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The European Society of Cardiology


Clinical Articles

Diabetic patients should be aware of 2-3 fold increase in cardiovascular risk

All patients with diabetes should monitor their blood pressure and lipid levels to lower the risk of developing cardiovascular disease, the European Society of Cardiology (ESC) recommends.

The theme of World Diabetes Day 2009 is Education and Prevention. In support of this, the ESC wishes to draw attention to the prevention strategies that diabetic patients can adopt to slow the development of heart disease.

“The important message for diabetics is that the rate of progression of cardiovascular disease can be retarded or halted,” said Professor Heinz Drexel, ESC spokesperson on diabetes. “Such changes have the potential to make a real difference to both people’s quality and quantity of life.”

The importance of following the recommendations is illustrated by the stark statistics. Coronary artery disease (CAD) is the most common cause of death for European adults with diabetes. The risk of developing cardiovascular disease is two to three times higher for diabetics, compared to the general population. Furthermore, people with diabetes who suffer a heart attack are more likely to die from the event than non-diabetic patients suffering heart attacks. With current estimates suggesting that the number of diabetics worldwide is likely to grow from 195 million today to 330 million by 2050, the problem of cardiovascular disease and diabetes looks set to increase.

While the diabetes/ heart connection is not fully understood, Professor Drexel, director of the Vorarlberg Institute for Vascular Intervention and Treatment in Feldkirch, Austria, said one theory currently gaining popularity is that fatty acids released from excess abdominal fat (common among diabetics) cue the liver to produce too much bad ‘LDL’ and ‘VLDL’ – the particles carrying triglycerides and cholesterol – which encourage the growth of atherosclerotic lesions.

Clinical Guidelines addressing cardiovascular disease and diabetes, published in 2007 by the ESC and the European Association for the Study of Diabetes (EASD), say that multi-factorial therapy, including statins for lipid normalisation, strict control of hypertension (through a range of pharmaceutical agents), near-normal glucose control and antiplatelet therapy can all help to prevent or delay cardiovascular complications in diabetic patients (1).

“It would be good practice for every diabetic patient to have a good grasp of their pattern of cardiovascular risk factors including cholesterol levels (both HDL and LDL) , trigycleride levels and blood pressure, and to closely monitor the success of interventions,” says Professor Drexel, adding that it is also essential for all diabetics to stop smoking.

While diabetics undertake regular measurements of their blood glucose levels, he said, less   emphasis is placed on some of the other parameters that can also have a major effect on cardiovascular outcomes.

“The important message for patients to understand is that glucose lowering alone will not suffice.  Heart disease is a multi-factorial problem that needs to be attacked on all fronts to achieve maximum benefits,” said Professor Drexel.

Patients with diabetes can also help themselves by making lifestyle changes. The ESC Guidelines say they should incorporate 150 minutes physical activity into their week. 

Studies assessing the association between physical activity and the risk of cardiovascular mortality among diabetic patients have shown that regular physical activity is associated with reduced CVD and total mortality. The ESC Guidelines suggest also that the reduction in cardiovascular risk associated with physical activity may be comparable with that of pharmacological treatment prescribed to patients with type 2 diabetes. However to some it may be unclear how much exercise is needed to achieve a positive effect.

“The simple message is that if you’re exercising enough to start sweating you’re probably in the right range, and should be exercising at least three days a week,” said Professor Drexel.

A low-glycaemic diet is also key.

A recent study published by the Journal of the American Medical Association (2) found that patients with type 2 diabetes who ate diets high in low-glycaemic foods (such as nuts, beans and lentils) had greater improvement in glycaemic control and risk factors for coronary heart disease (such as the LDL/HDL ratio), than those consuming diets with an emphasis on high-cereal fibre. 

In addition to reviewing strategies to slow the progression of heart disease, the ESC guidelines also recommend that patients with established CAD should have an oral glucose tolerance test if their diabetic status is unknown. “If you look at patients with CAD you’ll find that on average one third has overt diabetes, one third borderline glucose level and only one third completely normal glucose metabolism. Testing patients with CAD  for diabetes offers a valuable way of  identifying diabetic patients who have fallen through the net and reducing their chance of experiencing a second cardiovascular event,” said Professor Drexel.

References and notes

World Diabetes Day was (held on on 14 November), initiated by the International Diabetes Federation (IDF) and WHO, marks the birthday of Frederick Banting who, together with Charles Best and a team of specialists, discovered insulin in 1922.  The campaign, which is represented by a blue circle logo, draws attention to important issues for diabetics and keeps the condition firmly in the public spotlight.

  1. ESC Clinical Guidelines on Diabetes, Pre-Diabetes, and Cardiovascular Diseases: The Task Force on Diabetes and Cardiovascular Diseases of the ESC and the European Association for the Study of Diabetes (EASD).
  2. Effect of a Low–Glycemic Index or a High–Cereal Fiber Diet on Type 2 Diabetes: A Randomized Trial
David J. A. Jenkins; Cyril W. C. Kendall; Gail McKeown-Eyssen; Robert G. Josse; Jay Silverberg; Gillian L. Booth; Edward Vidgen; Andrea R. Josse; Tri H. Nguyen; Sorcha Corrigan; Monica S. Banach; Sophie Ares; Sandy Mitchell; Azadeh Emam; Livia S. A. Augustin; Tina L. Parker; Lawrence A. Leiter JAMA. 2008;300(23):2742-2753.

Published on: December 10, 2009

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