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Peripheral Artery Disease in Diabetes

Peripheral artery disease (PAD) is generally defined as partial or complete obstruction of one or more arteries affecting the lower extremities and is usually caused by atherosclerosis. Symptoms of PAD include pain with ambulation, resulting from an inadequate blood supply relative to demand in the lower extremities, termed intermittent claudication. In severe cases, symptoms occur at rest and tissue ischemia may lead to ulceration or amputation.…

Treatment of Heart Failure in Diabetes : Systolic Dysfunction, Diastolic Dysfunction, and Post-Acute Coronary Syndrome

Diabetes and heart failure commonly occur together in a patient. Up to a quarter of patients with diabetes also have heart failure, and approximately a third of patients with heart failure also have diabetes. In this chapter we review the evidence-based medications device, and surgical treatment of heart failure. The primary focus is on patients with chronic heart failure, but when it exists, evidence about the…

Prevention of Heart Failure in Patients with Diabetes

Chronic heart failure (HF) is increasing in prevalence, affecting over 5 million patients in the United States, and it is estimated that more than 20 million individuals have HF globally. , An ageing population, improved survival after myocardial infarction (MI), and a rising incidence of noncommunicable diseases such as hypertension and diabetes in developing economies have all contributed to the increased disease burden worldwide. Although studies…

Diabetic Cardiomyopathy: Mediators and Mechanisms

Acknowledgments This work was supported by grants from the NIH (HL-075173, JAH; HL-080144, JAH; HL-090842, JAH), AHA (0640084 N, JAH; 12POST9030041, PKB; 10POST4320009, ZVW), ADA mentor-based postdoctoral fellowship (7-08-MN-21-ADA, JAH and PKB), the AHA-Jon Holden DeHaan Foundation (0970518 N, JAH). Scope of the Problem Heart disease is the greatest noninfectious health hazard ever to confront the human race. Rampant for some years in the developed world,…

Epidemiology of Heart Failure in Diabetes

Multiple epidemiologic studies have demonstrated that diabetes mellitus (DM) is associated with increased risk for the development of heart failure (HF). The mechanisms contributing to this greater risk are likely multifactorial and include the often accelerated comorbid conditions such as obesity, hypertension, and coronary artery disease (CAD). In addition, diabetes may contribute to cardiac dysfunction through other pathways related to insulin resistance, including lipotoxicity, abnormal calcium…

Role of Primary Invasive Strategy and Revascularization in Diabetic Patients with Acute Coronary Syndromes

In patients with diabetes mellitus, the risk of developing coronary artery disease is increased by twofold to fourfold compared with patients without diabetes. , Moreover, patients with diabetes are more likely to present with acute coronary syndromes (ACSs) than people without diabetes mellitus. In the contemporary INTERHEART study, the presence of diabetes more than doubled the risk of myocardial infarction. Similarly, a large proportion of patients…

Antiplatelet and Antithrombotic Therapy in Diabetic Patients with Acute Coronary Syndrome

Patients with diabetes mellitus (DM) and acute coronary syndrome (ACS) are at particularly high risk for recurrent cardiovascular events and death. The reason for this increased risk is multifactorial, including a higher risk profile, higher platelet reactivity, and underuse of evidence-based medications in these patients. This chapter includes a summary and review of antiplatelet and antithrombotic therapies that are approved in the United States and in…

Hyperglycemia and Acute Coronary Syndromes: Association with Outcomes and Management

The observation that elevated glucose can occur in patients hospitalized with acute coronary syndromes (ACS; unstable angina, non–ST-segment elevation myocardial infarction [NSTEMI], and ST-segment elevation myocardial infarction [STEMI]) was made many decades ago. Since then, numerous studies have documented that hyperglycemia is common, affects patients with and without established diabetes, and is associated with adverse outcomes, with a graded, incremental increase in the risk of mortality…

Epidemiology of Acute Coronary Syndromes in Patients with Diabetes

Global Burden of Cardiovascular Disease and Diabetes Cardiovascular diseases are the number one cause of death worldwide. In 2008, approximately 17.3 million people died from cardiovascular disease, accounting for approximately one third of all deaths; an estimated 7.3 million were caused by coronary heart disease and another 6.2 million by stroke. Until recently, cardiovascular diseases were more frequent in the developed countries, but during the past…

Role of Coronary Artery Bypass Surgery in Diabetes and Perioperative Glucose Management

Diabetes mellitus is a major contributor to the development of cardiovascular illness and results in a twofold to fourfold increase in coronary artery disease (see also Chapter 7 ). It accounts for approximately one fourth of all patients who undergo coronary revascularization procedures each year and is more likely to be associated with diffuse and extensive three-vessel and left main disease. , This contributes to increased…

Role of Percutaneous Coronary Intervention in Patients with Diabetes

Diabetes mellitus is a major risk factor for cardiovascular disease affecting multiple vascular territories. At the cardiac level, it is associated with a risk of coronary artery disease (CAD) equivalent to 15 years of ageing. Although coronary revascularization has definitively shown a benefit in terms of major cardiovascular event (MACE) reduction, especially in acute coronary syndromes (ACSs), several studies have reported worse outcomes associated with revascularization…

Effect of Antiplatelet Therapy on Coronary Heart Disease Risk in Patients with Diabetes Mellitus

Platelets play a central role in the pathobiology of atherogenesis and atherothrombosis. Therefore therapies that are directed toward platelet inhibition are widely used in patients with established coronary heart disease (CHD) or in moderate- to high-risk individuals for primary prevention of cardiovascular (CV) events. As our armamentarium of potent antiplatelet therapies continues to expand, there is growing interest in identifying the appropriate groups of patients who…

Effect of Lipid Management on Coronary Heart Disease Risk in Patients with Diabetes

Overview This chapter describes strategies for and effects of therapeutic lifestyle changes and/or pharmacologic interventions with lipid-lowering medications on coronary heart disease (CHD) risk in patients with diabetes mellitus (DM), focusing on the most recent data from randomized clinical trials in the context of contemporary clinical care. Planning a strategy to manage dyslipidemia for CHD risk reduction for patients with DM can be partitioned into five…

Effect of Blood Pressure Management on Coronary Heart Disease Risk in Patients with Type 2 Diabetes

The effects of aggressive blood pressure (BP) management on the risks of coronary heart disease (CHD) and other vascular outcomes among individuals with type 2 diabetes mellitus (T2DM) has been a matter of intense debate recently, with the results of large-scale clinical trials leading to variable interpretation. This chapter reviews the epidemiologic associations between BP and CHD in diabetes and the efficacy of BP lowering on…

Effect of Glucose Management on Coronary Heart Disease Risk in Patients with Diabetes

Coronary heart disease (CHD) is the most common vascular complication of diabetes. Because elevated glucose defines diabetes and because diabetes is a well-recognized risk factor for CHD, strategies that lower glucose should theoretically reduce the risk of CHD events in diabetes. In reality, the relationship between glucose-lowering strategies and cardiovascular outcomes is complex and suggests that the impact of interventions on patient outcomes cannot be easily…

Effect of Lifestyle Interventions on Coronary Heart Disease Risk in Patients with Diabetes

In the United States, the prevalence of high cholesterol, hypertension, and cigarette smoking together with age-adjusted cardiovascular deaths has declined over the last several decades. On the other hand, the prevalence of diabetes has risen steadily, largely because of an epidemic of obesity and adiposity and our increasingly inactive lifestyle (see also Chapters 1 and 5 ). These trends will likely mitigate further reductions in cardiovascular…

Type 1 Diabetes and Associated Cardiovascular Risk and Disease

Type 1 diabetes (T1D) is an autoimmune disease that causes destruction of the pancreatic beta cells, leading to absolute insulin deficiency (see also Chapter 3 ). Type 2 diabetes (T2D), in contrast, is associated with obesity and is characterized by insulin resistance accompanied by an insufficient compensatory insulin secretory response (see also Chapter 1 ). T1D is not a rare condition; it affects an estimated 1.5…

Vascular Biology of Atherosclerosis in Patients with Diabetes: Dyslipidemia, Hypercoagulability, Endothelial Dysfunction, and Inflammation

Overview The interaction between diabetes and atherosclerosis is complex and multifactorial. Despite unequivocal evidence for increased cardiovascular disease (CVD) risk in patients with diabetes; a well-documented epidemic of obesity and diabetes; intensive research efforts that include major preclinical scientific progress using unbiased “-omic” approaches; large cardiovascular (CV) outcome studies in diabetes; and new glucose-lowering therapies, the mechanisms that link diabetes to atherosclerosis remain murky. Indeed, challenges…

Vascular Biology of Atherosclerosis in Patients with Diabetes: Hyperglycemia, Insulin Resistance, and Hyperinsulinemia

Diabetes and Accelerated Atherosclerosis Scope and Complexity of the Problem One of the most deadly complications of types 1 and 2 diabetes is accelerated atherosclerosis, the consequences of which include more frequent and more deadly heart attacks and strokes, as well as myocardial dysfunction. The latter occurs both secondary to myocardial infarctions and as a result of innate diabetes-mediated damage to the myocardium. With the worldwide…

Pathology of Diabetic Atherosclerosis: Composition, Characteristics, and Distribution

Diabetes mellitus is associated with the development of accelerated atherosclerotic coronary artery disease, which results in increased morbidity and mortality from cardiovascular complications including acute myocardial infarction and stroke. , Atherothrombosis is the leading cause of death worldwide despite major progress in the understanding of the role of traditional risk factors in its etiopathogenesis. In this chapter we address morphologic characteristics of coronary and carotid plaques…