This document discusses the link between diabetes and cardiovascular disease. It provides guidance on screening and managing both conditions, including maintaining optimal blood sugar levels, treating risk factors like high blood pressure and cholesterol, and adopting a healthy lifestyle. Close monitoring of patients can help prevent diabetes-related complications like heart attack, stroke, and peripheral artery disease. While intensive glucose control shows long-term cardiovascular benefits in type 1 diabetes, the evidence in type 2 diabetes is more mixed and depends on individual patient factors.

1. Management of Diabetes & Heart Disease

2. Overview
• Evidence is beginning to emerge that
diabetes and cardiovascular disease –
two of the leading causes of global
morbidities and mortalities – are linked.
This is a brief clinical summary of
current knowledge, with an emphasis
on evidence-based management
approaches

3. Contents
• Screening for Diabetes
• Tailor Glycemic Control
• Why CVD Management Matters
• Link between Diabetes & Heart Disease
– Key Mechanisms
– Clinical Manifestations of Atherosclerosis (A)
– Risk Factors
• Diabetic ABCS
• Therapeutic Lifestyle Changes
• Monitoring
• Glucose Control & Heart Disease: Evidence

4. Screening
for
Diabetes
Assess risk in symptomatic adults who are
overweight or obese (BMI ≥25 kg/m2) and
who have ≥1 of the following additional risk
factors for diabetes: physical inactivity; first-
degree relative with diabetes; high-risk
ancestry (e.g., African American, Latino,
Native American, Asian American, Pacific
Islander).
Women diagnosed with gestational
diabetes; hypertension (BP ≥140/90
mmHg or taking therapy for
hypertension); women with polycystic
ovary syndrome.
HDL cholesterol level <35 mg/dL (0.90
mmol/L) and/or a triglyceride level >250
mg/dL (2.82 mmol/L); HbA1c ≥5.7%;
impaired glucose tolerance, or impaired
fasting glucose on previous testing; other
clinical conditions associated with insulin
resistance (e.g., severe obesity,
acanthosis nigricans); or a history of CVD.
If no risk factors, then screening is
recommended beginning at age 40.
Abbreviations: BMI, body mass index; BP, blood pressure; CVD, cardiovascular disease; HDL, high-density lipoprotein; HbA1c, glycated hemoglobin
Reference: Epocrates (An AthenaHealth Company): https://online.epocrates.com/diseases/53337/Diabetic-cardiovascular-disease/Screening.

5. Tailor Glycemic
Control
A1c >6.5% for
patients with comorbid
conditions and high
risk for hypoglycemia
A1c ≤6.5% for
patients without
comorbid conditions
and at risk for
hypoglycemia
Abbreviations: A1c, glycated hemoglobin test
Reference: Epocrates (An AthenaHealth Company):2017; https://online.epocrates.com/diseases/53337/Diabetic-cardiovascular-
disease/Screening.

6. Why CVD
Management Matters
Reference: Epocrates (An AthenaHealth Company): 2017; https://online.epocrates.com/diseases/53337/Diabetic-cardiovascular-disease/Treatment-
Approach.
CAD is the most
common form
of CVD in
patients with
diabetes
Risk of stroke
up to 4-fold in
patients with
diabetes
Up to 20% of
patients with
PAD are known
to have
diabetes
Aortic
atherosclerosis
may be present
in patients with
diabetes

7. Link between Diabetes & Heart
Disease: Key Mechanisms
Abbreviation: CVD, cardiovascular disease
Reference: Epocrates (An AthenaHealth Company): https://online.epocrates.com/diseases/53337/Diabetic-cardiovascular-disease/Etiology.
This Photo by Unknown Author is licensed under CC BY-SA
Key mechanism underlying CVD in diabetes is accelerated
atherosclerosis.

8. Clinical
Manifestations
of
Atherosclerosis
(A)
A
Coronary
Arteries
Angina
Pectoris and
Acute
Coronary
Syndromes
Reference:
Epocrates (An AthenaHealth Company): Diabetic cardiovascular disease. Etiology. 2017;
https://online.epocrates.com/diseases/53337/Diabetic-cardiovascular-disease/Etiology.
A
Cerebral or
Cerebellar
Arteries
Transient
Ischemic
Attacks/
Strokes
A
Peripheral
Circulation
Intermittent
Claudication
/Gangrene

9. Link between Diabetes
& Heart Disease: Risk
Factors
• Heart disease risk the longer you have diabetes
• Patients with diabetes are nearly 2x as likely to die of heart
disease/stroke versus people without the disease
• Patients with diabetes die at a younger age than patients
without diabetes
• Blood vessels and nerves of the heart are damaged
• Risk factors must be managed to prevent a stroke or
heart disease
• Smoking
• High blood pressure
• Abnormal cholesterol levels
• Obesity and belly fat
• Genetic predisposition
• Control diabetic ABCS
Acronym
ABCS: A =A1c or glycated hemoglobin test; B=blood pressure; C=cholesterol; S=smoking
Reference:
US National Institutes of Health. National Institutes of Diabetes and Digestive and Kidney Diseases. Diabetes, Heart Disease, and Stroke. 2017;
https://www.niddk.nih.gov/health-information/diabetes/overview/preventing-problems/heart-disease-stroke.

10. Diabetic ABCS
A. The average hemoglobin A1c, HbA1c, or glycohemoglobin
test measures average blood glucose levels over the past 3
months
B. High blood pressure (BP) can precipitate a heart attack
– Goal for most people with diabetes is below 140/90 mm
Hg, but should be tailored based on patient needs
C. Patients over 40 years may need to take a statin
– Lowers cholesterol and may protect the heart
– Younger patients with too much “bad” cholesterol/LDL
may also be candidates for statins
S. Both smoking and diabetes narrow the blood vessels i.e., the
heart works harder
Abbreviation: A1c, glycated hemoglobin
Reference:
Epocrates (An AthenaHealth Company) 2017; https://online.epocrates.com/diseases/53337/Diabetic-cardiovascular-disease/Screening.
Acronym
ABCS: A = A1c or glycated hemoglobin test; B=blood pressure; C=cholesterol; S=smoking
Reference: US National Institutes of Health. National Institutes of Diabetes and Digestive and Kidney Diseases. Diabetes, Heart Disease, and
Stroke. 2017; https://www.niddk.nih.gov/health-information/diabetes/overview/preventing-problems/heart-disease-stroke.

11. Therapeutic Lifestyle Changes
• Lifestyle changes may lower the risk of CVD in high-risk patients,
including individuals with diabetes
Reference: Hennekens CH, Lopez-Sendon J. UpToDate. 2017; https://www.uptodate.com/contents/prevention-of-cardiovascular-disease-events-in-those-with-established-disease-
or-at-high-risk.
Weight
Reduction
Yoga
Physical
Activity
Diet/Alcohol
Smoking
Cessation
Text
Messaging
Cardiac
Rehabilitation
Programs
Adjunctive
Therapies

12. Monitoring
Overall
•Diabetes should be
monitored every 6 to
12 months in
patients with
controlled disease
•Healthy lifestyle
modifications should
be encouraged
•BP
•Weight
•Activity level
PAD
•An ankle brachial
index (ABI) to test
for PAD could benefit
patients with
diabetes to test
•Exertional leg
symptoms;
nonhealing wounds;
age 65 years or
older; or age 50
years or older with
diabetes or smoking
history are further
considerations for
ABI test
CVD
•Patients with known
CVD should consider
ACE inhibitors,
statins, and aspirin
•-blockers should be
considered for at
least 2 years after MI
•Patients with
CHF/risk for heart
failure should avoid
thiazolidinediones
•Patients with stable
CHF and normal
renal function can
consider metformin
Abbreviations:
ACE, angiotensin-converting enzyme inhibitors; BP, blood pressure; CVD, cardiovascular disease; CHF, chronic heart failure; MI, myocardial infarction; PAD, peripheral artery disease
Reference:
Epocrates (An AthenaHealth Company): 2017; https://online.epocrates.com/diseases/53351/Diabetic-cardiovascular-disease/Prognosis

13. Glucose Control & Heart Disease: Evidence
Type 1 diabetes
• Intensive glycemic control has long-term beneficial CVD
effects, as determined in the Diabetes Control and
Complications Trial (DCCT)a
1
Type 2 diabetes
• Very intensive glucose control (goal HbA1c <6% to 6.5% over 3-5
years) studied in patients with type 2 diabetes in ACCORD,
ADVANCE, and VADT trialsb
• Differences among ACCORD, VADT, and ADVANCE trials may be
due to study design and patient characteristics
• MI, revascularization, and unstable angina less frequent in
intensive glycemic control arm versus standard group (<6.0%
versus 7.0%-7.9%) of ACCORD study (follow-up analysis)b
2
Abbreviations:
ACCORD = Action to Control Cardiovascular Risk in Diabetes trial; ADVANCE = Action in Diabetes and Vascular Disease trial; CVD, cardiovascular disease; HbA1c, glycated hemoglobin; MI, myocardial infarction; VADT =
Veterans Administration Diabetes Trial
Reference: a. Nathan DM, Cleary PA, Backlund JY, et al. N Engl J Med. 2005;353(25):2643-2653; b. Epocrates (An AthenaHealth Company): 2017; https://online.epocrates.com/diseases/53337/Diabetic-cardiovascular-
disease/Prognosis.