Diabetes greatly increases the risk of cardiovascular disease. The document discusses several studies showing higher rates of heart disease and stroke in people with diabetes. It recommends aspirin and statin therapy to lower cardiovascular risk based on a patient's individual risk factors. Lifestyle interventions like diet and exercise are also emphasized as a way to both prevent and manage diabetes and related health risks.

1. Diabetes and Cardiovascular Risk
Dr S C Sinha MD DM FACC FSCAI

2. WHO: 2012

5. CHD Risk Equivalent
• Clinical Coronary Artery disease
• Symptomatic Carotid artery disease
• Peripheral artery disease
• Abdominal aortic aneurysm
• Diabetes Mellitus
• Chronic kidney disease

6. PREVALENCE OF RISK FACTORS IN OUR
POPULATION (CAD)
60
50
40
30
20
10
0
P= .000
ACS N= 981
Control N = 882
HT DM Sm FH
ACS Control
P=0.000
54.0%
51.6%
44.0%
22.4%
33.8%
5.7%
12.5%
3.5%
P=0.287
P=0.000

7. LIPID PROFILE IN DM PATIENTS WITH ACS
DM (mg/dl) Non-DM (mg/dl)
T. Cholesterol 170.20± 42.82 167.72± 41.21
Triglyceride 165.83± 82.31 142.55± 78.76
LDL-C 98.90± 39.81 99.23± 38.33
HDL-C 38.47 ±7.74 40.55± 12.47

8. CAG IN DM WITH ACS
50
45
40
35
30
25
20
15
10
5
0
SVD DVD TVD
DM Non DM
33.6% 42.9%
22.7%
21.2% 22.5%
12.6%

9. OUTCOME
DM Non-DM
LV EF (%) 51.83± 12.65 52.53± 12.81
Alive at discharge(%) 97.9 97.8
Death at discharge(%) 2.1 2.2

10. DM VS NON-DM WITH ACS
90
80
70
60
50
40
30
20
10
0
Male Female <55y >55y
DM Non-DM
71.5%
81.2%
28.5% 18.8%
57.8%
42.3%
42.2%
57.8%

12. • IN INDIA, IT IS ESTIMATED THAT MORE THAN HALF OF
ALL DEATHS IN 2005 WERE DUE TO CHRONIC DISEASE. IF
THE CURRENT TREND CONTINUES CHRONIC DISEASE
DEATHS ARE PROJECTED TO INCREASE BY 18% IN THE
NEXT TEN YEARS. MOST MARKEDLY, DEATHS FROM
DIABETES IN INDIA WILL INCREASE BY 35%.

16. RISK OF CARDIOVASCULAR EVENTS IN
DIABETICS FRAMINGHAM
STUDY
AGE-ADJUSTED
BIENNIAL RATE AGE-ADJUSTED
PER 1000 RISK RATIO
_________________________________________________________________
CARDIOVASCULAR EVENT MEN WOMEN MEN WOMEN
CORONARY DISEASE 39 21 1.5** 2.2***
STROKE 15 6 2.9***
2.6***
PERIPHERAL ARTERY DIS. 18 18 3.4*** 6.4***
CARDIAC FAILURE 23 21 4.4*** 7.8***
ALL CVD EVENTS 76 65 2.2*** 3.7***
_________________________________________________________________
SUBJECTS 35-64 36-YEAR FOLLOW-UP **P<.001,***P<.0001

17. CARDIOVASCULAR DISEASE AND DIABETES

18. PROBABILITY OF DEATH FROM CHD IN
PATIENTS WITH TYPE 2 DIABETES WITH OR
WITHOUT PREVIOUS MI

19. FRAMINGHAM HEART STUDY 30-YEAR FOLLOW-UP:
CVD EVENTS IN PATIENTS WITH DIABETES (AGES
35-64)
10
9
Men Women
20
11
19
38 9 6
3*
30
10
8
6
4
2
0
Age-adjusted annual rate/1,000
Total
CVD
CHD Cardiac
failure
Intermittent
claudication
Stroke
Risk
ratio
P<0.001 for all values except *P<0.05.
Wilson PWF, Kannel WB. In: Hyperglycemia, Diabetes and Vascular
Disease. Ruderman N et al, eds. Oxford; 1992.

20. REVISED ATP III METABOLIC SYNDROME OCT
2005
Risk Factor Defining Level
>102 cm (>40 in)
>88 cm (>35 in)
Abdominal obesity†
(Waist circumference‡)
TG 150 mg/dL or Rx for ↑ TG
<40 mg/dL
<50 mg/dL or Rx for ↓ HDL
Men
Women
HDL-C
Men
Women
130/85 mm Hg or on HTN
Rx
Blood pressure
Fasting glucose 100 mg/dL or Rx for ↑ glucose
*Diagnosis is established when 3 of these risk factors are present.
†Abdominal obesity is more highly correlated with metabolic risk
factors than is BMI.
‡Some men develop metabolic risk factors when circumference is only
marginally increased.

21. International Diabetes Federation Definition:
Abdominal obesity plus two other components:
elevated BP, low HDL, elevated TG, or impaired
fasting glucose

24. Cardiovascular Disease (CVD) and Total Mortality:
US Men and Women Ages 30-74
(age, gender, and risk-factor adjusted Cox regression) NHANES II Follow-
Up (n=6255)(Malik and Wong, et al., Circulation 2004; 110: 1245-1250)
7
6
5
4
3
2
1
0
Relative Risk
***
***
*
***
**
***
***
***
***
***
***
CHD Mortality CVD Mortality Total Mortality
None
MetS
Diabetes
CVD
CVD+Diabetes
* p<.05, ** p<.01, **** p<.0001 compared to none

26. Aspirin : ADA 2014 Recommendations
• Consider aspirin therapy (75–162 mg/day) as a primary
prevention strategy in those with type 1 or type 2 diabetes at
increased cardiovascular risk (10-year risk >10%). This includes
most men aged >50 years or women aged >60 years who have
at least one additional major risk factor (family history of CVD,
hypertension, smoking, dyslipidemia, or albuminuria). C
• In patients in these age-groups with multiple other risk factors
(e.g.,10-year risk 5–10%), clinical judgment is required. E

27. Aspirin : ADA 2014 Recommendations
• Aspirin should not be recommended for CVD prevention
for adults with diabetes at low CVD risk (10-year CVD risk
< 5%, such as in men aged <50 years and women aged <60
years with no major additional CVD risk factors), since the
potential adverse effects from bleeding likely offset the
• potential benefits. C

28. Aspirin : ADA 2014 Recommendations
• For patients with CVD and documented aspirin allergy,
• clopidogrel (75 mg/day) should be used. B
• Dual antiplatelet therapy is reasonable for up to a year after
an acute coronary syndrome. B

29. Statins : ADA 2014 Recommendations
• Statin therapy should be added to lifestyle therapy, regardless of
baseline lipid levels, for diabetic patients:
with overt CVD
without CVD who are over the age of 40 years and
have one or more other CVD risk factors (family
history of CVD, hypertension, smoking,
dyslipidemia, or Albuminuria).

30. Statins : ADA 2014 Recommendations
• For lower-risk patients than the above (e.g., without overt
CVD and under the age of 40 years), statin therapy should
be considered in addition to lifestyle therapy if LDL
cholesterol remains above 100 mg/dL or in those with
multiple CVD risk factors. C
• In individuals without overt CVD, the goal is LDL
cholesterol <100 mg/dL.

31. Statins : ADA 2014 Recommendations
• In individuals with overt CVD, a lower LDL cholesterol
goal of < 70 mg/dL (1.8 mmol/L), with a high dose of a
statin, is an option. B
• If drug-treated patients do not reach the above targets on
maximum tolerated statin therapy, a reduction in LDL
cholesterol of >30–40% from baseline is an alternative
therapeutic goal. B

32. Statins : ADA 2014 Recommendations
• Triglyceride levels <150 mg/dL (1.7 mmol/L) and HDL cholesterol
>40 mg/dL (1.0 mmol/L) in men and >50 mg/dL (1.3 mmol/L) in
women are desirable. C However, LDL cholesterol–targeted statin
therapy remains the preferred strategy. A
• Combination therapy has been shown not to provide additional
cardiovascular benefit above statin therapy alone and is not
generally recommended. A
• Statin therapy is contraindicated in pregnancy. B

33. IMMUNIZATION: ADA 2014 Recommendations
• Annually provide an influenza vaccine to all diabetic patients > 6 months of
age. C
• Administer pneumococcal polysaccharide vaccine to all diabetic patients >2
years of age. A one-time revaccination is recommended for individuals >65
years of age who have been immunized >5 years ago.Other indications for
repeat vaccination include nephrotic syndrome, chronic renal disease, and other
immunocompromised states,such as after transplantation. C
• Administer hepatitis B vaccination to unvaccinated adults with diabeteswho
are aged 19–59 years. C
• Consider administering hepatitis B vaccination to unvaccinated adults
with diabetes who are aged>60 years. C

34. Point Designation based on predictors for 8-Year
Risk of Type 2 Diabetes in Middle-aged Adults
(45- 64 yr)
Points
Fasting glucose level 100-126 mg/dL 10
BMI 25.0-29.9 2
BMI >30.0 5
HDL-C level <40 mg/dL in men or <50 mg/dL in women 5
Parental History of diabetes mellitus 3
Triglyceride level >150 mg/dL 3
Blood pressure >130/85 mmHg or receiving treatment 2
Total Points
8 Year Risk,
%
≤10 <3
11 4
12 4
13 5
14 6
15 7
16 9
17 11
18 13
19 15
20 18
21 21
22 25
23 29
24 33
≥25 >35
Risk Of Development of Type 2 DM

35. Primary Prevention of Type 2 Diabetes
• Among individuals at high risk for developing type 2 diabetes,
structured programs that emphasize lifestyle changes that include
moderate weight loss (7% of body weight) and regular physical
activity (150 min/week), with dietary strategies including reduced
calories and reduced intake of dietary fat, can reduce the risk for
developing diabetes and are therefore recommended. A
• Individuals at high risk for type 2 diabetes should be encouraged to
achieve dietary fiber (14 g fiber/1,000 kcal) and foods containing
whole grains (one-half of grain intake). B

37. RECOMMENDATIONS FOR CHECK-UP IN DM
PERSONS