Coronary Vascular Disease

In 2000, 37.2 percent of people with diabetes age 35 years or older were diagnosed with cardiovascular disease (13). Prevalence of ischemic heart disease among people with diabetes was approximately 14 times that of those without diabetes in people 18 to 44 years of age (2.7 percent versus 0.2 percent), three times more in people 45 to 64 years of age (14.3 percent versus 4.7 percent), and approximately twice more in people 65 years of age or older (13). Classical risk factors for coronary artery disease include age, male gender, hypertension, and diabetes (57). The risk of clinical or isolated subclinical ischemic heart disease is more pronounced in women than men in older individuals, although there is a lower absolute prevalence, with an increased risk noted with the presence of diabetes (58, 59). Additional factors include diet and serum cholesterol, cigarette smoking, obesity, and sedentary lifestyle (57). The Framingham Study showed that smoking, hypertension, and elevated triglycerides were significant, independent predictors of coronary-vascular disease in patients with diabetes (60). A few studies have shown LDL cholesterol to be a significant, independent predictor of cardiovascular disease (60). Premature development and accelerated progression of macrovascular atherothrombotic disease is a major factor contributing to the high morbidity and mortality rates in diabetes (2). The relationship between hyperinsulinemia and the risk of cardiovascular disease is somewhat controversial, with articles both supporting and challenging this relationship (61-66). It still remains unclear whether the relationship is causal or whether the two diseases are causally unrelated, independent manifestations of an underlying disease state (2). Diabetes is well-established as an independent risk factor for the development of coronary-artery disease (2). Once a patient with diabetes develops clinical coronary-artery disease, cardiac complications occur with increased frequency, with diabetic patients with coronary-artery disease experiencing more morbidity and mortality than nondiabetic patients with coronary artery disease (67). Longitudinal studies looking at mortality from all causes, heart disease, and ischemic heart disease have shown that adults with diabetes experience less decline in their mortality rates than adults without diabetes (68).

Diabetes has been shown to increase left ventricle wall thickness and mass (69). In the setting of ischemic heart disease, diabetes is associated with twice the incidence of acute coronary syndromes and a 1.5-fold to twofold increase in the incidence of death after myocardial infarction (2). Cardiovascular disease accounts for up to 80 percent of deaths in patients with diabetes, with approximately 75 percent of these deaths occurring as a result of ischemic heart disease (2). The most common cause of death is myocardial pump failure, and the second most common cause is myocardial reinfarction (70).

The clopidogrel versus aspirin in patients at risk of ischemic events (CAPRIE) study, which looked at the use of aspirin versus clopidogrel in patients with recent ischemic stroke, recent myocardial infarction (MI), or established peripheral vascular disease, showed an 8.7 percent relative risk reduction in vascular death, MI, or ischemic stroke with use of clopidogrel (54, 71). There was an additional 8.7 percent reduction noted in rehospitalization for ischemia or bleeding (54, 71).

Postmenopausal women with diabetes have a twofold to fivefold increased risk of death from coronary-artery disease (72). Also, women who undergo simple hysterectomies and those who undergo bilateral oophorectomies have an increased risk of coronary-artery disease (72). In one study, women with diabetes who are prescribed hormonal-replacement therapy have been shown to be 40 percent less likely to suffer acute heart disease than women with diabetes who have never been prescribed hormonal-replacement therapy (72). Other studies, however, have shown no cardiovascular benefit from hormonal-replacement therapy (72). Women with insulin-treated diabetes were found to be more likely to develop coronary-artery disease than women treated with oral hypoglycemic medication or diet alone (72).

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