Coronary Heart Disease
GENERAL PRINCIPLES
• Coronary heart disease (CHD), stroke, and peripheral vascular disease (PVD) are responsible for 80% of deaths in persons with diabetes (see Chapter 4, Ischemic Heart Disease).
• Coronary artery disease (CAD) occurs at a younger age and may have atypical clinical presentations in patients with diabetes.
• MI carries a worse prognosis, and angioplasty gives less satisfactory results in patients with diabetes.
• Persons with diabetes have an increased risk of ischemic and nonischemic heart failure (HF) and sudden death.34
Risk Factors
Risk factors for macrovascular disease that are common in persons with diabetes include insulin resistance, hyperglycemia, albuminuria, hypertension, hyperlipidemia, cigarette smoking, and obesity.
Prevention
• CV risk factors should be assessed at least annually and treated aggressively.
• Screening asymptomatic persons with cardiac stress test has not been shown to reduce mortality or events in asymptomatic patients with T2DM.35
• Aspirin 81-325 mg/d has proven beneficial in secondary prevention of MI or stroke in patients with diabetes and may be considered for persons over age 40 years with diabetes.
TREATMENT
• Glycemic control should be optimized to A1C lt;7% (lt;53 mmol/mol) and as close to normal as possible in the first few years after diagnosis. Hypoglycemia should be avoided.
• Hypertension should be controlled to a target blood pressure of lt;140/90 mm Hg (or lt;130/80 mm Hg if this can be achieved without adverse effects).
• Hyperlipidemia should be treated appropriately, with a high-intensity statin in patients with known CVD.
• Cigarette smoking should be actively discouraged, and weight loss should be promoted in obese patients.