Anais da Academia Brasileira de Ciencias (2017) 89 (2): 1383-1393 (Annals of the Brazilian Academy of Sciences) Printed version ISSN 0001-3765 / Online version ISSN 1678-2690 http://scielo.br.com/en/scielo.php/script=sci_serial&pid=0001-65&nrm=iso www.scielo.br/aabc
Trends in Clinical Outcomes (the Mortality and Disability Rate) in Patients with Arterial Hypertension Combined with Type 2 Diabetes Mellitus in Kazakhstan
ZHANAR AKIMBAYEVA1 and ZHUMAGALI ISMAILOV2
1PhD
student, Asfendiyarov Kazakh National Medical University, Republic of Kazakhstan, Almaty, Tole bi Str., 94,
[email protected], +77771821101 2Director of Republican center for Health Development, Republic of Kazakhstan, Astana, Orynbor Str., 8, entr. 18 B,
[email protected], +77772337000
ABSTRACT
The purpose of the article is to reveal and study the topic, and also to analyze the trends in clinical outcomes in patients with arterial hypertension combined with type 2 Diabetes Mellitus in Kazakhstan. This research is aimed at the study, comparing and analysis of: dynamics in the disability and mortality rate among male patients with AH combined with type 2 DM aged 18 and above before and after the introduction of CPG in the SKR and the Republic of Kazakhstan (from 2000 to 2014); dynamics in the disability and mortality rate in female patients with AH combined with type 2 DM aged 18 and above in the SKR and the Republic of Kazakhstan (from 2000 to 2014); the disability and mortality rate in patients of both genders with AH combined with type 2 DM aged 18 and above before and after the introduction of CPG in the SKR and the Republic of Kazakhstan (from 2000 to 2014); the disability and mortality rate in patients of both genders with AH combined with type 2 DM aged 18 and above before and after the introduction of CPG in the SKR and the Republic of Kazakhstan (from 2000 to 2014); trends in the disability and mortality rate in patients of both genders with AH combined with type 2 DM aged 18 and above before and after the introduction of CPG in the SKR (from 2000 to 2014). According to the research, the authors will find out the following: a gradual decrease in the specified indicators (the disability and mortality rate) both in the SKR and in the RK; a more significant decrease in the disability and mortality rate among male patients in 2008-2014; the SKR disability rate in that group of patients compared to that in the RK in 2014; the disability rate among male patients with AH combined with type 2 DM aged 18 and above in the SKR and the average in the RK in 2000; the SKR disability rate in female patients with AH combined with type 2 DM aged 18 and above, compared to the average in the RK from 2006 to 2014; the reduction dynamics in the mortality rate among female patients with AH combined with type 2 DM aged 18 and above in the SKR and in the RK in 2000-2014. Key words: mortality rate, disability rate, arterial hypertension, diabetes mellitus, atherosclerosis, coronary heart disease.
An Acad Bras Cienc (2017) 89 (2)
INTRODUCTION Diabetes is a rapidly growing health problem worldwide, related in part to improved living conditions and increasing rate of obesity (World Health Report 2003). It is estimated that approximately 5% of people in the general population of most industrialized societies have diabetes mellitus and that an additional 3%–5% have either undiagnosed diabetes or impaired glucose tolerance. According to the World Health Organization, worldwide the number of people living with diabetes is projected to increased from 172 million in 2000 (prevalence: 2.8%) to 366 million (prevalence: 4.4%) in 2030 (Wild et al. 2004). Hypertension is a common co-morbid condition in diabetes and found in 20%–60% of patients with diabetes (American Diabetes Association 2004). Prevalence of hypertension in the diabetic population is 1.5–3 times higher than in the age- and weight-adjusted non-diabetic group (Hypertension in Diabetes Study 1993). In type 2 diabetes, hypertension is often present as a part of metabolic syndrome, while in type 1 diabetes it may herald the onset of diabetic kidney disease. The hypertensive diabetic individuals are at a 2- to 4fold greater risk of vascular complications, such as coronary artery disease, cerebrovascular accident, and death compared with age-matched control subjects and with the patients with type 2 diabetes mellitus but normal blood pressure. Similarly, they also have a 7-fold greater risk of progression to end stage renal disease (ESRD) (Perneger et al. 1994; Beckman 2002). Reduction of high blood pressure reduces cardiovascular morbidity and mortality and delays the progression to ESRD. Indeed, various studies has shown that lowering blood pressure in high risk patients with diabetes reduces overall mortality, death from stroke and cardiovascular events and slows the progression of renal disease in patients with type 2 diabetes mellitus. Consensus statements and guidelines from various international authorities recommend initiation of pharmacological therapy with the goal of reduction of blood pressure to <130/80 mmHg (National Kidney Foundation 2002; American Diabetes Association 2004) and/or <130/85 mmHg (Chobanian et al. 2003) and consider diabetes as a risk equivalent similar to history of myocardial infarction (Chobanian et al. 2003) because of the increased risk of cardiovascular events in these groups of patients.
Evidence has shown that achieving this goal requires multiple drug antihypertensive therapy. Indeed, because of the fact that blood pressure reduction to recommended goal is often difficult to achieve with monotherapy, the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC) (Chobanian et al. 2003) suggests initial use of a twodrug combination, even in non-diabetic patients. Greater efficacy is likely to be achieved when two or more antihypertensive agents with complementary modes of action are used to reduce blood pressure. This approach is also likely to reduce adverse effects of drugs, as both drugs can be given at a lower dose than either drug as monotherapy. In addition, combination of two fixeddose agents in a single capsule or tablet is expected to increase compliance. In treatment of hypertensive diabetic patients adverse effects on metabolic control and insulin sensitivity is an issue to be considered. MATERIALS AND METHODS We have studied clinical outcomes (the disability and mortality rate) in 13,737 patients in the South Kazakhstan Region (SKR) and 118,131 patients with arterial hypertension combined with type 2 diabetes mellitus aged 18 and above in the Republic of Kazakhstan before and after the introduction of arterial hypertension and diabetes mellitus clinical practice guidelines (CPG) based on the retrospective analysis of the database of the National Center for Healthcare Promotion of the RK Ministry of Healthcare and Social Development from 2000 to 2014. The dynamics in the disability and mortality rate according to the gender of the patients were assessed. The statistical processing of the data obtained was performed with the help of Student's t-test. The number of patients with arterial hypertension by 2009 exceeded 1 billion, and by 2015 it reached 1.5 billion. Every year 7.5 million people die from arterial hypertension complications (WHO 2013). More than 70% of patients with type 2 diabetes mellitus (type 2 DM) die from cardiovascular diseases (Laakso 2001). There are currently 382 million people in the world, suffering from type 2 diabetes mellitus, with 80% of them living in low- and middle-income countries. Another 316 million people have An Acad Bras Cienc (2017) 89 (2)
TRENDS IN CLINICAL OUTCOMES IN KAZAKHSTAN
impaired glucose tolerance, which means a high risk of the disease development (IDF 2014). In 2013, type 2 DM caused 5.1 million deaths worldwide, and 548 million USD was spent on its treatment. 175 million people live with undiagnosed DM, which accounts for 46%. As a result, they do not receive treatment, which leads to severe complications (lesions of the heart, eyes, kidneys, lower limbs and early mortality). Arterial hypertension (AH) and type 2 diabetes mellitus (DM) are interrelated diseases that predispose to the incidence of atherosclerosis and, consequently, coronary heart disease, stroke, etc. It is estimated that 3 million Americans have AH and type 2 DM combination. AH develops twice as often in DM patients compared to those who do not have type 2 DM (Report on hypertension in diabetes, 1994). In 2014 G. Bakris examined 3 500 incidence patients with type 2 DM, 39% of whom had AH. According to the data provided by S. Haffner et al. (1998) the risk of fatal myocardial infarction in patients with type 2 DM without prior myocardial infarction is the same as in diabetes-free patients, who have survived myocardial infarction. Therefore, according to the authors' opinion, patients with diabetes should be treated as if they have coronary heart disease. Numerous studies have shown that the mortality risk is higher for female patients with type 2 DM than for male patients (S. Heyden et al., 1980; E. Barrett-Connor et al., 1991; D. Nathan et al. 1997, G. Li. et al. (2014) Based on a randomized 23-year study in 33 hospitals in China, they have shown that six-year lifestylechanging program (diet, physical exercises and their combination) significantly improves the cardiovascular disease mortality rate, as well as the mortality rate caused by whatever reasons; it also reduces the incidence rate of impaired glucose tolerance. A. Becker et al. (2003) assessed 10-year risk of cardiovascular diseases in 208 patients with type 2 DM and 2,253 diabetes-free patients (the Netherlands) and found out that female patients with type 2 DM without previous heart disease have the same risk as diabetes-free female patients with previous heart disease. The authors speak in favor of the need for vigorous treatment of risk factors in female patients with type 2 DM. The pathogenesis of hypertension in diabetes is complex, involving strong interactions between genetic predisposition and a range of environmental
1385
and biological factors such as unhealthy eating, sedentary behaviour, sodium retention, abdominal obesity, autonomic derangements, premature arterial stiffening, and endothelial dysfunction. Not only are patients with diabetes more likely to have coexistent hypertension, but any given systolic BP value in patients with diabetes is associated with a more than 2-fold increase in age-adjusted cardiovascular death rates. For example, a diabetic patient with a systolic BP between 120 and 139 mm Hg has a similar cardiovascular mortality rate to a patient without diabetes whose systolic BP is 160 to 179 mm Hg. The exact cause of the increased morbidity and mortality associated with hypertension in people with diabetes independent of other risk factors is unclear. However, the frequent absence of the usual nocturnal BP dip among patients with diabetes is likely to be contributory. Despite similar daytime office and home BP recordings, a “non-dipper” will have higher 24-hour and nocturnal BP values, with the latter in particular being a strong predictor of cardiovascular death. Pharmacologically reducing BP in people with diabetes is one of the most effective medical interventions available to prevent death and disability. Randomized controlled trials of BPlowering treatments in people with diabetes have demonstrated substantial reductions in death, cardiovascular disease, eye disease, and kidney disease rates, and the benefits are accrued in a short time. For example, in the Syst-Eur (Systolic Hypertension in Europe) trial, in which isolated systolic hypertension was clinically defined as having a systolic BP value of more than 160 mm Hg and a diastolic BP value of less than 90 mm Hg, active treatment reduced cardiovascular mortality by 76% (number needed to treat [NNT] was approximately 21 for 2 years’ treatment) and all cardiovascular events by 67% (NNT approximately 13 for 2 years’ treatment), with a reduction in BP of 9.8/3.8 mm Hg. RESULTS According to IDF estimates (2014), in Kazakhstan the number of type 2 DM patients aged 20-79 amounted to 526,000. The prevalence of type 2 DM in the same age group was equal to 4.87%; 10,932 persons died annually from the disease.
An Acad Bras Cienc (2017) 89 (2)
1386
ZHANAR AKIMBAYEVA, ZHUMAGALI ISMAILOV TABLE 1 Dynamics in the disability and mortality rate among male patients with AH combined with type 2 DM aged 18 and above before and after the introduction of CPG in the SKR and the Republic of Kazakhstan (from 2000 to 2014). Years Region/Republic Total Incl. the disabled Mortality rate 2000
2001
2002
2003
2004
2005
Total 2000-2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
SKR
174
63 (36.2%)
87 (50%)
RK
1,072
231 (21.5%)
445 (41.5%)
SKR
294
101 (39.3%)
159 (54%)
RK
1,207
288 (23.8%)
550 (45.5%)
SKR
372
76 (20.4%)
171 (45.9%)
RK
1,622
294 (18.1%)
665 (40.9%)
SKR
391
87 (22.2%)
143 (36.5%)
RK
1,667
286 (17.1%)
572 (34.3%)
SKR
373
63 (16.8%)
130 (34.8%)
RK
1,770
283 (15.9%)
596 (33.6%)
SKR
390
61 (15.6%)
137 (35.1%)
RK
2,064
312 (15.1%)
676 (32.7%)
SKR
1,994
451 (22.6%)
827 (41.5%)
RK
9,402
1,694 (18.0%)
3,504(37.3%)
SKR
380
66 (17.3%)
112 (29.4%)
RK
2,108
264 (12.5%)
567 (26.8%)
SKR
332
47 (14.1%)
69 (20.7%)
RK
2,294
286 (12.4%)
553 (24.1%)
SKR
263
29 (11.0%)
47 (17.8%)
RK
2,780
344 (13.4%)
525 (18.8%)
SKR
399
47 (11.7%)
79 (19.7%)
RK
3,109
430 (13.8%)
504 (16.2%)
SKR
524
28 (5.3%)
77 (14.6%)
RK
3,362
353 (10.5%)
472 (14.0%)
SKR
507
36 (7.1%)
64 (12.6%)
RK
3,155
324 (10.2%)
384 (12.1%)
SKR
489
14 (2.8%)
39 (7.9%)
RK
3,137
296 (9.4%)
264 (8.4%)
SKR
439
93 (21.1%)
25 (5.6%)
RK
3,331
390 (11.7%)
199 (5.9%)
SKR
376
14 (3.7%)
11 (2.9%)
An Acad Bras Cienc (2017) 89 (2)
TRENDS IN CLINICAL OUTCOMES IN KAZAKHSTAN RK 2,869 224 (7.8%) Total 2006-2014
1387 82 (2.8%)
SKR
3,709
374 (10.2%)
523 (14.1%)
RK
22,814
2,911 (12.7%)
3,550 (15.6%)
40 36.2 35 30 25
21.5
20.4
20
SKR
18.1 16.8 17.3 15.9 12.5
15
RK
13.4 10.5
11
9.4
10 5.3 5
2.8
7.8 3.7
0 2000
2002
2004
2006
2008
2010
2012
2014
Figure 1 - The comparative analysis of the dynamics in the disability rate in male patients with AH combined with type 2 DM aged 18 and above in the SKR and the Republic of Kazakhstan (from 2000 to 2014) (the RK Ministry of Healthcare and Social Development, 2015) 60 50 50
45.9 41.5
40.9
40
34.8 33.6 29.4
30
SKR
26.8
RK 18.8 20
17.8
14.6
14 7.9 8.4
10
2.9 2.8 0 2000
2002
2004
2006
2008
2010
2012
2014
Figure 2 - The comparative analysis of the dynamics in the mortality rate in male patients with AH combined with type 2 DM aged 18 and above in the SKR and the Republic of Kazakhstan (from 2000 to 2014) (in percentage terms) (the RK Ministry of Healthcare and Social Development, 2015)
TABLE 2 Dynamics in the disability and mortality rate in female patients with AH combined with type 2 DM aged 18 and above in the SKR and the Republic of Kazakhstan (from 2000 to 2014) (in percentage terms) (the RK Ministry of Healthcare and Social Development, 2015). Years Region/Republic Total Incl. the disabled Mortality rate 2000
RK
3,014
317 (10.5%)
970 (32.1%)
An Acad Bras Cienc (2017) 89 (2)
1388 SKR 2001
2002
2003
2004
2005
Total 2000-2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
Total 2006-2014
ZHANAR AKIMBAYEVA, ZHUMAGALI ISMAILOV 240 41 (17%)
108 (45%)
RK
3,223
366 (11.3%)
1,128 (34.9%)
SKR
409
71 (17.3%)
201 (49.1%)
RK
4,100
342 (8.3%)
1,289 (31.4%)
SKR
473
55 (11.6%)
191 (40.3%)
RK
4,014
338 (8.4%)
1,184 (29.4%)
SKR
590
73 (12.3%)
222 (37.6%)
RK
4,552
357 (7.8%)
1,180 (25.9%)
SKR
573
44 (7.6%)
163 (28.4%)
RK
5,024
425 (8.4%)
1,234 (24.5%)
SKR
485
36 (7.4%)
116 (23.9%)
RK
23,927
2,145 (8.9%)
6,985 (29.2%)
SKR
2,770
320 (11.5%)
1,001 (36.1%)
RK
5,052
362 (7.1%)
1,031 (20.4%)
SKR
530
33 (6.2%)
113 (21.3%)
RK
5,199
364 (7.0%)
896 (17.2%)
SKR
446
40 (8.9%)
76 (17.0%)
RK
6,289
499 (7.9%)
864 (13.7%)
SKR
344
29 (8.4%)
48 (13.9%)
RK
6,799
559 (8.2%)
844 (12.4%)
SKR
553
29 (5.2%)
82 (14.8%)
RK
7,141
572 (8.0%)
699 (9.7%)
SKR
708
19 (2.6%)
80 (11.2%)
RK
7,459
452 (6.0%)
602 (8.0%)
SKR
705
26 (3.4%)
64 (9.0%)
RK
6,849
409 (5.9%)
334 (4.8%)
SKR
738
26 (3.5%)
33 (4.4%)
RK
7,363
497 (6.7%)
270 (3.6%)
SKR
657
124 (18.8%)
17 (2.5%)
RK
6,406
309 (4.8%)
111 (1.7%)
SKR
583
9 (1.5%)
11 (1.8%)
RK
58,557
4,023 (6.9%)
5,651 (9.6%)
SKR
4,681
335 (7.1%)
524 (11.1%)
An Acad Bras Cienc (2017) 89 (2)
TRENDS IN CLINICAL OUTCOMES IN KAZAKHSTAN 18
1389
17
16 14 11.3
12
10.5
10 8.3 8
8.4
7.6 7.8
7.1
SKR
8
7.9
6
RK
5.9
6.2
4.8 3.5
4
2.6 1.5
2 0 2000
2002
2004
2006
2008
2010
2012
2014
Figure 3 - The comparative analysis of the dynamics in the disability rate in female patients with AH combined with type 2 DM aged 18 and above in the SKR and the Republic of Kazakhstan (from 2000 to 2014) (the RK Ministry of Healthcare and Social Development, 2015)
From 2000 to 2014 dynamics in the reduction of the mortality rate in female patients with AH combined with type 2 DM aged 18 and above in the
SKR and the RK were similar, but statistically significant (p <0.05) (Figure 4).
50 45 45 40.3 40 35
32.1
31.4 28.4
30
25.9 25
21.3
SKR 20.4
RK
20 13.9 13.7
15
11.2 9.7
10
4.4 4.8
5
1.8 1.7
0 2000
2002
2004
2006
2008
2010
2012
2014
Figure 4 - The comparative analysis of the dynamics in the mortality rate in female patients with AH combined with type 2 DM aged 18 and above in the SKR and the Republic of Kazakhstan (from 2000 to 2014) (the RK Ministry of Healthcare and Social Development, 2015)
TABLE 3 The disability and mortality rate in patients of both genders with AH combined with type 2 DM aged 18 and above before and after the introduction of CPG in the SKR and the Republic of Kazakhstan (from 2000 to 2014) (the RK Ministry of Healthcare and Social Development, 2015). Years Age Republic SKR (the Incl. the disabled Mortality rate number of AH+DM patients) Total 2000-2005
18 years old and above
RK (33,329)
3,839 (11.5%)
10,489 (31.4%)
An Acad Bras Cienc (2017) 89 (2)
1390
ZHANAR AKIMBAYEVA, ZHUMAGALI ISMAILOV SKR (4,764) 771 (16.2%) Total 2006-2014
18 years old and above
1,828 (38.4%)
RK (84,708)
6,934 (8.2%)
9,201 (10.9%)
SKR (8,973)
709 (7.9%)
1,047 (11.6%)
35 31.4 30 25 20 before CPG 15
after CPG
11.5
10.9 8.2
10 5 0
the disabled
the deceased
Figure 5 - Trends in the disability and mortality rate in patients of both genders with AH combined with type 2 DM aged 18 and above before and after the introduction of CPG in the RK (from 2000 to 2014) (the RK Ministry of Healthcare and Social Development, 2015) 45 38.4
40 35 30 25
before CPG 20
after CPG
16.2
15
11.6 7.9
10 5 0
the disabled
the deceased
Figure 6 - Trends in the disability and mortality rate in patients of both genders with AH combined with type 2 DM aged 18 and above before and after the introduction of CPG in the SKR (from 2000 to 2014) (the RK Ministry of Healthcare and Social Development, 2015)
DISCUSSION As it appears from the data presented in Table 1, the disability rate among male patients with AH combined with type 2 DM aged 18 and above in the SKR was higher (36.2%) than the average in the RK (21.5%) in 2000 (p> 0.05). The patient mortality
An Acad Bras Cienc (2017) 89 (2)
rate was also higher in the SKR (50%) than the average in the RK (41.5%) (p> 0.05). Figures 1 and 2 show that from 2002 to 2006, i.e. before the introduction of clinical practice guidelines, there was a gradual decrease in the specified indicators both in the SKR and in the RK. After the introduction of clinical practice guidelines in 2008-2014 there was a more significant decrease
TRENDS IN CLINICAL OUTCOMES IN KAZAKHSTAN
in the disability and mortality rate among male patients with AH combined with type 2 DM aged 18 and above both in the SKR and in the RK. However, the SKR disability rate in the group of patients was significantly lower (3.7%) in 2014 compared to that in the RK (7.8%). The mortality rate that year turned out to be approximately the same both in the SKR and in the RK (2.9% and 2.8%, respectively). As it can be seen in Figure 3, from 2006 to 2014 the disability rate in female patients with AH combined with type 2 DM aged 18 above in the SKR decreased from 6.2% to 1.5%, respectively (P> 0.05) compared to the average in the RK (from 7.1% to 4.8%, respectively) (p> 0.05). In general, as it can be seen from Table 3, from 2000 to 2014 the average disability rate in patients of both genders with AH combined with type 2 DM in the SKR was higher (10.7%) than that in the RK (9.1%). The SKR mortality rate was also higher (20.7%) (20.9% and 16.6%, respectively). As shown in Table 3 and Figures 5 and 6, after the introduction of clinical practice guidelines in 2006-2014 there was a decrease in the disability and mortality rate among patients of both genders with AH combined with type 2 DM both in the SKR and throughout the RK. Thus, our studies have shown that before the introduction of clinical practice guidelines, there was a gradual decrease in the specified indicators (the disability and mortality rate) both in the SKR and in the RK. After the introduction of clinical practice guidelines in 2008-2014 there was a more significant decrease in the disability and mortality rate among male patients with AH combined with type 2 DM aged 18 and above both in the SKR and in the RK. However, in 2014 the SKR disability rate in that group of patients was significantly lower (3.7%) compared to that in the RK (7.8%). That year the mortality rate among patients was approximately the same in SKR and the RK (2.9% and 2.8%, respectively). In 2000 the disability rate among male patients with AH combined with type 2 DM aged 18 and above in the SKR was higher (36.2%) than the average in the RK (21.5%). The SKR patient mortality rate (50%) was also higher than the average in the RK (41.5%). From 2006 to 2014 the SKR disability rate in female patients with AH combined with type 2 DM aged 18 and above was more significantly decreased
1391
(from 6.2% to 1.5%, respectively) if compared to the average in the RK (from 7.1% to 4.8%, respectively). In 2000-2014 the reduction dynamics in the mortality rate among female patients with AH combined with type 2 DM aged 18 and above in the SKR and in the RK were similar, but statistically significant. After the introduction of clinical practice guidelines from 2006 to 2014 there was a decrease in the disability and mortality rate among patients of both genders with AH combined with type 2 DM both in the SKR and throughout the RK. CONCLUSION In our article the topic was revealed and studied, and the trends in clinical outcomes in patients with arterial hypertension combined with type 2 Diabetes Mellitus in Kazakhstan were analyzed. We studied, compared and analyzed the following: dynamics in the disability and mortality rate among males with AH combined with type 2 DM aged 18 and above before and after the CPG was introduced in the SKR and the Republic of Kazakhstan (from 2000 to 2014); dynamics in the disability and mortality rate in females with AH combined with type 2 DM aged 18 and above in the SKR and the Republic of Kazakhstan (from 2000 to 2014); the disability and mortality rate in patients of both genders with AH combined with type 2 DM aged 18 and above before and after the CPG was introduced in the SKR and the Republic of Kazakhstan (from 2000 to 2014); the disability and mortality rate in patients of both genders with AH combined with type 2 DM aged 18 and above before and after the CPG was introduced in the SKR and the Republic of Kazakhstan (from 2000 to 2014); trends in the disability and mortality rate in patients of both genders with AH combined with type 2 DM aged 18 and above before and after the CPG was introduced in the SKR (from 2000 to 2014). We found out: a gradual decrease in the specified indicators (the disability and mortality rate) both in the SKR and in the RK; a more significant decrease in the disability and mortality rate among male patients in 2008-2014; the SKR disability rate in that group of patients compared to that in the RK in 2014; the disability rate among male patients with AH combined with type 2 DM aged 18 and above in the SKR and the average in the RK in 2000; the SKR disability rate in female An Acad Bras Cienc (2017) 89 (2)
1392
ZHANAR AKIMBAYEVA, ZHUMAGALI ISMAILOV REFERENCES
patients with AH combined with type 2 DM aged 18 and above, compared to the average in the RK from 2006 to 2014; the reduction dynamics in the mortality rate among female patients with AH combined with type 2 DM aged 18 and above in the SKR and in the RK in 2000-2014. After the research of the diseases and implementation of clinical practice guidelines, our article has some prospects. It would be possible to develop new and improved methods and technologies to diagnose, prevent, control and treat such diseases as Arterial Hypertension Combined with Type 2 Diabetes Mellitus. According to a deep and thorough study and analysis of Trends in Clinical Outcomes (the Mortality and Disability Rate) in Patients with Arterial Hypertension Combined with Type 2 Diabetes Mellitus in Kazakhstan, the diseases and their reasons can be better researched. Then due to that scientists, particularly, in Kazakhstan, and generally, all over the world, would be able to make a new scientific discoveries. So, less people, male and female, would suffer from Arterial Hypertension Combined with Type 2 Diabetes Mellitus. The dynamics in the disability and mortality rate according to the gender of the patients is particularly important in our research. Its Assessment would allow medical specialists to find out the reasons and probability of Arterial Hypertension and Diabetes Mellitus to appear among male and female patients. So, we would better define more efficient ways to treat the diseases and to modify their process. Thus, our research would contribute to future scientific breakthrough in this area, and probably, it would be easier to prevent, avoid or even treat arterial Hypertension and Diabetes Mellitus. Clinical outcomes improved notably from 2010 to 2013, coincident with more experience and newer thrombectomy devices. The present study and the previous reports indicate the importance of adhering to evidencebased medical and non-pharmacological therapy for secondary prevention and the necessity of further establishing renewed measures to reduce fatal cardiovascular events. Our research has an importance for medical science in Kazakhstan at a global level.
An Acad Bras Cienc (2017) 89 (2)
BAKRIS G. 2014. Treatment of hypertension in patients with diabetes mellitus. UpToDate. BARRETT-CONNOR E, COHN B, WINGARD D et al. 1991. Why is diabetes mellitus a stronger risk factor for fatal ischemic heart disease in women than in men? The Rancho Bernardo Study. JAMA, 265, pp. 627 – 631. BECKER A, BOS G, de VEGT F et al. 2003. Cardiovascular events in type 2 diabetes: comparison with nondiabetic individuals without and with prior cardiovascular disease. European Heart Journal, 1 August. BURKE A, KOLODQIE F, ZIESKE A et al. 2004. Morphologic findings of coronary atherosclerotic plaques in diabetics: a postmortem study. AtherosclerThrombVasc Bio. 414, pp. 813 – 817. HAFFNER S, LEHTO S, RONNEMAA T et al. 1998. Mortality from coronary heart disease insubjects with type 2 diabetes and nondiabetic subjects with and without prior myocardial infarction. N Engl J Med., 339, pp. 229 – 234. HEYDEN S, HEISS G, BARTEL A et al. 1980. Sex differences in coronary mortality among diabetics in Evans County, Georgia. J Chronic Dis., 33, pp. 265 – 273. LAAKSO M. 2001. Cardiovascular disease in type 2 diabetes: challenge for treatment and prevention. J Intern Med, 249 pp. 225 – 235. LI G, ZHANG P, WANG J et al. 2014. Cardiovascular mortality, all-cause mortality, and diabetes incidence after lifestyle intervention for people with impaired glucose tolerance in the Da Qing Diabetes Prevention Study: a 23year follow-up study. The Lancet. Diabetes and Endocrinology, 2 (6). pp. 474 – 480. NATHAN D, MEIGS J, SINGER D et al. 1997. The epidemiology of CVD in type 2 diabetes mellitus: how sweet it is …. or is it? Lancet, 350 (1), pp. S14 – S19. LICKERMAN A, GROVER-MCKAY M, DELLSPERGER K. 1997. Hyperglycemia-induced angina pectoris in a patient with diabetes mellitus. Clin. Cardiol., 20 (8), pp. 736-737. Report on hypertension in diabetes, 1994. ROSS R. 1999. Atherosclerosis – an inflammatory disease. N Engl J Med., 340, pp. 115-126. SVENSSON A-M, ABRAHAMSSON P, MCGUIRE D. 2004. Influence of diabetes on long-term outcome among unselected patients with acute coronary events. Scandinavian Cardiovascular Journal, 38 (4), pp. 229 – 234. WANDELL P, BRORSSON B, ABERG H. 2000. Functioning and well-being of patients with type 2 diabetes or angina pectoris, compared with the general population. Diabetes Metabolism, 26 (6), p. 465. World Health Organization 2014. Fact sheet № 311, Updated August. YAO K, LU H, HUANG R et al. 2011. Changes of dendritic cells and fractalkine in type 2 diabetic patients with unstable angina pectoris: a preliminary report. Cardiovascular Diabetology, 10 June. STENLÖF K, CEFALU WT, KIM KA, ALBA M, USISKIN K, TONG C, CANOVATCHEL W, MEININGER G. 2013. Efficacy and safety of canagliflozin monotherapy in subjects with type 2 diabetes mellitus inadequately controlled with diet and exercise. Diabetes Obes Metab. 15(4): 372–82.
TRENDS IN CLINICAL OUTCOMES IN KAZAKHSTAN 1393 LAVALLE-GONZÁLEZ FJ, JANUSZEWICZ A, DAVIDSON SINCLAIR AJ, BODE B, HARRIS S, VIJAPURKAR U, J, TONG C, QIU R, CANOVATCHEL W, MEININGER SHAW W, DESAI M, MEININGER G. 2016. Efficacy G. 2013. Efficacy and safety of canagliflozin compared and safety of canagliflozin in individuals aged 75 and with placebo and sitagliptin in patients with type 2 older with type 2 diabetes mellitus: a pooled analysis. J diabetes on background metformin monotherapy: a Am Geriatr Soc.; 64(3): 543–52. randomised trial. Diabetologia; 56(12): 2582–92. PIEPOLI MF, HOES AW, AGEWALL S, ALBUS C, WILDING JP, CHARPENTIER G, HOLLANDER P, BROTONS C, CATAPANO AL, COONEY MT, GONZALEZ-GALVEZ G, MATHIEU C, CORRA U, COSYNS B, DEATON C et al. 2016. VERCRUYSSE F, USISKIN K, LAW G, BLACK S, European Guidelines on cardiovascular disease prevention CANOVATCHEL W et al. 2013. Efficacy and safety of in clinical practice: The Sixth Joint Task Force of the canagliflozin in patients with type 2 diabetes mellitus European Society of Cardiology and Other Societies on inadequately controlled with metformin and Cardiovascular Disease Prevention in Clinical Practice sulphonylurea: a randomised trial. Int J Clin Pract.; (constituted by representatives of 10 societies and by 67(12): 1267–82. invited experts): developed with the special contribution FORST T, GUTHRIE R, GOLDENBERG R, YEE J, of the European Association for Cardiovascular VIJAPURKAR U, MEININGER G, STEIN P. 2014. Prevention & Rehabilitation (EACPR). Eur J Prev Efficacy and safety of canagliflozin over 52 weeks in Cardiol.; 23(11): NP1–96. patients with type 2 diabetes on background metformin JARDIANCE® (empagliflozin) tablets, for oral use [package and pioglitazone. Diabetes Obes Metab.; 16(5): 467–77. insert]. Ridgefield: Boehringer Ingelheim WILDING JPH, BLONDE L, LEITER LA, CERDAS S, TONG Pharmaceuticals, Inc; 2016. C, YEE J, MEININGER G. 2015. Efficacy and safety of MUDALIAR S, ALLOJU S, HENRY RR. 2016. Can a shift in canagliflozin by baseline HbA1c and known duration of fuel energetics explain the beneficial cardiorenal type 2 diabetes mellitus. J Diabetes Complications; 29(3): outcomes in the EMPA-REG OUTCOME study? A 438–44. unifying hypothesis. Diabetes Care; 39(7): 1115–22. USISKIN K, KLINE I, FUNG A, MAYER C, MEININGER G. FERRANNINI E, MARK M, MAYOUX E. 2016. CV 2014. Safety and tolerability of canagliflozin in patients protection in the EMPA-REG OUTCOME trial: a “thrifty with type 2 diabetes: pooled analysis of phase 3 study substrate” hypothesis. Diabetes Care; 39(7): 1108–14. results. Postgrad Med.; 126(3): 16–34 pp. HEERSPINK HJ, PERKINS BA, FITCHETT DH, HUSAIN M, MEININGER G, CANOVATCHEL W, POLIDORI D, CHERNEY DZ. 2016. Sodium glucose cotransporter 2 ROSENTHAL N. 2015. Canagliflozin for the treatment of inhibitors in the treatment of diabetes: cardiovascular and adults with type 2 diabetes. Diabetes Manag.; 5(3): 183– kidney effects, potential mechanisms and clinical 201 pp. applications. Circulation; 134(10): 752–72. BLONDE L, WOO V, MATHIEU C, YEE J, VIJAPURKAR NEAL B, PERKOVIC V, MAHAFFEY KW, FULCHER G, U, CANOVATCHEL W, MEININGER G. 2015. ERONDU N, DESAI M, SHAW W, LAW G, WALTON Achievement of treatment goals with canagliflozin in MK, ROSENTHAL N, de ZEEUW D, MATTHEWS DR. patients with type 2 diabetes mellitus: a pooled analysis of 2017. CANVAS Program collaborative group. Optimising randomized controlled trials. Curr Med Res Opin.; 31(11): the analysis strategy for the CANVAS Program - a pre1993–2000 pp. specified plan for the integrated analyses of the CANVAS GARBER AJ, ABRAHAMSON MJ, BARZILAY JI, BLONDE and CANVAS-R trials. Diabetes Obes Metab. L, BLOOMGARDEN ZT, BUSH MA, GOGO-JACK S, doi:10.1111/dom.12924. DEFRONZO RA, EINHORN D, FONSECA VA et al. NEAL B, PERKOVIC V, de ZEEUW D, MAHAFFEY KW, 2016. Consensus statement by the American Association FULCHER G, STEIN P, DESAI M, SHAW W, JIANG J, of Clinical Endocrinologists and American College of VERCRUYSSE F et al. 2013. Rationale, design, and Endocrinology on the comprehensive type 2 diabetes baseline characteristics of the canagliflozin cardiovascular management algorithm—2016 executive summary. assessment study (CANVAS)—a randomized placeboEndocr Pract.; 22(1): 84–113 pp. controlled trial. Am Heart J.; 166(2): 217–23. SINCLAIR A, BODE B, HARRIS S, VIJAPURKAR U, NEAL B, PERKOVIC V, MATTHEWS DR, MAHAFFEY MAYER C, FUNG A, SHAW W, USISKIN K, DESAI KW, FULCHER G, MEININGER G, ERONDU N, M, MEININGER G. 2014. Efficacy and safety of DESAI M, SHAW W, VERCRUYSSE F et al. 2017. canagliflozin compared with placebo in older patients Rationale, design and baseline characteristics of the with type 2 diabetes mellitus: a pooled analysis of clinical CANagliflozin cardioVascular Assessment Study-Renal studies. BMC Endocr Disord.; 14(1): 37. (CANVAS-R): a randomized, placebo-controlled trial. Diabetes Obes Metab.; 19(3): 387–93.
An Acad Bras Cienc (2017) 89 (2)