Insulin resistance and coronary artery disease

A large body of clinical evidence supports aggressive cardiovascular risk management in combination with glycaemic control in patients with type 2 diabetes and insulin resistance. Glycaemic management in a patient with HbA1c that is at or near goal should include an assessment of postprandial glycaemia. Insulin sensitisers have glycaemic and non-glycaemic benefits and warrant consideration even if the HbA1c is not significantly elevated. Oral agents should always be combined with lifestyle modification, including regular exercise and attention to both individual food choices and overall calorie intake to further optimise glycaemic control. For cardiovascular risk reduction, LDL cholesterol as well as HDL cholesterol and triglycerides should be treated appropriately through lifestyle changes. Often pharmacotherapy with at least one lipid-lowering agent is required. Blood pressure control often requires the use of 3 or more antihypertensive agents in patients with diabetes. Clinical data support use of an ACE-inhibitor as first-line therapy for the prevention of micro-albuminuria in patients with diabetes and hypertension. Urine should be tested for micro-albumin at least annually. Low-dose (81 mg) aspirin is appropriate for patients over age 45 years for primary prevention of coronary heart disease. Multifactorial intervention has been shown in large studies such as the Diabetes Prevention Programme and Steno-2 to have significant cardiovascular benefit among patients at risk of developing diabetes and those with type 2 diabetes and micro-albuminuria. Evidence-based treatments and therapeutic goals can build a practical framework for comprehensive outpatient management of patients with type 2 diabetes and insulin resistance. Data from important ongoing studies will continue to shape this framework in the years ahead.