Reducing the burden of diabetes: Managing cardiovascular disease

Of the threats to health and life that beset the person with diabetes, card iovascular disease (CVD), particularly coronary heart disease (CHD) but als o cerebrovascular and peripheral vascular disease, represent the heaviest b urden. The relative risk for CVD is very high for Type 1 diabetes, but the absolute risk, in terms of numbers, is much higher for Type 2. In all socie ties, diabetes increases cardiovascular risk twofold or more, compared with the local non-diabetic population. Some of the evidence for this diabetes- related increase in cardiovascular risk is reviewed and its relationship to recognised cardiovascular risk factors considered. The explanation of the enhanced susceptibility to atherosclerotic disease i n diabetes remains a matter of contention. How much can be explained by gre ater prevalence in diabetes of such risk factors as hypertension and dyslip idaemia? To what extent is the impact of a given level of risk factor magni fied by a co-existing diabetic state? Is the increased cardiovascular morbi dity and mortality secondary to risk factors specifically related to the di abetic state itself? Does the explanation lie in altered coagulability due to changes in platelet activation and aggregability, fibrinogen levels, Fac tor VII, von Willebrand factor or PAI-1, in the concentration or compositio n of plasma lipoproteins, in defective endothelial cell function or other m etabolic abnormalities of the arterial wall? To what extent is cardiovascul ar risk related to the degree of hyperglycaemia, protein glycation, relativ e hyperinsulinaemia and insulin resistance? Data from recent epidemiological, intervention and laboratory investigation s bearing on causation, management and prevention of CVD in diabetes are re viewed. Evidence for the impact of correction of glycaemia, dyslipidaemia a nd raised arterial pressure is considered and reasons are adduced for a bro ad and proactive therapeutic approach with early identification and vigorou s correction of key risk factors. Copyright (C) 1999 John Wiley & Sons, Ltd .