Risk for coronary heart disease, cerebrovascular disease and peripheral vascular disease (PVD) is higher in those with diabetes (2-5x > than those without diabetes); coronary heart disease is the main cause of early mortality in those with diabetes – due to premature and accelerated atherosclerosis ( major cause of morbidity and mortality). Risk is greater in women (risks are about equal in the non-diabetes populations). First symptom of type 2 diabetes may be a myocardial infarction.
In type 2 diabetes ‘clock starts ticking’ for macrovascular disease well before the clinical onset of diabetes due to insulin resistance, obesity, hypertension and dyslipidaemia.
Glycaemic control is a risk factor for atherosclerosis. Those with proteinuria are at an even greater risk (hypothesised that the presence of microalbuimuria is a marker for the generalised endothelial dysfunction that predisposes to atherosclerosis). The effects of dyslipidaemia, hypertension and cigarette smoking on atherosclerosis are amplified in those with diabetes. The atherosclerosis tends to more diffuse in those with diabetes than those without diabetes.
Dyslipidaemia increases the risk for macrovascular disease differently in type 1 and 2:
in type 1 – total and LDL cholesterol is normal; triglycerides are normal or decreased; HDL cholesterol is normal or increased this possibly an anti-atherogenic profile. However, there may be changes in structure of lipoproteins (eg glycation)
in type 2 – triglycerides and VLDL are increased; HDL is decreased; increase in small dense LDL particles (these particles are very atherogenic) this profile is often called ‘diabetic dyslipidaemia’
In those with diabetes, the peripheral vascular disease is more common in younger age groups; progresses more rapidly; affects many segments; has a predilection for tibial vessels; tends to spare vessels in the foot; tends to be bilateral; and has more involvement of vessels adjacent to occlusions. The main risk factors for lower extremity arterial disease in those with diabetes have been shown to be duration of diabetes, waist to hip ratio and triglycerides . The PVD in those with diabetes is frequently complicated by the presence of neuropathy greater risk for complications.
Management – lifestyle modifications; lower HbAic; lower blood pressure; lower lipids