The link between diabetes and heart disease

Diabetes is a highly prevalent chronic illness. Approximately one in 10 adults in the United States are diagnosed with diabetes. The adult onset diabetes (also called Type 2) is much more common and its prevalence is expected to increase substantially in the future. If the current obesity 
epidemic continues, one in three US adults will have 
diabetes by 2050.

The Cayman Islands Health Services Authority estimates 6 per cent of the population has diabetes in the Cayman Islands. This number is considered a conservative estimate 
and is likely higher.

Diabetes, regardless of its type, is a major risk factor for several long-term complications. These include microvascular conditions – that affect small blood vessels in the body – such as retinopathy (disease of the retina, which is a part of the eye), nephropathy (small blood vessels in the kidney, which may cause reduced kidney function or even kidney failure) and neuropathy, a condition that can affect small nerve endings (most commonly in the feet).

Even more importantly, diabetes is also a major risk factor for coronary artery disease, or CAD, which impacts blood vessels in the heart. Coronary artery disease is the greatest cause of death in patients with diabetes. The risk of CAD is twice as high in patients with diabetes, as compared with those without diabetes; patients with diabetes also have more severe and diffuse form of CAD. As a result, diabetes increases the risk for a heart attack, and doubles the risk of cardiac death.

For these reasons, control of heart disease risk factors is critically important in patients with diabetes to prevent all types of complications, including heart disease. Specifically, high blood pressure, cholesterol, smoking, body weight and blood sugar control need careful attention. Patients with diabetes should aim for blood pressure at least <140/80 mmHg (American Diabetes Association recommends an even more aggressive goal of <130/80 mmHg).

Research studies have demonstrated that treatment with cholesterol lowering medications (called statins) lowers the risk of heart attacks and strokes in patients with diabetes, regardless of whether their cholesterol levels are elevated or not. Although strict blood sugar control does not reduce the risk of a heart attack in patients with adult onset (Type 2) diabetes, studies have shown that it significantly reduces the progression of microvascular complications, such as kidney disease; thus, the American Diabetes Association recommends strict blood sugar control with a general goal of Haemoglobin A1C less than 7 per cent.

Lifestyle modifications are highly effective in improving all CAD risk factors in patients with diabetes. In one study, calorie restriction and physical exercise improved blood pressure, cholesterol, blood sugar control and weight, and reduced the number of medications needed to treat risk factors in patients with Type 2 diabetes.

Finally, use of low-dose aspirin is recommended in older patients with diabetes, and in all diabetic patients with known CAD (5). Of course, smoking cessation is also strongly encouraged. Any symptoms suggestive of CAD, such as chest discomfort, shortness of breath, palpitations or excessive fatigue, require early evaluation in patients with diabetes to exclude significant heart problems. Patients with diabetes who are diagnosed with CAD are at particularly high risk for a heart attack, and should have aggressive risk factor management and close follow up.

If you, or someone you love, have diabetes, you can help reduce the risk of diabetes complications by becoming an active partner in your health care. Here are several simple steps to help you get started:

Monitor your blood sugar. Use a glucose meter at home on a daily basis. In addition, monitor your A1C levels at least twice a year in your doctor’s office.

Monitor your blood pressure and maintain it within the appropriate range with lifestyle modifications and medications, when needed.

Know your cholesterol levels. For many patients with diabetes, cholesterol-lowering medications (statins) should be used to prevent heart-related complications.

Maintain a healthy weight through combination of appropriate diet (low in salt, saturated fat and starchy foods; high in vegetables, fruit and lean protein) and physical activity. American Diabetes Association recommends at least two and a half hours of activity per week for patients with diabetes.

Monitor your vision (through yearly eye exams) and kidney function. Your doctor can order a blood test that measures kidney function, and a urine test that measures protein levels. Presence of protein in the urine can be an early sign of kidney damage, even if the kidney function is normal.

Be aware of signs and symptoms of diabetes complications, and discuss them right away with your doctor.

Ask your doctor what you can do to improve the control of your risk factors and reduce your risk of complications.

Dr. Mikhail Kosiborod is a 
cardiologist at Saint Luke’s Mid America Heart Institute Kansas 
City, Missouri, and medical director of The Heart Health Centre, Cayman Islands.

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