Many of the treatment modalities for cardiovascular disease are similar irrespective of whether diabetes is present or not. However specific issues related to diabetes include the difficulty of diagnosing silent cardiovascular disease, the need for the aggressive management of all risk factors, and the use of insulin therapy to achieve blood glucose control when a heart attack occurs.
An electrocardiogram (ECG)A test using electrodes placed on the chest, arms and legs to record the rhythm and electrical activity of the heart. may be helpful for screening people at risk, particularly Caucasians and south Asians over the age of 40. The first step is to screen patients with angina or any other coronary heart disease symptoms. However, in view of the often silent, asymptomatic nature of coronary heart disease in people with type 2 diabetes, the diagnosis often needs to be made by exercise cardiac stress testingThe most widely used screening test for heart disease. The patient exercises on a treadmill, whose speed and elevation increases progressively. During this test the heart rate, heart rhythm, and blood pressure are monitored.. If the symptoms and/or the test findings are highly suggestive of coronary heart disease, the person will require further investigation. In these patients all cardiovascular risk factors must be re-examined and treated aggressively.
| Treatment for patients who have experienced an acute heart attack and their effectiveness in people with diabetes compared to the general population | |
|---|---|
| Treatment | Efectiveness in people with diabetes |
| Aspirin | Equally effective |
| Beta-blockers | Equally effective |
| ACE inhibitors | Particularly advantageous if started withing 24 hours |
| Statins | Equally effective |
| Clot dissolving agents (thrombolytic therapy) | Useful within the first 12 hours, although slightly less effective in diabetes |
People with stable anginaWhen individuals experience angina on a regular basis and can be given medication to treat it. are usually treated by tight control of cardiovascular risk factors and by prescribing drugs (eg aspirin, beta-blockers, nitratesDrugs that dilate blood vessels. They are effective in treating angina. and long-acting calcium channel blockers). When unstable anginaIf an attack of angina differs from a person’s regular pattern (stable angina), appearing suddenly, with greater intensity or when at rest it is considered unstable. It may warn of an impending heart attack. develops, the risk of heart attack is very high and rapid preventive treatment in an intensive or coronary care unit may be required.
People with diabetes who have experienced an acute heart attack benefit to the same degree, and in some cases even more, from therapeutic interventions that are used in people without diabetes.
Intensive insulin therapy for tight blood glucose control when the patient is in hospital has also proven to decrease death rates, and may be beneficial for at least three months following hospitalization. The DIGAMI Study from Sweden stresses the importance of controlling blood glucose levels during the acute phase and demonstrates that intensive insulin treatment also improves survival over the longer term, with a 24% reduction in death rates after three and a half years. This means a saving of one life for every nine patients on intensive insulin treatment.
Intensive insulin treatment in those who have experienced an acute heart attack improves survival over the short and long term with a 24% reduction in deaths after three and a half year.
If people with diabetes require revascularizationThe procedure by which a blocked vessel can be either dilated (angioplasty) or bypassed. - a procedure to either open up blocked blood vessels (angioplastySurgery whereby a balloon is inflated inside a blocked artery to open it up.) or to bypass them using implanted vessels from other parts of the body (bypass surgeryAn operation whereby a blood vessel is taken from another part of the body and is used to redirect the flow of blood around a blocked or narrowed part of a heart vessel.) - bypass has proven to be a judicious choice particularly when several coronary vessels are involved, which is frequently the case in diabetes. The use of tiny metal devices called stents to keep arteries open has also improved the prognosis of some patients with diabetes and coronary heart disease.
Heart failure is a complication of coronary heart disease which occurs more frequently in people with diabetes. It is usually treated with drugs such as 'water tablets' (diuretics), ACE inhibitors, beta-blockers and digitalisA plant-based drug used to treat heart failure and certain abnormalities of the heart rhythm..
As well as being a risk factor for stroke, diabetes and other high blood glucose conditions have adverse effects on both the short and long-term prognosis for stroke victims. Hyperglycaemia in the acute phase of stroke has been associated with high death rates, regardless of the presence or absence of diabetes. Tight glucose control improves the time of recovery.
The standard therapies of intervention in stroke in people without diabetes are also helpful in people with diabetes. Indeed, the effect of aspirin on cardiovascular events in people with diabetes has been suggested to be even stronger than in people without diabetes.
Resources need to be made available for the rehabilitation of stroke patients, which may be particularly complicated in people with diabetes due to the presence of other complications.
Almost all people with diabetes who have established vascular disease (including diabetic foot problems, microvascular disease, macrovascular disease, neuropathy and a history of amputations) present a higher risk of amputation in another limb as well as a greater risk of heart attack and cardiovascular death. Smoking should be avoided in patients with peripheral vascular disease.
In people with both diabetes and peripheral vascular disease, revascularization performed by an expert team can be a good alternative to amputation. The use of pharmacological interventions depends on the nature of the underlying disease. However the benefit of drugs is unproven.
The best treatment of the diabetic foot is prevention. This can only be achieved by educating people with diabetes about foot care. Although not all foot complications can be prevented, dramatic reductions in their frequency can be achieved through the implementation of diabetic foot programmes by a multidisciplinary team involving primary healthcare professionals, community carers and the diabetes team. There should also be better access to amputation, rehabilitation, prostheses and chiropody facilities for all patients.