Cardiovascular Risk in Diabetes

Having diabetes greatly increases your risk of cardiovascular disease. Diabetics have twice the incidence of stroke or a myocardial infarction (or heart-attack) when compared with the non-diabetic population.

The absolute risk of a cardiovascular event is lower in type 1 diabetes than in type 2 diabetes. This is because those with type 1 are more likely to be of a younger age and thus have a lower prevalence of risk factors. But up to 80% of those with type 2 diabetes die of cardiovascular disease.

Time with Disease
The timing of diagnosis seems to be important if you look at cardiovascular mortality in middle aged diabetics. During the first five years after a diagnosis there is not much of an excess of mortality from cardiovascular disease in diabetics.

The 10-year event rate of cardiovascular mortality is 25% in males and 20% in females, so if you have your diabetes for 10 years or more, as you approach middle age your risk is much higher than normal. For diabetic men and women the same risk appears 20 years earlier than those with similar cardiovascular risk factors, but who don’t have diabetes.

Clusters of Symptoms
Diabetes does not usually occur in isolation and a whole cluster of cardiovascular factors including hypertension, dyslipidaemia, endothelial dysfunction and chronic low grade inflammation are common. Hyperglycaemia or high blood sugar, as part of the cardiometabolic syndrome cluster of symptoms, has been identified as a cardiovascular disease risk factor. Even high blood sugar in those who have impaired glucose tolerance is a cardiovascular risk factor.

Prevention Strategies
The problem is there is a varied array of conditions that need to be addressed to prevent cardiovascular and microvascular disease. For the diabetic at risk of cardiovascular disease, multiple interventions are required to reduce risk.

Impaired Glucose Tolerance
There is evidence that other risk factors for cardiovascular complications may be present in those with impaired glucose tolerance who later go on to develop diabetes. Even when we diagnose type 2 diabetes there is already a huge abundance of primary heart disease, peripheral vascular disease, and at the same time the clustering of cardiometabolic risk factors. Even at 15 years prior to the manifestation of disease there is already an excessive risk.

Guidelines for Treatment
Current American Diabetic Association A1c guidelines are to achieve an A1c of less than 7% and to normalise levels without putting patients at risk of hypoglycaemia. Each 1% rise in A1c is associated with an 18% increased risk of a cardiovascular event.

There is a linear relationship between A1c and cardiovascular complications. The relationship between hyperglycaemia and cardiovascular risk should be seen as a continuum for each percentage increase in A1c.

Benefits of Insulin
Early intervention and intensive treatment of type 2 diabetes reduces the risk of a cardiovascular event. Intensive drug therapy during the first five years translates into prevention of major cardiovascular complications. Starting blood sugar lowering therapy has a major impact on cardiovascular risk.

Most people with type 2 will need insulin at some point in their life as decline in beta cell function is inevitable over time. Early intensified insulin therapy has long-term CVD benefits. It can be particularly beneficial to put people on insulin replacement if oral medications fail to attain goals and intensive early.

Postprandial Glucose as a Marker
Postprandial hyperglyc1aemia may be a more important predictor of the risk of cardiovascular disease than fasting blood glucose levels. The risk of cardiovascular for people with high post load glucose is two to three times increased for men and three to five times increased for women. The information on high post load glucose provides better information on the future risk of vascular disease than fasting blood glucose. Attenuated postprandial or post load glucose also predicts increased cardiovascular risk in those with normal fasting glucose.

Conor Caffrey is a writer on health, science and medicine

Other articles by Conor Caffrey about diabetes



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