Diabetes and Coronary Heart Disease: A Risk Factor for the Global Epidemic
The American Heart Association explains the strong correlation between cardiovascular disease, CVD or heart disease and diabetes. This triad of poor lipid counts often occurs in patients with premature coronary heart disease. It is also. CHD is much more common in diabetics than in the The extent of the disease in coronary arteries is also link between the afferent and efferent limbs of the. If atheroma builds up in your coronary arteries (the arteries that supply . tells us more about the links between diabetes and heart and circulatory diseases, but.
Clinically, patients with diabetes are more likely to be without chest pain in the setting of unstable angina or MI, and thus late presentation contributes to a higher mortality in these patients.
In one small study, 58 diabetic men without symptoms and with normal electrocardiograms ECGs underwent cardiac stress testing.
Coronary artery disease and diabetes mellitus
Seventeen percent were found to have significant CAD despite their absence of symptoms. Several studies of silent ischemia have demonstrated that MI and death rates and CAD disease severity are the same in patients with silent ischemia as they are in those with symptomatic ischemia. Diabetic patients, on the other hand, are more likely to be truly "silent patients.
There is a suggestion that early diagnosis and intervention in diabetic patients with silent ischemia is beneficial. In the Coronary Artery Surgery Study CASSdiabetic patients with silent ischemia had a higher mortality than did nondiabetic patients with silent ischemia, and their outcome was better with revascularization than with pharmacological therapy. However, the goal of cardiac stress testing is not only to diagnose CAD, but also to assess risk for cardiovascular morbidity and mortality.
The ability to assess risk of future events is helpful in determining management. Patients with diabetes have a higher rate of MI and repeat revascularization after PTCA than do nondiabetic patients, presumably due to increased rates of restenosis. Currently, a proposal is being planned for a multicenter trial that will ask whether early revascularization is better than pharmacological therapy in diabetic patients found to have CAD.
Unfortunately, there are no ongoing or planned trials to evaluate whether the high cardiovascular death rate among diabetic patients can be reduced with aggressive early identification of CAD and aggressive risk factor management. At this time, there are no recommendations to perform early revascularization in diabetic patients.
The indications for surgery are left-main disease or three-vessel disease, especially in the setting of reduced left ventricular LV function. Not all patients with diabetes and CAD should undergo cardiac catheterization.
Cardiac stress testing can accurately assess this risk. The American Diabetes Association recommends annual risk factor assessment, including a history for possible anginal symptoms, a lead ECG, and evaluation for hyperlipidemia and hypertension. Presence of significant Q waves suggests a history of a silent MI.
In patients with type 1 diabetes, the duration of diabetes is an important risk factor, with onset of clinical CAD as early as the third and fourth decade, although usually after age Recent studies have also identified diabetic nephropathy and microalbuminuria as strong independent risk factors for cardiovascular morbidity and mortality in people with diabetes.
This suggests that all diabetic patients should be screened for proteinuria, which is also recommended as a screening tool for those who may progress to nephropathy.
Those with nephropathy or microalbuminuria should be considered for cardiac stress testing. The role of diabetic autonomic neuropathy in increasing the risk from cardiovascular disease is controversial. Several studies have implicated autonomic neuropathy as a contributing factor in the mechanism of silent ischemia. However, there are no current recommendations for cardiac stress testing in patients with autonomic neuropathy.
Peripheral vascular disease PVD in diabetic patients is associated with a particularly high rate of cardiovascular mortality. Clearly, all diabetic patients with chest pain should undergo cardiac stress testing. However, as noted above, the absence of chest pain in people with diabetes and severe CAD is well recognized.
Symptoms to consider as anginal equivalents in diabetic patients include dyspnea, lightheadedness, or severe fatigue with exertion. Unfortunately, there are no studies evaluating screening of diabetic patients with exertional symptoms that are not chest pain. However, diabetic patients with these symptoms should be screened for significant CAD.
The advantage of this system is that the risk of a particular individual can be determined based on risk factors, and deciding on whom to perform further testing can be based on what level of risk is considered unacceptable. For women with diabetes, the protection seen in premenopausal women without diabetes is lost. Therefore, diabetic women should be risk-stratified similarly to men. Diabetic patients who are currently sedentary but are planning to begin an exercise program should also first be risk-stratified.
The frequency with which stress testing should be repeated in asymptomatic patients whose first test was negative is an unanswered question.Diabetes-Related Heart Disease
Annual reassessment of risk should be performed. In patients who have symptoms associated with their CAD, their symptoms should guide testing. Exercise testing is warranted in any CAD patients with a change in clinical status.
In diabetic patients who are to undergo surgical procedures, particularly vascular procedures, there should be a low threshold for risk stratification before surgery.
Heart Disease — The Diabetes Connection | Everyday Health
Those with chest pain should be tested if their angina has been difficult to control or has recently changed in pattern. Patients with known silent ischemia should probably be tested within the year before surgery. In a study published by Iskandrian and associates, the risk of death or MI in patients with known CAD but a normal or mildly abnormal radioisotope myocardial perfusion scan was very low for 24 months, at which time the event rate began to increase.
Cardiac prognosis in asymptomatic patients cannot usually be predicted by an exercise tolerance test ETT. Several large studies have demonstrated the inadequacy of the ETT at identifying individuals in a large, asymptomatic population who are at risk for future cardiac events.
The exception to this is patients with multiple atherosclerotic risk factors with a markedly abnormal exercise test. Nomogram of the prognostic relations embodied in the treadmill score. Determination of prognosis proceeds in five steps. First, the observed amount of exercise-induced ST-segment deviation the largest elevation or depression after resting changes have been subtracted is marked on the line for ST- segment deviation during exercise.
Second, the observed degree of angina during exercise is marked on the line for angina. Third, the marks for ST-segment deviation and degree of angina are connected with a straight edge. The point where this line intersects the ischemia-reading line is noted.
Fourth, the total number of minutes of exercise in treadmill testing according to the Bruce protocol or the equivalent in multiples of resting oxygen consumption [METs] from an alternative protocol is marked on the exercise-duration line. Fifth, the mark for ischemia is connected with that for exercise duration. The point at which this line intersects the line for prognosis indicates the 5-year survival rate and average annual mortality for patients.
Reprinted with permission of the New England Journal of Medicine. The best-studied method of combining symptoms, ECG changes, and exercise time to predict prognosis is the Duke Treadmill Score Figure 1which was generated in 2, patients with known or suspected CAD without a history of MI or revascularization.
The score has been validated as a prognostic tool in several smaller studies at Duke University and other centers. Extrapolating from existing studies may be difficult given that diabetic patients should have a higher pretest likelihood, presumably increasing the sensitivity of the test; yet they are more likely to have angina without chest pain, thus probably decreasing the specificity of the test.
Not all patients with CAD will be identified, particularly those with single-vessel disease. However, those with good exercise capacity should have an acceptable prognosis even in the setting of a false-negative test for diagnosis of CAD.
Those patients with poor exercise tolerance but a negative test by standard ECG criteria should be considered for an alternative method of stress testing to improve the diagnostic and prognostic accuracy of identifying significant CAD. There are a number of situations in which exercise testing should not be used. Absolute contraindications to exercise testing include patients with severe symptomatic aortic stenosis, uncontrolled symptomatic cardiac arrhythmias, and acute cardiovascular or cardiopulmonary events.
Relative contraindications include moderate aortic stenosis, severe arterial hypertension, electrolyte abnormalities, arrhythmias, and hypertrophic cardiomyopathy. These patients should be considered for a stress imaging test. Eat a heart-healthy diet. Reduce consumption of foods high in saturated fat, trans fat, salt, and cholesterol, such as fried foods, red meats, and eggs.
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- Heart Disease: The Diabetes Connection
Instead, focus on eating more high-fiber foods, including whole grains, vegetables, and fruits. Following a heart-healthy diet can also help you manage your diabetes.
If you're overweight, try to shed the pounds. Start by choosing a heart-healthy diet and being more active every day. Keep blood cholesterol levels within target ranges. LDL bad cholesterol should be below ; HDL good cholesterol should be higher than 40 — but the higher, the better. If you have high cholesterol, talk to your doctor about what steps you can take to help lower it. Keep your blood glucose level within the target range. Your doctor should help you determine the right range for you.
A normal A1C level should be below 5.
Maintain a controlled blood pressure level. Be sure to have your pressure checked during every visit to your doctor's office, and if you have high blood pressure, talk to your doctor about steps you can take to lower it.
People with either heart disease, diabetes, or both who smoke are at an increased risk of health complications. Quitting smoking is one of the best things you can do for your health. Talk to your doctor about getting help when you're ready to quit.
Take all your medications as prescribed. Diabetes and heart disease are serious health conditions. If you have either of these conditions, your doctor may prescribe medication to help you manage.
If you have diabetes and develop heart disease, treatment — first and foremost — will include lifestyle changes such eating a healthy dietexercising regularly, maintaining a healthy weight, and quitting smoking.
You might also need medication to lower your blood glucose, blood pressure, or cholesterol level, and to treat any heart damage.