Turtle's Diabetes Case

[Turtle]

Dr Steve,
I’m a regional marketing manager for a mid size pharmaceutical company. Myself and about ten other managers were sent to the Josslin Diabetes Center at Harvard Medical School this past week to learn more about diabetes. During our time at this seminar, we heard lectures from assistant professors of medicine at the clinic. Lectures were given by; Internal Medicine, Endocrinologists, Diabetologists, Lipidologists, Nephrologists, Cardiologists, and Interventional Cardiologists.

The goal was to give us a greater understanding of physician perspective and priorities as well as deepen our disease state knowledge. We were then each given a case to take back to regions and present to the sales force. The idea is that we go through the case and talk about each point that is presented and what is going on with the patient and why it is important. With a goal of helping the drug rep becoming more educated.

Bottom line I think I got a fairly tough case and would like to post it along with my thoughts. If you are willing to give me some feedback I would appreciate it, if not I understand as you deal with things like this on a day to day basis. Thanks.

[Dr Steve]

Dr Steve,
I’m a regional marketing manager for a mid size pharmaceutical company. Myself and about ten other managers were sent to the Josslin Diabetes Center at Harvard Medical School this past week to learn more about diabetes. During our time at this seminar, we heard lectures from assistant professors of medicine at the clinic. Lectures were given by; Internal Medicine, Endocrinologists, Diabetologists, Lipidologists, Nephrologists, Cardiologists, and Interventional Cardiologists.

The goal was to give us a greater understanding of physician perspective and priorities as well as deepen our disease state knowledge. We were then each given a case to take back to regions and present to the sales force. The idea is that we go through the case and talk about each point that is presented and what is going on with the patient and why it is important. With a goal of helping the drug rep becoming more educated.

Bottom line I think I got a fairly tough case and would like to post it along with my thoughts. If you are willing to give me some feedback I would appreciate it, if not I understand as you deal with things like this on a day to day basis. Thanks.

Absolutely! You want to do it here? It may help someone, you never know.

I just read an article about a group that turned diabetic mouse pancreas cells into working islet cells (insulin producing cells) and CURED type I diabetes in these mice. We may be only 10 years away from a stem-cell-free solution to type I diabetes.

your pal,


steve

[Turtle]

History
56 year old male presents with a 2 month history of recurrent exertion substernal chest pain, with diaphoresis, relieved by rest or sublingual nitroglycerine. Smoker w/ a 40 pack/year history. Past history reveals hypertension, controlled in past with lisinopril and HCTZ, and chronic obesity. Family history; father type II diabetes and died of MI at 61, 2 brothers w/ type II diabetes, and an older sister had a three vessel CABAG at 66.

Physical Exam
Obese male complaining of mild chest discomfort.
Vital signs: Weight 262lbs, height 68 inches, waist circumference 44 inches, BP 156/92, pulse 88.
Heart, lungs and abdominal exams are unremarkable.
Extremities: Decreased anterior and popliteal pulses, some dependent rubor, and cold feet.
Neurological examination unremarkable.

Lab Results
Electrolytes, BUN, creatinine, & CBC all within normal limits.
Blood glucose (fasting) 122
TC 255
HDL C 23
LDL C 174
TG (fasting) 323
ALT 78
AST 122
CRP 0.96
Oral glucose tolerance test, 2 hrs postprandial glucose 221

Follow up
Patient underwent exercise test w/ modified Bruce protocol, developed chest pain w/ ST segment depression in inferior leads after 2 minutes, MIBI w/ reversible perfusion defect in anterior region of heart.
Cardiac catheterization revealed 90% blockage of LAD, w/ 30% lesions in circumflex and RCA.
PTCA w/ stent placement in LAD w/ amelioration of symptoms.
Started on 325 mg asprin QD, atenolol 50 mg QD, simvastatin 20mg QD.






The substernal chest pain means that it is not a torn muscle and probably not heartburn. Since the pain seems to be from within the chest good chance his heart is the problem. He is a smoker and that increased his CV risk. Family history of diabetes and CV disease and father died at the age of 61 from MI. His BMI is >40 so he has central adiposity. His extremities show signs of PVD. His LDL, HDL and Tg all need to be treated. His LFT shows he may have a fatty liver, so he might be insulin resistant. He is diabetic if for no other reason than his 221 oral glucose tolerance test. Sad that he was not able to walk for more that 2 min.



Questions
1. Is he diabetic?-Yes
2. What should his target BP be? 130/80
3. What should his target LDL be? <100
4. How should the HDL and Tg be treated? Fibrate or naspan
5. How could insulin resistance be identified?
6. Should this patient have been treated medically?
7. ST segmentation shows what?
8. What other meds should this patient be given?- Tricor, a CCB, increase the statin...

[Turtle]

The intervential part of this class was totaly new to me. As his blockage was not three vessel disease I'm not sure he should have gotten a stient. But with a 90% blockage left anterior descending, something should be done…I don’t know should he have gotten a bypass? 30% lesions in circumflex and right corated artery will grow to 40% and 50% rather quickly due to his weight, hypertension and elevated lipids.

[Turtle]

The intervential part of this class was totaly new to me. As his blockage was not three vessel disease I'm not sure he should have gotten a stient. But with a 90% blockage left anterior descending, something should be done…I don’t know should he have gotten a bypass? 30% lesions in circumflex and right corated artery will grow to 40% and 50% rather quickly due to his weight, hypertension and elevated lipids.

Wait, 90% LAD, lesions in circumflex & RCA that is three vessel disease...shit like I said this part is totaly new to me.

[Dr Steve]

sorry dude, it's late and I gots some mean eyestrain...so how can I help you with this? :-)

[patsopinion]

survey says









http://womeninterestedinsurgery.org/images/scalpel_in_hand.jpg

triple bipass

and a smoker?
diet and exercize 1 hour a day
after quitting smoking advise on stomach stapling along with liposuction

[Turtle]

sorry dude, it's late and I gots some mean eyestrain...so how can I help you with this? :-)

just let me know if I was off base on anything and or missed anything

[Dr Steve]

OK, I'm not a cardiologist, so there may be some subtle points that I'll miss in this but I'll give it a whack.

History
56 year old male presents with a 2 month history of recurrent exertion substernal chest pain, with diaphoresis, relieved by rest or sublingual nitroglycerine.

These are classic symptoms for angina, which is a syndrome of symptoms that occur when someone's heart is demanding more blood than the coronary arteries can deliver.


Smoker w/ a 40 pack/year history. Past history reveals hypertension, controlled in past with lisinopril and HCTZ, and chronic obesity. Family history; father type II diabetes and died of MI at 61, 2 brothers w/ type II diabetes, and an older sister had a three vessel CABAG at 66.

they are really loading this guy up in this case. The five big independent risk factors for coronary artery disease are:


diabetes
high blood pressure
high cholesterol
family history of early heart disease
tobacco use


There's this thing called "Metabolic syndrome" that is related to all this:


diabetes mellitus type 2 or impaired fasting glucose, impaired glucose tolerance, or insulin resistance;
High blood pressure;
Central obesity (also known as visceral, male-pattern or apple-shaped adiposity), overweight with fat deposits mainly around the waist;
Decreased HDL cholesterol;
Elevated triglycerides;


people with metabolic syndrome are at high risk for heart disease as well.

Physical Exam
Obese male complaining of mild chest discomfort.
Vital signs: Weight 262lbs, height 68 inches, waist circumference 44 inches, BP 156/92, pulse 88.
Heart, lungs and abdominal exams are unremarkable.
Extremities: Decreased anterior and popliteal pulses, some dependent rubor, and cold feet.
Neurological examination unremarkable.

He's fat, with high blood pressure, and poor circulation.


Lab Results
Electrolytes, BUN, creatinine, & CBC all within normal limits.
Blood glucose (fasting) 122
TC 255
HDL C 23
LDL C 174
TG (fasting) 323
ALT 78
AST 122
CRP 0.96
Oral glucose tolerance test, 2 hrs postprandial glucose 221

He has high cholesterol, low "GOOD" cholesterol (HDL...we can talk about that if you like), and high triglycerides (blood fats). Oh! also he has elevated liver tests (AST/ALT) so he probably has "fatty liver" too, which would go along with the diagnosis of METABOLIC SYNDROME. Oh, and he's diabetic, too (2 hour post prandial glucose of 221).



Follow up
Patient underwent exercise test w/ modified Bruce protocol, developed chest pain w/ ST segment depression in inferior leads after 2 minutes, MIBI w/ reversible perfusion defect in anterior region of heart.
Cardiac catheterization revealed 90% blockage of LAD, w/ 30% lesions in circumflex and RCA.
PTCA w/ stent placement in LAD w/ amelioration of symptoms.
Started on 325 mg asprin QD, atenolol 50 mg QD, simvastatin 20mg QD.

With only 30% blockage in the circumflex and RCA, he was a candidate for PTCA instead of bypass. If he'd had more blockage of those arteries, I think they would have done surgery first.




The substernal chest pain means that it is not a torn muscle and probably not heartburn. Since the pain seems to be from within the chest good chance his heart is the problem.

yeah, there's no question, they're wanting you to diagnose him with angina.


He is a smoker and that increased his CV risk. Family history of diabetes and CV disease and father died at the age of 61 from MI. His BMI is >40 so he has central adiposity. His extremities show signs of PVD. His LDL, HDL and Tg all need to be treated. His LFT shows he may have a fatty liver, so he might be insulin resistant. He is diabetic if for no other reason than his 221 oral glucose tolerance test. Sad that he was not able to walk for more that 2 min.

you're right on the money. So he has metabolic syndrome and he had ST changes on his EKG after ONLY TWO MINUTES. That's really, really bad.

Does that help?


your pal,



Steve

[Turtle]

OK, I'm not a cardiologist, so there may be some subtle points that I'll miss in this but I'll give it a whack.



These are classic symptoms for angina, which is a syndrome of symptoms that occur when someone's heart is demanding more blood than the coronary arteries can deliver.




they are really loading this guy up in this case. The five big independent risk factors for coronary artery disease are:


diabetes
high blood pressure
high cholesterol
family history of early heart disease
tobacco use


There's this thing called "Metabolic syndrome" that is related to all this:


diabetes mellitus type 2 or impaired fasting glucose, impaired glucose tolerance, or insulin resistance;
High blood pressure;
Central obesity (also known as visceral, male-pattern or apple-shaped adiposity), overweight with fat deposits mainly around the waist;
Decreased HDL cholesterol;
Elevated triglycerides;


people with metabolic syndrome are at high risk for heart disease as well.



He's fat, with high blood pressure, and poor circulation.




He has high cholesterol, low "GOOD" cholesterol (HDL...we can talk about that if you like), and high triglycerides (blood fats). Oh! also he has elevated liver tests (AST/ALT) so he probably has "fatty liver" too, which would go along with the diagnosis of METABOLIC SYNDROME. Oh, and he's diabetic, too (2 hour post prandial glucose of 221).





With only 30% blockage in the circumflex and RCA, he was a candidate for PTCA instead of bypass. If he'd had more blockage of those arteries, I think they would have done surgery first.






yeah, there's no question, they're wanting you to diagnose him with angina.




you're right on the money. So he has metabolic syndrome and he had ST changes on his EKG after ONLY TWO MINUTES. That's really, really bad.

Does that help?


your pal,



Steve

Thanks very much doc.

[Dr Steve]

Thanks very much doc.

NP man, sorry it took so long