Review
Cardiovascular risk in diabetes: A brief review

https://doi.org/10.1016/S1056-8727(00)00065-9Get rights and content

Abstract

Cardiovascular disease (CVD) is the major cause of the morbidity and mortality associated with diabetes in the US. A 2- to 3-fold incidence of CVD occurs in both type 1 and type 2 diabetic individuals over that in age- and gender-matched non-diabetic persons. Recent encouraging data demonstrating a decline in CVD mortality in the general US population do not reflect such a decline in the diabetic population, particularly in women.

Increased risk for CVD is related to duration of diabetes and hyperglycemia, as well as hypertension, dyslipidemia, insulin resistance, gender, coagulation abnormalities, and other factors. Health care providers need to advocate for an uncompromising, multi-component attack on all modifiable risk factors for CVD, including glucose control, in the person with diabetes mellitus. This review focuses on known modifiable risk factors for CVD associated with diabetes, potential targets for primary and secondary prevention.

Section snippets

Epidemiology of CVD morbidity and mortality

Examination of the natural histories of both types of diabetes reveals the significance of CVD in each. Data generated in the late 1980s from a cohort of 292 patients with type 1 diabetes followed for 20–40 years revealed an alarmingly high rate of coronary artery disease (CAD) and CAD mortality in this population. The cumulative mortality in the diabetic men and women was 3.5- to-4-fold higher than that of a cohort of similar aged non-diabetic population from the Framingham Heart Study, used

Hyperglycemia

A preponderance of evidence suggests that hyperglycemia is an important contributor to the increased CVD risk associated with diabetes. Hyperglycemia leads to glycation and peroxidation of proteins which, in animal studies, cause arterial damage, and it also has direct toxic effects on arterial walls. Logic dictates that exposure to hyperglycemia would enhance atherogenesis.

Many observational studies suggest that severity of hyperglycemia is an independent predictor of CVD. The Whitehall study

Effect of intensive glucose management

A number of prospective interventional studies support improvement in glycemic control as an important step toward reducing CVD risk. Conflicting data, however, do exist.

In type 1 diabetes, results of the DCCT showed a reduction in macrovascular complications in the intensively treated group of 41%, which is not a statistically significant difference (p=0.065), because of the small number of events in this young population. However, intensive management did reduce the development of

Relationship of insulin resistance to CVD risk

A number of studies have shown that hyperinsulinemia, a marker for insulin resistance, is associated with risk of CVD, even in the absence of diabetes. An Italian study in healthy persons with normal glucose tolerance showed that risk factors for CVD, such as high total and LDL-cholesterol levels, low HDL-cholesterol levels, and high blood pressure, were associated with hyperinsulinemia (Zavaroni et al., 1989). The Paris Prospective study, an 11-year study in 7028 diabetic and non-diabetic men,

Dyslipidemia and CVD risk

The Framingham Heart Study found that dyslipidemia was common in adults with diabetes, characterized most often by high triglyceride and low HDL-cholesterol levels (Garg & Grundy, 1990). This pattern occurs in both type 1 and type 2 diabetes, reflecting the basic pathogenic mechanism of lack of effective insulin action in each, either due to inadequate secretion or resistance. It is generally accepted, based on data from numerous studies, that dyslipidemia is an independent risk factor for CVD

Hypertension and cardiovascular risk in diabetes

Extensive data from a number of studies have demonstrated that tightly controlling blood pressure effectively reduces cardiovascular risk even more in the diabetic population than in the non-diabetic population. The results from the active treatment group of the Systolic Hypertension in the Elderly Program (SHEP) demonstrated reductions in rates for all major cardiovascular events of 34%, for stroke, 22%, and for MI, 56%, in older diabetic patients with isolated systolic hypertension (ISH)

Aspirin use and CVD reduction

There have been a number of trials of anti-platelet agents in populations at increased CVD risk. The HOT trial, described previously, included an evaluation of the benefits of aspirin use, and showed that, compared with placebo, the active treatment diabetic group had significant reductions in all major cardiovascular events of 15% and in MI of 46%. Reductions in risk for MI were also demonstrated in the Early Treatment Diabetic Retinopathy Study (EDTRS) (EDTRS Investigators, 1992).

Recommendations and perspective on risk factor reduction

Abundant data demonstrates that early aggressive control of glucose, blood pressure, and lipids is clearly beneficial in diabetic patients. The goals for risk factor reduction put forth by the American Diabetes Association, the American Heart Association, and others are summarized in Table 2.

Finally, a recent Finnish population-based study evaluating CVD risk in 1373 type 2 diabetic and 1059 non-diabetic subjects, with and without prior history of CVD, underlines the magnitude of the risk

References (49)

  • American Heart Association Consensus Panel Statement. (1997). Guide to primary prevention of cardiovascular disease....
  • J.D. Curb et al.

    Effect of diuretic-based antihypertensive treatment on cardiovascular disease risk in older diabetic patients with isolated systolic hypertension

    JAMA

    (1996)
  • J.D. Curb et al.

    Sudden death, impaired glucose tolerance and diabetes in Japanese American men

    Circulation

    (1995)
  • J.-P. Despres et al.

    Hyperinsulinemia as an independent risk factor for ischemic heart disease

    N Engl J Med

    (1996)
  • J.-P. Despres et al.

    Risk factors for ischaemic heart disease: is it time to measure insulin?

    Eur Heart J

    (1996)
  • R.P. Donahue et al.

    Postchallenge glucose concentration and coronary heart disease in men of Japanese ancestry

    Diabetes

    (1987)
  • Aspirin effects on mortality and morbidity in patients with diabetes mellitus. Early Diabetic Retinopathy Study Report 14

    JAMA

    (1992)
  • A.M. Fontbonne et al.

    Insulin and cardiovascular disease: Paris Prospective Study

    Diabetes Care

    (1991)
  • A. Garg et al.

    Management of dyslipidemia in NIDDM

    Diabetes Care

    (1990)
  • R.B. Goldberg et al.

    Cardiovascular events and their reduction with pravastatin in diabetic and glucose-intolerant myocardial infarction survivors with average cholesterol levels: subgroup analyses in the cholesterol and recurrent events (CARE) trial

    Circulation

    (1998)
  • K. Gu et al.

    Diabetes and decline in heart disease mortality in US adults

    JAMA

    (1999)
  • S.M. Haffner et al.

    Mortality from coronary heart disease in subjects with type 2 diabetes and in nondiabetic subjects with and without prior myocardial infarction

    N Engl J Med

    (1998)
  • R.J. Jarrett et al.

    The Bedford Survey: ten year mortality rates in newly diagnosed diabetics, borderline diabetics, and normoglycaemic controls and risk indices for coronary heart disease in borderline diabetics

    Diabetalogia

    (1982)
  • K.J. Jensen-Urstad et al.

    Early atherosclerosis is retarded in by improved long-term blood glucose control in patients with IDDM

    Diabetes

    (1996)
  • Cited by (95)

    • Efficacy of probiotic supplementation in patients with diabetic nephropathy: A systematic review and meta-analysis

      2020, Clinical Nutrition ESPEN
      Citation Excerpt :

      It is an end-stage kidney disease characterized by impaired renal function with elevated urinary albumin excretion rate (UAER) [2]. It is usually associated with cardiovascular complications that increase both mortality and morbidity rates [3,4]. With poor control of hyperglycaemia, hypertension, heavy smoking, anaemia, and dyslipidaemias, patients will be at higher risk of DN and end-stage Kidney disease (ESKD) [5,6].

    • Elevated fasting serum insulin level predicts future development of hypertension

      2014, International Journal of Cardiology
      Citation Excerpt :

      These findings suggest that elevated fasting insulin level can be an early predictor for hypertension. Especially, considering the clinical significance of hypertension as a definite causative factor for cardiovascular diseases, our study may be an etiologic background for previous studies showing increased cardiovascular risk in hyperinsulinemic, non-diabetic population [16–18]. Although there is still ongoing debate for relationship between fasting insulin level and BP, our findings correspond to previous reports sustaining the positive association between these 2 factors [19–23].

    View all citing articles on Scopus
    View full text