Cardiovascular risk reduction in diabetes: underemphasised and overdue. Messages from major trials

Abstract

Diabetes markedly increases the risk of coronary artery disease and death, but is underrecognised as a cardiovascular risk factor, despite the existence of effective treatments. Because patients with diabetes are at high risk for coronary disease, they have more to gain from prevention. There is evidence from clinical trials that select cardiovascular therapies may work better in diabetes, beyond their expected benefit, and may prevent diabetes itself.Diabetes more than doubles the risk of heart disease 1 . This increase is made more serious by figures showing that cardiovascular disease is already the most common cause of death in the general population. In the UK, 35% of all deaths are attributable to cardiovascular disease 2 ; in people with type 2 diabetes this figure reaches almost 60% 3 . Myocardial infarction (MI) is the most common and the most costly complication in diabetes, as well as the number one cause of death. Despite this, doctors and patients apparently do not perceive diabetes to be a major risk for cardiovascular disease. Trials have identified a number of effective means of reducing cardiovascular complications in patients with diabetes. This article will highlight differences between diabetes and other known cardiovascular risk factors and, using examples from large trials, discuss why interventions: may be more important in diabetes work better in diabetes work beyond their expected benefit may prevent diabetes itself. Differences between diabetes and other risk factorsThere are several differences between diabetes and other well-acknowledged risk factors for cardiovascular disease, but perhaps the most important is the lack of prominence and import accorded to diabetes. The under-recognition of diabetes was admitted in 1997 by officials from the US National Institutes of Health who convened a special emphasis panel on the prevention and treatment of cardio- As further evidence, patients with diabetes appear less likely to receive cardiovascular prevention. Aspirin reduces the risk for cardiovascular events in patients with diabetes, hypertension and coronary artery disease to a degree equivalent to other hypertensive patients 5 , but rates of aspirin use for cardiovascular prophylaxis are poor. US national survey data show that only 32% of individuals with both diabetes and cardiovascular disease take aspirin 6 . Diabetic patients admitted for suspected MI are less likely to receive treatment with thrombolysis and aspirin 7 , while diabetic patients discharged following MI are less likely to receive aspirin 8 .Diabetes and cardiovascular disease have been shown to be equivalent in terms of the risk increase for MI 9 . However, among over 15,000 patients enrolled in the MRC/BHF HPS only 7% of those with diabetes but without coronary artery disease reported taking aspirin compared to 77% of patients with coronary artery disease 10 (see end of text for explanation of trials). Aspirin trials for primary prevention in diabetes have not been performed, but there is no obvious reason to believe ...

Canadian Cardiovascular Society position statement – Recommendations for the diagnosis and treatment of dyslipidemia and prevention of cardiovascular disease

“…Chronic hyperglycemia is believed to contribute to premature atherosclerosis in individuals with diabetes (83,84). Nondiabetic individuals with impaired glucose tolerance also have an elevated risk of CAD.…”

Endoplasmic reticulum stress: a novel mechanism and therapeutic target for cardiovascular diseases

“…AMPK controls systemic energy balance and metabolism and has been found to improve endothelial function and reduce cardiovascular risk in diabetic patients [148] . Its activation suppresses ERS in endothelial cells [149] , which is associated with several diseases, including atherosclerosis and obesity.…”

A vércukorértékek nem feltétlenül jellemzik megfelelően a sejtanyagcsere-állapotot

“…A fibrátok, a tiazolidindionok, sőt a statinok is -a PPARmagreceptorokon történő hatá sukkal -alapvető celluláris metabolikus folyamatokat be folyásolnak [48,51]. Ez felveti annak a lehetőségét, hogy a metabolikus szindrómában feltételezett sejtanyag cserezavarra fejtsenek ki jótékony hatást [48,52,53]. Ezen új megközelítésre irányítják a figyelmet a fenti biz tató adatok, de jelenleg még nem rendelkezünk meg győző bizonyítékokkal.…”