Diabetes and Heart Disease

Although people with diabetes are often focused on controlling blood sugar levels, management of cardiovascular disease (CVD) is equally important. CVD includes heart disease (i.e heart attacks), peripheral vascular disease (PVD) and cerebral vascular disease (i.e. strokes). This group of diseases accounts for 70% of deaths in people with diabetes. Heart attacks, also known as myocardial infarctions or MI's, are 2-3 times more common in people with diabetes. People with Type 2 diabetes have the same risk of a MI as someone without diabetes who has already had a MI. MI's tend to be more serious in diabetics with a greater risk of post-MI complications and death. 1/3 of diabetics have no symptoms with their heart attack. Prompt diagnosis and treatment of MI's is thus very difficult.

Prevention of a complication which is common, serious, and often asymptomatic, is a critical goal.

The following four steps will help you achieve this goal.

Step #1: Improve your lipid profile.

Cholesterol is made up of bad cholesterol (LDL-cholesterol or LDL-c) and good cholesterol (HDL-cholesterol or HDL-c). 30 years of clinical trial data suggests that high LDL-c levels are a significant risk factor for heart disease. For every 1 mg/dl the LDL-c is reduced, the total rate of death is reduced by 1%. In people with diabetes without known heart disease, the goal LDL-c is <100 mg/dl. If heart disease is already documented, or the person is considered at very high risk, the goal LDL-c is <70 mg/dl. With successful reduction of LDL-c, the risk of CVD may be reduced by 30-50%. Statins are the drug class of choice for LDL-c reduction.

The statins will reduce the LDL-c by 18-55%, raise HDL-c by 4-9% and lower triglycerides (goal is <150 mg/dl) by 7-30%.

No lower thresholds have been established below which further LDL reduction offers no benefit.

The ADA recommends moderate or high dose statin therapy for people with diabetes who are 40 years or older.  

High dose therapy (atorvastatin 40-80 mg, rosuvastatin 20-40 mg) is reserved for people with additional heart disease risks and/or the presence of documented heart disease.

Since people with Type 1 diabetes have exhibited similar benefits, albeit in smaller studies, recommendations regarding therapy are the same

Step #2: Optimize your blood pressure

High blood pressure is a well know risk factor for CVD. If a diabetic has high blood pressure, their risk for CVD doubles. Although exact goals remain controversial, the ADA recommends a goal blood pressure of <140/90. More aggressive reduction (<130/80) may be appropriate if other heart related risks of present. The majority of people with diabetes will require two or more medications to achieve the ADA blood pressure goal.

The most commonly prescribed blood pressure lowering medications in people with diabetes are the angiotensin-converting enzyme (ACE) inhibitors and the angiotensin receptor blockers (ARB's).

ACE inhibitors are the typical first choice because of their potential for kidney protection and improved heart outcomes.

In the UKPDS, a classic study of newly diagnosed Type 2 diabetics published in 2002, each 10 mm hg reduction in the mean systolic blood pressure reduced the risk of a heart attack by 11%.

The risk of a diabetes related death was reduced by 15%.

Control of cholesterol and blood pressure may have an even greater benefit than either complication treated alone.

Step #3: Make smart lifestyle choices.

Smoking is a risk factor for CVD in all people. Non-diabetic smokers have a 2x increased risk of MI or stroke. These occur 10 years earlier than in non-smokers. CVD risk in diabetics who smoke is increased at least 4-fold. Cigarettes must be stopped.

Weight loss will help you lower your blood pressure and triglycerides.

Remember that abdominal fat is especially bad.

Exercise moderately, with a goal of 30 minutes daily, 5 days per week.

Discuss a formal exercise stress test with your physician before beginning exercise, especially if you're 35 years or older.

Restrict your salt intake, reduce your carbohydrate and saturated fat intake, increase omega-3 fatty acids and increase vegetables.

Research the Mediterranean diet.

Don't drink more than 1-2 drinks per day.

Be happy and eliminate stress.

Step #4: Avoid hypoglycemia

The exact role of sugar control in the prevention of heart disease is unknown.

In the DCCT/EDIC trial, a reduction in the HA1c from 9% to 7% in people with Type 1 diabetes resulted in a 42% reduction in risk for any CVD event.

The risk of nonfatal MI, strokes and CVD related death was reduced by an astounding 57%.

Proof of CVD risk reduction with better sugar control in people with Type 2 diabetes has been more problematic.

The UKPDS, published in 1991, reported a 16% reduction in MI's and sudden death with tight glucose control. The difference was not statistically significant compared to the poorly controlled group.

More recently, the ADVANCE and VADT trials showed no CVD benefit with improved sugar control.

Although the ACCORD trial reported a non-significant reduction in the 5-year risk of nonfatal MI's with improved glucose control, there was a greater risk of death at 5 years in the patients with tighter glucose control.

The cause of the greater risk of death remains unknown.

Given the concern that unrecognized hypoglycemia may be the unknown causative factor for the increased death rate in ACCORD, it has been suggested that the goal of glucose control should be to find a regimen that allows the best glucose control with the lowest risk of hypoglycemia.

It is interesting to note that those people in each of the trials with the shortest duration of diabetes and/or no evidence of CVD did benefit from improved glucose control.

This has been interpreted by some physicians to suggest that improved sugar control must be started early in the course of diabetes before significant CVD appears.

Each of these steps is important in the prevention of CVD

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