Review 45

Received: 05/02/2013 Accepted: 14/05/2013 Published: 15/07/2013

EJCM 2013; 01 (2): 45-49 Doi: 10.15511/ejcm.13.00245

Diabetes and coronary artery disease:

Scary duo of the developing world
Ali Oto

1)
MD, FESC, FACC, Hacettepe Univ of Medical School, Ankara, Turkey

Summary

Abstract: For many years, diabetes mellitus (DM) has been known to be an independent risk factor for atherosclerosis. However in
recent years, better understanding of the relations between DM and cardiovasculary system, and especially the accumulating epidemio-
logical evidence caused DM to be referred as “cardivascular disease equivalent” in risk evaluation. Indeed, morbidity and mortality risk
related with coronary artery disease in diabetic patients is 2 - 3-fold higher than normal population. Diabetics without a history of pre-
vious myocardial infarction and non-diabetics with a history of previous myocardial infarction show similar mortality characteristics.
Coronary artery disease is the primary cause of death in adult DM patients. Moreover, when acute coronary syndrome is developed in
diabetic patients, both in-hospital and long-term mortality rates are higher than non-diabetics.

Keywords: Diabetes mellitus, atherosclerosis, coronary artery disease.

Introduction ease in diabetics has been known for a long time, data
regarding the glucometabolic regulation in patients with
Another important subject is that macrovascular
coronary artery disease started to draw attention rather
complications induced by diabetes may develop years
recently. For example, “Euro-Heart Survey on Diabetes
before emergence of overt diabetes. Epidemiological
and the Heart” have shown that 20% of the coronary ar-
studies have revealed that the frequency of type 2 di-
tery patients have apparent diabetes, 30% of them have
abetes increases with age both in males and females.
impaired glucose tolerance test, and 5% of them have
The incidence of coronary artery disease also increases
impaired fasting glucose. Recently performed GAMI
with age, therefore one should take into account the fact
trial showed that the glucose tolerance test performed
that possibility of co-existence of these two illnesses in
before discharge of the patients who had acute myocar-
elderly would be high. With the aging society, the im-
dial infarction, reveals previously unknown glucometa-
portance of this duo regarding community health will
bolic disorder in up to 30% of the patient, and more
gradually increase.
importantly long-term prognosis is worse in the group
While the information regarding coronary artery dis- with impaired glucose tolerance.

Copyright © 2013 Heart and Health Foundation of Turkey (TÜSAV). Published by Medikal Akademi.
This article is licensed by Medikal Akademi and TÜSAV under the terms of Creative Commons Attribution License.

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 Review 46

Diabetes and coronary artery disease: Patho- and prevention of cardiovascular complications, and
physiological considerations thus RAAS became a treatment target. Therefore now
in our day, ACE inhibitors and/or angiotension receptor
There is no doubt that risk factors such as hyper-
blockers are considered as the essential elements of the
tension, dyslipidemia, etc. co-existing with DM have a
current therapy in diabetic patients.
contribution to the development of atherosclerotic heart
disease. However hyperglycemia on its own probably In fact the adverse effects of diabetes on cardiovas-
also has an important contribution to pathophysiology. cular system are much more complicated. In Figure 1,
Hyperglycemia results in production of free oxygen the adverse effects of DM on cardiovascular system are
radical directly, and indirectly by increasing free fatty shown. As observed, in addition to hyperglycemia and
acid load. And this is known as the initiator of a process RAAS activation, there are many negative factors pre-
triggering many adverse the metabolic pathway, in- disposing diabetic patient to the rapid and generalized
creasing vascular permeability, decreasing fibrinolytic development of atherosclerosis. New investigations
activity and triggering inflammation. have focused on the pathogenetical relations between
diabetes, inflammation, atherosclerosis and athero-
On the other hand, there is also evidence showing
thrombosis.
that the activity of renin-angiotensin aldosterone sys-
tem (RAAS) is increased in diabetic patients. These In diabetic coronary artery disease patients, multi-
evidences led RAAS blockers to be used for treatment, ple vessel disease, left main coronary artery disease,

Figure 1. The adverse effects of DM on cardiovascular system

oxidative hypertension hyperglycaemia RAAS activation ET-1

platelet
dyslipidaemia activation
Endothelial dysfunction
thrombosis,
inflammation of prol
smooth muscle cells
disinsulinemy advanced
glycosylation
products

increase in
mitogen tendency to
rapid and extensive atherosclerosis
cytotoxins thrombosis

Oto A. Diabetes and coronary artery disease: Scary duo of the developing world. EJCM 2013; 01 (2): 45-49. DOI: 10.15511/ejcm.13.00245
 Review 47

involvement of multiple vessel segments and distal Significant decreases in mortality have been shown
lesions are seen frequently. Furthermore, diabetic ath- after establishing good glycemic control also in patients
erosclerotic lesions mostly exert unstable plaque char- in intensive care unit due to acute coronary syndrome.
acteristis as a result of decreased collagen production, The decreased risk of mortality has been associated with
increased degradation, increased matrix metalloprotein the elimination of toxic effects due to acute hyperglyce-
activity and increased cytokines. mia which suddenly emerges in critical patients by estab-
lishing a good glycemic control, and the direct beneficial
Glycemic control and coronary artery disease
effects of insulin treatment in critical patients.
The glycemia margin for the onset of atherosclero-
sis and cardiovascular disease in diabetics, has been Practical approach recommendations for diabet-
tried to be explained for many years. Several trials have ic patients are as follows:
shown that post-prandial glycemia is an independent 1. Diabetic patients should be closely monitored and
risk factor for cardiovascular disease. On the other hand investigated for coronary artery disease.
there is evidence showing that the risk of cardiovas-
cular event increases with the elevating fasting blood 2. Concomitant risk factors (e.g., hypertension, dys-
glucose levels. lipidemia) should be detected and corrected.

While it remains controversial, in light of the availa- 3. Effective blood glucose control should be established.
ble evidence, current opinion is that effective glycemic
control is beneficial for prevention of cardivovascular 4. Antithrombotic medications (aspirin, clopidogrel)
events both type I and type II diabetics. HbA1c is the 5. RAAS blockers should be given.
gold standard method for the monitorization and evalu-
ation of glycemic control. The fact that each 1% incre- Risk assessment should be performed rapidly in dia-
ment in HbA1c may cause up to 20% increase in the betic patients having acute coronary syndrome. Fibrino-
risk of cardiovascular event, is highly significant. lytic treatment indications in acute myocardial infarction

E Journal of Cardiovascular Medicine | Volume 01 | Issue 2 | 2013

 Review 48

are similar to non-diabetics. If possible, early coronary before in percutaneous coronary intervention. While the
angiography and mechanical revascularization should use of drug-eluting stents in diabetic patients is still con-
be preferred in diabetics. Strict blood glucose control is troversial, the tendency is towards using the drug-eluting
considered to be beneficial in acute myocardial infarc- stents in diabetic patients.
tion (AMI). Beta receptor blocking medications decrease
morbidity and mortality in diabetics having acute coro- Conclusion
nary syndrome. Aspirin should be given in doses and in-
dications similar to non-diabetics. However, in diabetics Diabetes and coronary artery disease are like two
having acute coronary syndrome, addition of clopidogrel sides of the same coin: Today, diabetes is considered to
to aspirin should be considered. Adding ACE inhibitors be coronary artery disease equivalent. Many coronary
to treatment in patients with diabetes and cardiovascular cardiac patients have diabetes. One should expect that
disease, has been shown to reduce cardiovascular events. the frequency of co-existence of these duo will increase
Treatment targets in patients with diabetes and coronary with the aging population.
artery disease are shown in Table I. As the cardiovascular complications of diabetes oc-
It is still controversial to choose coronary bypass or cur in a very wide glycemia range, prevention, early di-
percutaneous coronary intervention in multiple vessel re- agnosis and control of diabetes is highly important for
vascularization in diabetic coronary artery patients. Tri- prevention of the development of cardiovascular com-
als featuring surgery, are usually related with pre-stent plications. Therefore, investigating and monitoring the
period. Initial studies performed with stents have shown diabetic patients for possible cardiovascular disease is
that while the mortality rates are similar, there are more as vitally important as evaluating the coronary cardiac
revascularization procedures involved although less than patients for diabetes.

Table 1. Recommended treatment

BLOOD PRESSURE 130/80 mmHg targets for patients with diabetes
Renal impairment and 125/75 mmHg and coronary artery disease

Proteinuria >1 g/24 h

(Modified based on the European Society
of Cardiology Cardiovascular Prevention
STRICT BLOOD GLUCOSE CONTROL Guidelines)
HbA1C < 6.5% / FBG < 108 mg/dL
Post-prandial < 135 mg/dL T2 DM
135-160 mg/dL T1 DM

LIPID PROFILE mg/dL

Total cholesterol < 175 / LDL-C < 70
HDL E > 40 / K > 46
Triglyceride > 150 / TC/HDL

Smoking cessation Mandatory

Regular physical exercise >30-45 min/day Weight control
BMI (kg/m2) <25
10% weight loss if overweight
Waist circumference <94 in males (cm) <80 in females

Oto A. Diabetes and coronary artery disease: Scary duo of the developing world. EJCM 2013; 01 (2): 45-49. DOI: 10.15511/ejcm.13.00245
 Review 49

References
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2007; 28: 2375-2414 diabetes mellitus. Am J cardiol. 2007; 99: 1399-1402.
3. Bartnik M,Norhammar A,Ryden L. Hyperglycemia and cardiovascular 6. Petersen J, Harrington RA. Revascularization of coronary atherosclero-
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sis in patients with diabetes mellitus-There is more to it than meets the
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Received: 05/02/2013
Accepted: 14/05/2013
Published: 15/07/2013

Disclosure and conflicts of interest:

Conflicts of interest were not reported.

Corresponding author:
Dr. Ali Oto
e-mail: [email protected]

E Journal of Cardiovascular Medicine | Volume 01 | Issue 2 | 2013