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Prevention of coronary heart disease in type 2 diabetes
1Department of Clinical Nutrition, University of Kuopio, Kuopio, Finland.
Insights
Diabetic patients face similar coronary heart disease (CHD) risks as those with prior heart attacks. Aggressive management of risk factors, including improved glycemic control and insulin sensitivity, is crucial for preventing cardiovascular events in diabetes.
Area of Science:
- Cardiology
- Endocrinology
- Metabolic Syndrome
Background:
- Patients with diabetes mellitus have a similar risk of coronary heart disease (CHD) events as non-diabetic individuals with a history of myocardial infarction.
- Diabetic patients experience a worse prognosis following their first myocardial infarction compared to non-diabetic individuals.
- Cardiovascular risk factor management in diabetic patients should be as intensive as in patients with established CHD.
Purpose of the Study:
- To emphasize the need for vigorous cardiovascular risk factor management in diabetic patients.
- To review the efficacy of various therapies in preventing macrovascular disease in type 2 diabetes.
- To explore the role of insulin resistance in the residual risk of CHD in type 2 diabetes.
Main Methods:
- Review of randomized controlled trials on lipid-lowering and antihypertensive therapies in type 2 diabetes.
- Analysis of the impact of antiplatelet therapy (aspirin) on CHD events in diabetic and non-diabetic individuals.
- Examination of the effects of improved glycemic control on CHD risk.
- Investigation into the role of insulin resistance and associated factors in predicting CHD events.
Main Results:
- Cholesterol-lowering and antihypertensive therapies are as effective in type 2 diabetes as in non-diabetic subjects for preventing macrovascular disease.
- Aspirin reduces CHD event risk similarly in high-risk diabetic and non-diabetic patients.
- Improved glycemic control offers a modest benefit in reducing CHD risk.
- A residual excess risk of CHD exists in type 2 diabetes, partly mediated by insulin resistance.
- Insulin resistance is associated with adverse lipid profiles, higher triglycerides, and elevated blood pressure, and predicts CHD events.
Conclusions:
- A multi-factorial approach is essential for preventing CHD in type 2 diabetes.
- This approach should include improved glycemic control, aggressive management of dyslipidemia and hypertension, antiplatelet therapy, and reduction of insulin resistance.
- Agents that improve insulin sensitivity, such as thiazolidinediones, may play a role in cardiovascular risk reduction.
Abstract:
Patients with diabetes without a prior myocardial infarction are at a similar risk of coronary heart disease (CHD) events as non-diabetic subjects with a prior myocardial infarction. Furthermore, prognosis after the first myocardial infarction is worse in diabetic compared to non-diabetic patients. Therefore, management of cardiovascular risk factors in subjects with diabetes should be as vigorous as in patients with known CHD who have had a myocardial infarction. Randomised controlled trials have shown that efficacy of cholesterol lowering and antihypertensive therapy in type 2 diabetes is at least as effective as in non-diabetic subjects in preventing macrovascular disease. Antiplatelet therapy with aspirin reduces the risk of CHD events in high-risk patients and the benefit is similar in subjects with and without diabetes. Improved glycaemic control has a modest beneficial effect on CHD risk. There is residual excess risk of CHD in type 2 diabetes, which is not explained by traditional cardiovascular risk factors. Insulin resistance may partly mediate this. Prediabetic subjects who are insulin resistant have more adverse levels of triglycerides, high density lipoprotein (HDL)-cholesterol and blood pressure than those who are insulin sensitive. Moreover, factors associated with insulin resistance are significant predictors of CHD events in subjects with diabetes, in addition to conventional risk factors. The thiazolidinedione, pioglitazone, improves glycaemia and insulin sensitivity in hyperglycaemic patients. It also improves insulin and triglyceride levels and lowers blood pressure. Thiazolidinediones have been found to have vasculo-protective effects in both acute and chronic vascular injury in animal models. For prevention of CHD in type 2 diabetes a multi-factorial approach should be considered, including improved glycaemic control, aggressive management of dyslipidaemia and hypertension, anti-platelet therapy, reduction of insulin resistance and use of agents that improve insulin sensitivity.
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