Diabetes and other cardiovascular diseases
Diabetic patients are 2–4 times likely to develop cardiovascular diseases mainly due to atherosclerosis and hypertension.
Signs and symptoms
The clinical spectrum of cardiovascular diseases includes:
• Coronary heart disease
• Angina (which may be silent)
• Acute coronary artery syndrome
• Congestive cardiac failure
• Sudden death
• Cerebral vascular accident (stroke, transient ischaemic attacks and dementia)
• Peripheral vascular disease (intermittent claudication, foot ulcer and gangrene).
• ECG, Chest X-Ray, if with symptoms/signs of heart failure.
• Peripheral vascular disease evaluation includes Doppler and angiography of lower limbs.
- Acute coronary syndrome
• All adults with T2DM and recent acute coronary syndrome and/or coronary stent should receive dual anti-platelet therapy, for 12 months after the event or procedure:
• Low-dose aspirin (75–100 mg daily)
• Clopidogrel (75mg daily)
• Aspirin is also indicated for primary prevention for people with T2DM over the age of 40 years with family history of ischaemic heart disease (IHD), cigarette smooking, obesity, proteinuria or dyslipidemia.
• It is contraindicated in peptic/duodenal ulcer, dyspepsia, hurtburn, malignant hypertension, haemorrhagic stroke.
• Statin therapy results in a significant decrease in CVD morbidity and mortality in T2DM for those at high CVD risk.
o Simvastatin 20mg daily. Dose may be increased to 40mg daily if required
o Atorvastatin 10mg daily. Dose may be increased to 80mg daily if required
• Fenofibrate reduces incidence of retinopathy and need for laser surgery, peripheral neuropathy and improvement in proteinuria, sugesting a more generalsed effect on microvascular disease independent of dyslipidaemia Fibrates
• Shouldbe used in mixed hyperlipidemias which have not responded adequately to diet or other therapy.
• Are more effective in lowering triglycerides and increasing HDL, but less effective in lowering cholesterol.
• Should be used with caution in combination with statins.
• Can enhance the effects of warfarin and antidiabetic agents
• Are contraindicated in patients taking Orlistat.
o Fenofibrate 67–267mg/day
o Gemfibrozil 0.9–1.2g/day
In people with T2DM, antihypertensive therapy with an angiotensin receptor blockers (ARB) or angiotensin-converting enzyme inhibitors (ACEI) decreases the rate of progression of albuminuria, promotes regression to normal albuminuria and may reduce the risk of decline in renal function. Therefore:
• BP-lowering therapy in people with diabetes should preferentially include an angiotensin converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) e.g:
o Enalapril: 10 mg–40 mg orally daily, taken either as a single dose or two divided doses (enalapril 5 mg–10 mg twice a day)
o Losartan: Initial dose: 50 mg orally once a day. Maintenance dose: 25–100 mg orally per day in 1 or 2 divided doses
• The target level for optimum BP is controversial. It is reasonable to target BP levels of <140/90 mmHg for people with diabetes, with lower targets for younger people and those at high risk of stroke. The target BP for people with diabetes and microalbuminuria or proteinuria remains <130/80 mmHg.
• Combining an ARB and an ACEI is not recommended.
• If monotherapy does not sufficiently reduce blood pressure (BP) add one of the following:
Calcium channel blocker:
o Amlodipine 5–10mg once daily
Low-dose thiazide or thiazide-like diuretic:
o Bendrofluazide 5mg once daily
• ACE-inhibitors and ARBs should be stopped pre-conception. Diltiazem in extended release forms may be a useful substitute.