Diabetes is strongly linked to cardiovascular disease through several mechanisms. It increases the risk of both macrovascular and microvascular complications. Treatment aims to control blood sugar and modify risk factors like smoking, physical inactivity, and high cholesterol to prevent vascular disease and related mortality. For those with existing vascular problems, medications that have shown cardiovascular benefits like SGLT2 inhibitors and GLP1 agonists may be recommended. Lifestyle changes and medical therapies can both help reduce cardiovascular risks in people with diabetes.

1. Diabetes mellitus and vascular
disease
Dr Ihab Suliman
0505244473
https://twitter.com/IhabFathiSulima
2022

2. Objectives
• Explain the relation between diabetes and
heart disease.
• Describe the relation between diabetes
control and cardiovascular disease.
• Explain the effect of diabetes drugs on
cardiovascular disease.

3. Out Line
• Diabetes Mellitus def.
• Types of DM
• CASE
• VASCULAR MACRO+MICRO
• PREVENTION
• TREATMENT

4. Types of DM
• Type 2, most common more than 90%, Insulin
resistance.
• Typ1 , IDDM , juvenile affect 12-14 years ,
Severe Insulin deficiency and very low insulin
C Peptide.
• Type 3 , DM+ALZHEIMERS
• TYPE 1.5 , TYPE I but onset at adult hood

5. • MODY, monogenic diabetes , autosomal
dominant below 25 years .
• Gestational , Related to type 2 and familial .

6. Prevention of Vascular Disease and Mortality
PREVENTION OR DELAY OF TYPE 2 DIABETES
3.8 Prediabetes is associated with heightened cardiovascular risk;
therefore, screening for and treatment of modifiable risk
factors for cardiovascular disease are suggested. B

7. Physical Activity
FACILITATING BEHAVIOR CHANGE AND WELL-BEING TO IMPROVE HEALTH OUTCOMES
5.27 Children and adolescents with type 1 or type 2 diabetes or
prediabetes should engage in 60min/day or more of moderate- or
vigorous-intensity aerobic activity, with vigorous muscle-
strengthening and bone- strengthening activities at least 3 days/week. C
5.28 Most adults with type 1 C and type 2 B diabetes should engage in
150 min or more of moderate to vigorous-intensity aerobic activity per week,
spread over at least 3 days/week, with no more than 2 consecutive
days without activity. Shorter durations (minimum 75min/week) of vigorous
intensity or interval training may be sufficient for younger and more
physically fit individuals.

8. Smoking Cessation: Tobacco & E-cigarettes
FACILITATING BEHAVIOR CHANGE AND WELL-BEING TO IMPROVE HEALTH OUTCOMES
5.33 Advise all patients not to use cigarettes and other tobacco products
or e- cigarettes. A
5.34 After identification of tobacco or e-cigarette use, include smoking
cessation counseling and other forms of treatment as a routine
component of diabetes care. A
5.35 Address smoking cessation as part of diabetes education programs
for those in need. B

9. Metabolic Surgery
OBESITY MANAGEMENT FOR THE TREATMENT OF TYPE 2 DIABETES
8.17 Metabolic surgery should be a recommended option to treat type 2
diabetes in screened surgical candidates with BMI $40 kg/m2 (BMI
$37.5 kg/m2 in Asian Americans) and in adults with BMI 35.0–39.9 kg/m2
(32.5– 37.4 kg/m2 in Asian Americans) who do not achieve durable weight
loss and improvement in comorbidities (including hyperglycemia) with
nonsurgical methods.. A
8.18 Metabolic surgery may be considered as an option to treat type 2
diabetes in adults with BMI 30.0–34.9 kg/m2 (27.5–32.4 kg/m2 in
Asian Americans) who do not achieve durable weight loss and
improvement in comorbidities (including hyperglycemia) with
nonsurgical methods. A

10. CARDIOVASCULAR DISEASE AND RISK MANAGEMENT
Recommendations
for the Treatment of
Confirmed
Hypertension in
People with
Diabetes (2 of 2)
Cardiovascular Disease and Risk Management:
Standards of Medical Care in Diabetes - 2022. Diabetes Care 2022;45(Suppl. 1):S144-S174

11. Statin Treatment—Primary Prevention
CARDIOVASCULAR DISEASE AND RISK MANAGEMENT
10.19 For patients with diabetes aged 40–75 years without atherosclerotic
cardiovascular disease, use moderate-intensity statin therapy in
addition to lifestyle therapy. A
10.20 For patients with diabetes aged 20–39 years with additional
atherosclerotic cardiovascular disease risk factors, it maybe reasonable to
initiate statin therapy in addition to lifestyle therapy. C
10.21 In patients with diabetes at higher risk, especially those with multiple
atherosclerotic cardiovascular disease risk factors or aged 50–70
years, it is reasonable to use high-intensity statin therapy. B
10.22 In adults with diabetes and 10-year ASCVD risk of 20% or higher, it
may be reasonable to add ezetimibe to maximally tolerated statin therapy to
reduce LDL cholesterol levels by 50% or more. C

12. Cardiovascular Disease—Screening
CARDIOVASCULAR DISEASE AND RISK MANAGEMENT
10.40 In asymptomatic patients, routine screening for coronary artery
disease is not recommended as it does not improve outcomes as long
as atherosclerotic cardiovascular disease risk factors are treated. A
10.41 Consider investigations for coronary artery disease in the presence
of any of the following: atypical cardiac symptoms (e.g., unexplained
dyspnea, chest discomfort); signs or symptoms of associated vascular
disease including carotid bruits, transient ischemic attack, stroke,
claudication, or peripheral arterial disease; or electrocardiogram
abnormalities (e.g., Q waves).E

13. Cardiovascular Disease—Treatment
CARDIOVASCULAR DISEASE AND RISK MANAGEMENT
10.42 Among patients with type 2 diabetes who have established
atherosclerotic cardiovascular disease or established kidney disease, a
sodium–glucose cotransporter 2 inhibitor or glucagon- like peptide 1 receptor
agonist with demonstrated cardiovascular disease benefit (Table 10.3B
and Table 10.3C) is recommended as part of the comprehensive
cardiovascular risk reduction and/or glucose-lowering regimens. A
10.42a In patients with type 2 diabetes and established atherosclerotic
cardiovascular disease, multiple atherosclerotic cardiovascular
disease risk factors, or diabetic kidney disease, a sodium– glucose
cotransporter 2 inhibitor with demonstrated cardiovascular benefit is
recommended to reduce the risk of major adverse cardiovascular events
and/or heart failure hospitalization. A

14. Cardiovascular Disease—Treatment (continued)
CARDIOVASCULAR DISEASE AND RISK MANAGEMENT
10.42b In patients with type 2 diabetes and established atherosclerotic
cardiovascular disease or multiple risk factors for atherosclerotic
cardiovascular disease, a glucagon-like peptide 1 receptor agonist
with demonstrated cardiovascular benefit is recommended to reduce the
risk of major adverse cardiovascular events. A
10.42c In patients with type 2 diabetes and established atherosclerotic
cardiovascular disease or multiple risk factors for atherosclerotic
cardiovascular disease, combined therapy with a sodium–glucose
cotransporter 2 inhibitor with demonstrated cardiovascular benefit
and a glucagon-like peptide 1 receptor agonist with demonstrated
cardiovascular benefit may be considered for additive reduction in the risk
of adverse cardiovascular and kidney events. A

15. Cardiovascular Disease—Treatment (continued)
CARDIOVASCULAR DISEASE AND RISK MANAGEMENT
10.43 In patients with type 2 diabetes and established heart failure with
reduced ejection fraction, a sodium–glucose cotransporter 2 inhibitor with
proven benefit in this patient population is recommended to reduce risk of
worsening heart failure and cardiovascular death. A
10.44 In patients with known atherosclerotic cardiovascular disease,
particularly coronary artery disease, ACE inhibitor or angiotensin
receptor blocker therapy is recommended to reduce the risk of
cardiovascular events. A

16. Cardiovascular Disease—Treatment (continued)
CARDIOVASCULAR DISEASE AND RISK MANAGEMENT
10.45 In patients with prior myocardial infarction, b-blockers should be
continued for 3 years after the event. B
10.46 Treatment of patients with heart failure with reduced ejection fraction
should include a b-blocker with proven cardiovascular outcomes
benefit, unless otherwise contraindicated. A
10.47 In patients with type 2 diabetes with stable heart failure, metformin
may be continued for glucose lowering if estimated glomerular filtration
rate remains >30 mL/min/1.73 m2 but should be avoided in unstable or
hospitalized patients with heart failure. B

37. CLASSIFICATION AND DIAGNOSIS OF DIABETES
Table 2.2
Classification and Diagnosis of Diabetes:
Standards of Medical Care in Diabetes - 2022. Diabetes Care 2022;45(Suppl. 1):S17-S38

38. CLASSIFICATION AND DIAGNOSIS OF DIABETES
Classification and Diagnosis of Diabetes:
Standards of Medical Care in Diabetes - 2022. Diabetes Care 2022;45(Suppl. 1):S17-S38

39. CLASSIFICATION AND DIAGNOSIS OF DIABETES
Classification and Diagnosis of Diabetes:
Standards of Medical Care in Diabetes - 2021. Diabetes Care 2021;44(Suppl. 1):S15-S33

40. CLASSIFICATION AND DIAGNOSIS OF DIABETES
Classification and Diagnosis of Diabetes:
Standards of Medical Care in Diabetes - 2021. Diabetes Care 2021;44(Suppl. 1):S15-S33

41. CLASSIFICATION AND DIAGNOSIS OF DIABETES
Classification and Diagnosis of Diabetes:
Standards of Medical Care in Diabetes - 2021. Diabetes Care 2021;44(Suppl. 1):S15-S33

42. Prevalence of cardiovascular disease
in younger people with type 1 diabetes

43. Prevalence of cardiovascular disease in middle-
aged people with diabetes

44. Cardiovascular disease mortality in
middle-aged people with diabetes

45. Case
• 77 lady with DM type 2
• IHD, CABG+ MV Repair
• Foot ulcer plus pain Right Foot

48. Describtion
• Arterial Ulcer
• Absent Pulses
• Cold Limbs
• PVD

50. CT Run OFF

51. • PCI to the right Femoral artery was done .
• Diabetic Ulcer started to heal

52. • A 61 year old is admitted to A&E with sudden onset of a
painful, cold, white right leg. His radial pulse rate is 86 bpm
and its rhythm follows no discernable pattern throughout
30 seconds of palpation. Abdominal examination is normal.
No pulses are palpable in the right leg and ankle Doppler
signals are absent. An ECG confirms the arrythmia but
shows no signs of acute ischaemia. Which is the single most
likely diagnosis?
• Abdominal aortic aneurysm
• Aorto-iliac dissection
• Atrial fibrillation
• DVT
• MI

53. • Atrial fibrillation
• Explanation
• The presentation is that of an embolic episode which occluded flow to the
femoral artery.
• Eighty percent of emboli have a cardiac cause (AF, MI and ventricular
aneurysm)
• Ten percent result from proximal peripheral arterial aneurysms (including
aortic aneurysms)
• Rarer causes of acute leg ischemia include aorti-iliac dissection, trauma,
iatrogenic injury, intra-arterial drug use.
• No aneurysm was palpable on abdominal examination and aorto-iliac
dissection is less likely.
• DVT is an unlikely cause of acute lower limb arterial ischemia but this may
occur rarely when a DVT embolizes with the resulting embolus passing
through a patent foramen ovale - allowing passage from the venous to the
arterial system.

54. • A 65-year-old woman with a 40-pack-year smoking history and
type 2 diabetes presents with cramp-like pain in her right calf
after walking 500 metres, relieved by rest. Her symptoms are
aggravated
by walking up steep hills. Which is the single most appropriate
management?
•
A Amputation
B Diagnostic angiography
C Endovascular stent
D Modification of risk factors
E Reassure and follow up in 6 months

55. • D Modification of risk factors
• Explanation
• Risk factors:
– hypertension
– hypercholesterolaemia
– diabetes
– smoking
– positive family history

56. • A 69-year-old man is referred to the vascular clinic after an
abdominal aortic aneurysm was detected coincidentally on ultrasound
examination. The patient is nervous about the diagnosis, has been
researching it on the Internet and has several questions. Which single
statement is correct?
•
A Abdominal aortic aneurysms are associated with tobacco smoking,
hypertension, family history, and diabetes mellitus
•
B Abdominal aortic aneurysms are considered for treatment by surgical
or endovascular repair when they reach a size of ≥5.5cm, in a patient
fit for intervention
•
C Abdominal aortic aneurysms most commonly involve the aorta at the
level of the renal arteries and below
•
D Abdominal aortic aneurysms occur in 10% of the population aged
over 65
•
E Abdominal aortic aneurysm screening is undertaken in the UK using
CT scanning

57. • B Abdominal aortic aneurysms are considered for treatment by surgical or
endovascular repair when they reach a size of >5.5cm, in a patient fit for
intervention
• Explanation
• Abdominal aortic aneurysms are associated with hypertension, smoking, family
history, but not with diabetes mellitus.
• Other rarer causes include infective causes (‘mycotic’) and connective tissue
disorders.
• The UK Small Aneurysm Trial suggested that intervention for abdominal aortic
aneurysms should be undertaken when the aneurysm reaches a threshold
diameter of 5.5cm.
• A national screening programme for aortic aneurysms is being implemented in the
UK, in which ultrasound detection is the screening modality of choice.
• CT would not be an appropriate screening tool due to high radiation dose and cost.
• Abdominal aortic aneurysms occur in 5% of males over 65 (they are
approximately nine times commoner in men than in women).
• Ninety-five per cent of abdominal aortic aneurysms are infrarenal; 15% extend into
the common iliac arteries.

58. • A 48-year-old man with type 1 diabetes and peripheral vascular
disease develops an infected ulcer in his right foot. The infection
spreads to involve the soft tissues of the foot resulting in necrosis, he
develops rigors and his diabetes becomes harder to control with insulin.
An amputation is planned and a medical student asks about the procedure
and its likely outcome. Which is the single most appropriate
advice?
•
A Above-knee amputation is preferred to supracondylar (Gritti–Stokes)
amputation for bilateral amputees
B Diabetics are 50 times more likely than non-diabetics to undergo
major lower limb amputation
C Likelihood of mobility following below-knee amputation is significantly
better than following above-knee amputation
D Postoperative phantom-limb pain is less common in below-knee
amputations than above-knee amputations
E Stump healing rates following below-knee amputation are higher than
following above-knee amputation

59. • C. Likelihood of mobility following below-knee amputation is
significantly better than following above-knee amputation
• Explanation
• For bilateral amputees, preservation of limb length is important for
balance, especially if they are likely to be confined to a wheelchair.
• The Gritti–Stokes amputation preserves more of the femur than an above-
knee amputation.
• Diabetics are 15 times more likely to require amputation than non-
diabetics.
• Stump healing rates are related to level of amputation and adequacy of
blood supply, which is generally better proximally in the limb.
• There is no evidence to suggest phantom-limb pain occurs less frequently
in below-knee amputations.
• 10

60. • A 23-year-old medical student returning from her elective in
Australia develops a tender, warm, swollen right calf within 12h
of her flight. She smokes five cigarettes daily and takes the oral
contraceptive
pill. She has no chest pain or shortness of breath. Which single
investigation is the most appropriate?
•
A Ascending venography
B CT pulmonary angiography
C D dimer
D Duplex ultrasound scan
E VQ scan

61. • D. Duplex ultrasound scan
• Explanation
• This student has clinical features suggestive of a deep vein thrombosis.
• This may be demonstrated by ascending venography, but this
requires contrast injection and has been superseded by duplex ultrasound
scanning which is sensitive and non-invasive.
• CT pulmonary angiography is the modality of choice for rapid and sensitive
investigation for suspected pulmonary embolus.
• It has now largely replaced ventilation perfusion (VQ) scans for
investigation of pulmonary embolus.
• D dimers are a sensitive test for deep vein thrombosis but are usually
employed as part of a thrombotic screen.
• The most sensitive, specific, and appropriate investigation in this case is
duplex ultrasound of the leg which will demonstrate occlusive thrombus
and blood flow disturbances caused by clot.

66. • A diabetic foot ulcer is an open sore or wound
that occurs in approximately 15 percent of
patients with diabetes and is commonly
located on the bottom of the foot.
• Of those who develop a foot ulcer, 6 percent
will be hospitalized due to infection or
other ulcer-related complication

69. Thank you very
much