[D274]Diet And Exercise Plan

If your patient has CAD, teach her to reduce her risk of developing complications, such as angina and an MI, by eliminating or reducing these modifiable risk factors:

hyperglycemia

hypertension

hypercholesterolemia

obesity

cigarette smoking.

Also, teach her about any prescribed drugs or invasive treatments for managing CAD.

Risk Factor Management

Hyperglycemia, a risk factor for cardiovascular disease, is always your diabetic patient's first priority. A combination of diet, exercise, drugs, and stress reduction can help your patient keep her blood glucose levels as close to normal as possible. Encourage her to monitor her blood glucose levels at home so that she can adjust different aspects of her treatment as needed. Keep in mind, however, that the physician may modify your patient's treatment after a severe cardiac problem to achieve stricter blood glucose control. That's because avoidance of severe hypoglycemia is crucial to preventing arrhythmias, which can lead to more serious cardiac problems, such as an MI.

Hypertension accelerates the vascular changes of already compromised coronary arteries. Monitor your patient's blood pressure frequently. If her blood pressure exceeds 140/85 mm Hg on two separate occasions, she's considered hypertensive. The physician may prescribe lifestyle modifications, such as a low-sodium diet, alcohol restriction, and regular exercise. If 3 months of nonpharmacologic therapy don't reduce your patient's diastolic blood pressure below 90 mm Hg, the physician may prescribe an antihypertensive drug, such as an ACE inhibitor. If your patient's diastolic pressure exceeds 110 mm Hg or if she has microalbuminuria, the physician may prescribe an antihypertensive drug immediately in conjunction with lifestyle modifications.

Many patients with diabetes are at risk for CAD because they have hypercholesterolemia. Even those with normal or nearnormal total cholesterol levels may be at risk because their heartprotective, high-density lipoprotein (HDL) levels are abnormally low, and their low-density lipoprotein (LDL) levels are abnormally high. Typically, a low-cholesterol, low-fat diet is recommended for patients whose total cholesterol level exceeds 200 mg/dl and whose LDL level exceeds 130 mg/dl. Encourage your patient to reduce her total fat intake to less than 30% of her total calories and her saturated fat intake to less than 10% of her total calories. If 6 months of diet therapy and exercise don't reduce your patient's LDL level to 160 mg/dl or less, the physician may prescribe a lipid-lowering agent, such as lovastatin.

To help your patient reduce her weight, the physician may prescribe an individualized diet and exercise plan. The goals of the weight-loss program are to help improve your patient's blood glucose levels and better control her blood pressure. She can achieve these goals with even a modest weight loss of 10 to 15 pounds. Help your patient understand that a large weight loss followed by a weight gain is stressful to her body. Instead, encourage her to maintain her weight and blood glucose levels by controlling her food portions, eating balanced nutritious meals, and eating her meals at the same time each day.

If your diabetic patient smokes, she should stop. To help ease her withdrawal symptoms, her physician may prescribe nicotine in a dermal delivery system or a chewing gum. The physician may also encourage her to attend a support group.

Drug Therapy

Your patient's physician may prescribe one or more drugs to manage CAD and help prevent its complications.

To treat coronary artery insufficiency, the physician may prescribe a beta-blocker, such as propranolol. But if your patient is using insulin, she may not be able to take beta-blockers because these drugs can impair insulin secretion and alter or mask the signs and symptoms of hypoglycemia. Without the typical warning signs and symptoms of hypoglycemia-such as dizziness, diaphoresis, or nausea-your patient may not realize that her blood glucose level has fallen dangerously low. However, some patients who use insulin can tolerate low doses of cardioselective beta-blockers, such as atenolol, metoprolol, or acebutolol.

If your patient has had an MI, the physician may prescribe aspirin to reduce the risk of further complications of CAD.

If she has angina, the physician may prescribe a nitrate, such as a nitroglycerin patch. Although the nitrate won't interfere with blood glucose control, it can produce severe hypotension. So monitor your patient's blood pressure and teach her about the signs and symptoms of hypotension, such as light-headedness when changing from a lying position to a standing one.

If your diabetic patient has heart failure and hypertension, drug therapy may pose problems. If she also has autonomic neuropathy and orthostatic hypotension, calcium channel blockers may be in appropriate. Although ACE inhibitors have been used successfully in patients with diabetes, they can increase serum potassium levels, requiring close monitoring for signs of hyperkalemia. Thiazide diuretics can raise blood glucose levels and reduce potassium levels, requiring close monitoring for signs of hypoglycemia and hypokalemia. They may also cause impotence or orthostatic hypotension, especially in a patient with autonomic neuropathy.

Invasive Treatments

Patients with CAD may also benefit from invasive treatments. In those with coronary ischemia or MI, percutaneous transluminal coronary angioplasty can restore blood flow in blocked coronary arteries. However, if a patient with nephropathy receives radiographic dye during this nonsurgical invasive procedure, she may develop further kidney problems. Coronary artery bypass surgery may also be performed in diabetic patients. However, high glucose levels during surgery can increase the risk of postoperative complications and death.