CARDIOVASCULAR DISEASES TREATMENT IN PATIENTS WITH TYPE 2 DIABETES MELLITUS IN CURRENT CLINICAL PRACTICE

Diabetes mellitus type 2 (DM 2) is an actual interdisciplinary problem of contemporary health protection. Cardiovascular complications (CVC) and mortality risks are 2-5 times larger than population risk [1,2]. The number of DM patients is expected to reach 380 million, with at least 90% of DN 2 patients, given the same morbidity rate [3]. Multi-factorial treatment tactics aimed at hyperglycemia, hypertension (HT) and dislipidemy (DL) correction decreases DM 2 complications as well as those of cardio-vascular diseases (CVD) [4]. Yet in accordance with both clinical (UKPDS and Steno II [4]) and epidemiological research [5] target levels of metabolic parameters are not attained in considerable part of patients. The aim of the study was to evaluate CVD treatment in DM 2 patients in current clinical practice. Сахарный диабет 2-го типа (СД 2) является актуальной междисциплинарной проблемой современного здравоохранения. Риск сердечно-сосудистых осложнений (ССО) и смертности при данном заболевании превышает популяционный в 2-5 раз [1,2]. Ожидается, что при сохранении имеющихся темпов роста заболеваемости к 2025 г будет насчитываться 380 миллионов больных СД, и не менее 90% из них будут составлять больные СД 2 [3]. Многофакторный подход, направленный на коррекцию гипергликемии, артериальной гипертонии (АГ) и дислипидемии (ДЛП), снижает частоту развития и прогрессирования осложнений СД 2 и сердечно-сосудистых заболеваний (ССЗ) [4]. Однако, по данным как клинических (UKPDS и Steno II [4]), так и эпидемиологических исследований [5], целевые уровни метаболических параметров не достигаются у значительной части пациентов. Cardiovascular diseases treatment in patients with type 2 diabetes mellitus in current clinical practice I.E. Sapozhnikova*, E.I. Tarlovskaya, E.N. Anufrieva Chair of Hospital Therapy, Kirov State Medical Academy, ul. K. Marxa 112, Kirov, 610027 Russia

Multi-factorial treatment tactics aimed at hyperglycemia, hypertension (HT) and dislipidemy (DL) correction decreases DM 2 complications as well as those of cardio-vascular diseases (CVD) [4].Yet in accordance with both clinical (UKPDS and Steno II [4]) and epidemiological research [5] target levels of metabolic parameters are not attained in considerable part of patients.
The aim of the study was to evaluate CVD treatment in DM 2 patients in current clinical practice.

Material and methods
200 DM 2 patients were examined in the "DIALOG" study (women -154, men -46).Ten endocrinologists took part in the research, each of which examined 20 first patients who agreed to participate in the study.
The "DIALOG" study (efficacy of medium-high doses of Diabeton in patients with diabetes mellitus type 2 in Kirov) conducted during 2007-2008 was initiated by Kirov's SMA Hospital therapy chair and Kirov's regional endocrinological clinic.The study included two stages: the first one -direct questioning of DM 2 out-patients (May 2007) and the second one -open research of Gliclazide SD 3-months treatment efficacy in medium-high doses (June 2007 -February 2008).
The following was conducted: 1. Questionnaire survey (original "Doctor's questionnaire" and "Patient's questionnaire" were used, which were then analyzed both individually and by comparison of corresponding pairs of questionnaires); 2. Anthropometric measurements [growth, body mass, waist size, calculation of body mass index (BMI)]; 3. Blood pressure (BP) at both arms measurement; heart rate (HR) and pulse at both arms counting.
Data in the text and tables is presented as Me [25; 75] for samples with abnormal distribution, where Me is median, 25 and 75 are percentiles.For estimation of quantitative attributes correlation Spearmen's coefficient of rank correlation was used (rs).For evaluation of prevalence distinction significance Chi-square test (χ 2 ) with Yates's correction was used.Critical level of significance (p) was accepted at 0,05.Statistical treatment was conducted with the help of MS EXCEL, BIOSTAT 4.03 and STATIS-TICA 6.0 software.

Results and discussion
Clinical description of examined patients is presented in Table 1.DM 2 patients' age ranged from 37 to 81 years.More than 75% of patients were women, which is in line with literary data about DM 2 patients sex distribution in Russian Federation [5] and regional diabetes mellitus Register data.
Selective epidemiological research conducted in RF demonstrated that real prevalence rate of the disease is 3,5-4 times larger than the registered one [5].Overt DM 2 development is preceded by boundary carbohydrate metabolism impairment, in particular impairment of glucose tolerance (IGT) [4].High topicality of tardy DM 2 diagnostics is confirmed in our study by the fact that IGT preceding DM 2 was registered in 10.5% cases only.
Received information confirms incomplete CVD revelation in these patients: 33% of interrogated patients answered the question depicting typical angina attack positively.
Significant prevalence of HT (n=166; 83%) among examined patients agrees with other RF regions data [5].DM and HT are complementary risk factors of atherosclerosis and CVD [4].Intensive treatment of DM 2 patients with pressure-lowering agents leads to decrease in cardio-vascular complications [6].Combination of antihypertensive agents is usually needed to reach the target BP level (<130/80 mm Hg).[4].The target level of "office" BP (<130/80 mm Hg) was registered in only 16% of patients with DM 2 and HT.The number of pressure-lowering drugs prescribed for permanent use varied from 1 to 4 (Table 3).
Таким образом, одной из причин выявленных погрешностей в тактике гипотензивной терапии у пациентов с СД 2 There is no doubt that permanent treatment is necessary for patients with arterial hypertension.Data, concerning antihypertensive therapy modes, which was obtained when comparing doctors' and patients' questionnaires, is displayed in Table 5.

Disease
Patients reported about significantly less frequent cases of regular drugs treatment (because of more frequent course treatment) than physicians did.Absence of permanent HT therapy significantly increases CVD development risk.
Thus, underestimation of cardiovascular risk due to inadequate IHD diagnostics is possibly one of the reasons of pressurelowering therapy faults in DM 2 patients.
Most patients (n=159; 79.5%) reported that they possess devices for blood pressure measurement.Less than half of them (n=43; 26%) check BP twice a day or more often, 36 (22%) patients -once a day.Some patients check BP 1-3 times a month or more seldom (n=12; 7%), while 23 (14%) patients -only when feeling sick.There were more DM 2 patients who regularly controlled their BP than those who regularly controlled glycemia (p<0.001).Besides, 95 atients (57% patients with AH) at times failed to take drugs and 25 patients didn't answer the question.The most frequent reasons of not taking drugs were "oblivion" (32%), "fear of addiction to drugs" (16%) and "necessity of frequent drugs intake" (12%).
Diet, changes in lifestyle and lipid-lowering medicines are used for dislipidemia correction in DM patients [4].Due to high risk of cardio-vascular complications and death in DM 2 patients, statins should be prescribed as means of primary and secondary prevention [4].Questioning revealed that only 47 (23.5%) patients received statins, so the target level of lipid spectrum was not achieved (see Table 1).The main reasons of statins therapy absence (according to opinion of patients who didn't receive it) were high cost of drugs (49; 32%) and lack of information about such treatment necessity (36; 23.5%).Only 32 (16%) patients received drugs with acetylsalicylic acid, which should be prescribed to DM patients with angiopathy.

Conclusion
Poor diagnostics of diseases caused by coronary and cerebral atherosclerosis can be explained by insufficient revelation of cardio-vascular complications in DM 2 patients.Low efficacy of pressure-lowering therapy was due to frequent use of monotherapy, inadequate doses and irrational drugs combinations as well as frequent non-taking of medicines and inadequate BP self-monitoring.Carbohydrate metabolism was decompensated in majority of patients.It was caused by absence of adequate glycemia self-monitoring, lack of patients' awareness and inadequate tactics of hypoglycemic therapy.

Table 2 .
CVD frequency according to data of Kirov's regional diabetes mellitus Register and the "DIALOG" research results

Table 3 .
Frequency of pressure-lowering agents prescription in patients with DM 2 and HТ

Table 4 .
Antihypertensive therapy mistakes in patients with DM 2 and HТ

Table 5 .
Antihypertensive therapy adherence in patients with DM 2 and HТ: patients' and doctors' opinion (%)