation. Other diagnostic test for the detection of arthrosclerosis, include cardiac catheterization, angiogram and echocardiogram. These tests help to analyze the position where exact thickening of the arteries have occurred (Park et al., 2015). Truong, Maahs and Daniels (2012) highlighted the importance of cardiovascular imaging in the diagnosis of MVD, a non-invasive imaging helps to analyze the involvement of heart and vasculature in diabetes.

The main foundation of care for the treatment and effective management of MVD complications among diabetic patient include proper patient education, nutritional planning, physical activity, smoking cessation and psychological care. Medical nutrition therapy is regarded as an effective means for the management and treatment of MVD. The medical nutrition therapy mainly promotes and support healthy eating patterns, which emphasize on a variety of nutrient-dense foods in proper size (Brown, Edwards, Seaton & Buckley, 2015). Consumption of nutritional rich food promotes reduction of the lipid content of the blood, reduction of glycemic level and blood pressure. Nutritional diet based on height and weight of the body helps to achieve proper body weight and thereby delaying the MVD complications in diabetes (Evert et al., 2014). In order to access the nutritional needs, personal and cultural preferences must be taken in to consideration along with proper health literacy. Proper health literacy will promote willingness to consume healthy food along with behavioural change in the diet plan (Gosmanov & Umpierrez, 2013). Khan, Stephens, Franks, Rook and Salem (2013) highlighted that physical activity is another important aspect for controlling MVD complications among diabetic patient. This promotion of physical activity also highlights the importance of reduction in sedentary time. Adults with T2DM should be encouraged to perform resistance training at least twice a week. Connelly, Kirk, Masthoff and MacRury (2013) however, highlighted that the older adults with sever MVD complication, might not be capable for entering into resistance training. In that case, of older adults, mild to moderate physical exercise like 15 minutes of walk can be proved to be effective. Apart from proper nutritional diet and physical activity, American Diabetes Association (2015) highlighted the importance of smoking cessation as important interventions for MVD. Smoking cessation counselling is regarded to be effective in controlling smoking habits (Tollefson & Hallman, 2016). In relation to treatment and management of MVD in diabetes, American Diabetes Association (2015) highlighted that the people with MVD in diabetes should receive medical care from an integrated and collaborative team who have supreme expertise in diabetes. The management plan should be written via taking inputs from both the healthcare professional, patients and their family members (American Diabetes Association, 2015). In domain of medication management, Bullock & Manias (2016) highlighted the use of subcutaneous insulin injection in order to manage hyperglycemic shocks and thereby preventing the chance of developing MVD. The dosage however, needs to be adjusted by the physicians as per the blood glucose level; age and body mass (Brotto & Rafferty, 2016).

Proper Screening methods for Macrovascular Complications in Diabetes

Thus from the above discussion, it can be concluded that pathological hallmark of DM are microvascular and macrovascular complications. Macorvascular complication of diabetes mainly arises from inflammation, which leads to the narrowing of the walls of the arteries. This narrowing of the arterial wall causes atherosclerosis, which increases the chance of developing several cardiac complications. The main assessment techniques used for the screening of MVD include detection of the lipid profile, blood glucose level and blood pressure. The main diagnostic approach that is used for the detection of MVD includes non-invasive screening techniques. The main treatment and management options for MVD as highlighted in the essay include observance of proper nutritional diet, daily physical activity, disease education, awareness, and cessation of smoking and medication management.

References

American Diabetes Association. (2015). Standards of medical care in diabetes—2015 abridged for primary care providers. Clinical diabetes: a publication of the American Diabetes Association, 33(2), 97. doi:  10.2337/diaclin.33.2.97

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Chawla, A., Chawla, R., & Jaggi, S. (2016). Microvasular and macrovascular complications in diabetes mellitus: distinct or continuum?. Indian journal of endocrinology and metabolism, 20(4), 546. doi:  10.4103/2230-8210.183480

Chilelli, N. C., Burlina, S., & Lapolla, A. (2013). AGEs, rather than hyperglycemia, are responsible for microvascular complications in diabetes: a “glycoxidation-centric” point of view. Nutrition, Metabolism and Cardiovascular Diseases, 23(10), 913-919. https://doi.org/10.1016/j.numecd.2013.04.004

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Khan, C. M., Stephens, M. A. P., Franks, M. M., Rook, K. S., & Salem, J. K. (2013). Influences of spousal support and control on diabetes management through physical activity. Health Psychology, 32(7), 739. https://dx.doi.org/10.1037/a0028609

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Zhang, M., Chen, P., Chen, S., Sun, Q., Zeng, Q. C., Chen, J. Y., … & Wang, J. K. (2014). The association of new inflammatory markers with type 2 diabetes mellitus and macrovascular complications: a preliminary study. Eur Rev Med Pharmacol Sci, 18(11), 1567-72. Retrieved from: https://s3.amazonaws.com/academia.edu.documents/43721927/imp_for_prediction_for_macovascualr_disease.pdf?AWSAccessKeyId=AKIAIWOWYYGZ2Y53UL3A&Expires=1535524597&Signature=S2tFc0uT6gsdfjlX3EnUgATQ%2F6M%3D&response-content-disposition=inline%3B%20filename%3DThe_association_of_new_inflammatory_mark.pdf