Diabetic cardiovascular disease

Last reviewed: 5 Sep 2023

Last updated: 22 Jun 2023

Cardiovascular disease (CVD) is the leading cause of death in people with diabetes.

People with diabetes have up to a fourfold increased risk of stroke and are twice as likely to die after myocardial infarction than people without diabetes.

Regular physical activity, medical nutrition therapy, and smoking cessation or non-initiation are important lifestyle changes for the primary prevention of CVD.

Selected glucose-lowering drugs reduce all-cause and cardiovascular mortality. Addition of a sodium-glucose cotransporter 2 (SGLT2) inhibitor or a glucagon-like peptide-1 (GLP-1) receptor agonist is strongly recommended in patients with established atherosclerotic cardiovascular and/or chronic kidney disease. SGLT2 inhibitors are also indicated in patients with heart failure.

Aggressive treatment of hypertension, use of statins, preventive anticoagulation, and coronary revascularization (percutaneous transluminal coronary angioplasty or coronary artery bypass graft surgery during episodes of acute coronary syndrome) can lead to improved survival.

Definition

Diabetes mellitus is a group of metabolic diseases characterized by hyperglycemia, resulting from defects in insulin secretion, insulin action, or both.[1] The chronic hyperglycemia of diabetes is associated with long-term damage, dysfunction, and failure of various organs, especially the eyes, kidneys, nerves, heart, and blood vessels.[1] Diabetes is an established major risk factor for the development of cardiovascular disease, including coronary artery disease (CAD), cerebrovascular disease (stroke or transient ischemic attack), and peripheral arterial disease.[2] This topic will discuss CAD in greatest detail.

History and exam

Key diagnostic factors

chest pain
dyspnea on exertion
hypotension
rales
S3 gallop
hypertension
nausea
diaphoresis
tachycardia
indigestion

More key diagnostic factors

Other diagnostic factors

unilateral weakness, numbness, and/or tingling
headache
intermittent claudication
bruits
aphasia
hemisensory loss
cranial nerve palsies
seizures
vertigo
limb pain at rest
diminished/absent lower extremity pulses
ulcers or gangrene
peripheral edema
smooth shiny skin with hair loss
pallor

Other diagnostic factors

Risk factors

cigarette smoking
hypertension
dyslipidemia
poor glycemic control
physical inactivity
overweight and obesity
albuminuria
elevated C-reactive protein
family history of cardiovascular disease
female sex
gestational diabetes

More risk factors

Diagnostic investigations

1st investigations to order

HbA1c
lipid profile

More 1st investigations to order

Investigations to consider

transthoracic Doppler echocardiogram
exercise ECG
exercise imaging test
pharmacologic imaging test
cardiac MRI or stress cardiac myocardial perfusion imaging
ankle-brachial index (ABI)
CT angiography
coronary angiography
noncontrast head CT
brain MRI
duplex ultrasonography of carotid arteries
C-reactive protein
chest x-ray

More investigations to consider

Treatment algorithm

INITIAL

acute myocardial infarction or unstable angina

ACUTE

highly significant coronary artery disease: without acute myocardial infarction or unstable angina

ONGOING

diabetic cardiovascular disease: stable and/or after intervention

Contributors

Authors

Mohamed Al-Kazaz, MD

Assistant Professor of Medicine (Cardiology)

Northwestern University Feinberg School of Medicine

Bluhm Cardiovascular Institute

Northwestern Memorial Hospital

Chicago

Disclosures

MA declares that he has no competing interests.

Acknowledgements

Dr Mohamed Al-Kazaz would like to gratefully acknowledge Dr Alexander Meyer, Dr Laura Davidson, Dr Charles Davidson, and Dr Leonard E. Egede, the previous contributors to this topic, and would like to gratefully acknowledge the review by Dr Shreenidhi Venuraju, MB BS, MRCP, Wellington Hospital South, UK.

Disclosures

AM, LD, CD, and LE declare that they have no competing interests. LEE is an author of a number of references cited in this topic. SV not disclosed.

Peer reviewers

Irfan Moinuddin, MD

Assistant Professor

Chicago Medical School

Rosalind Franklin University

Lombard

Disclosures

IM declares that he has no competing interests.

David Leehey, MD

Medical Director

Hines VA Hospital

Hines

Disclosures

DL declares that he has no competing interests.

Differentials
- Unstable angina
- ST-elevation myocardial infarction (STEMI)
- Non-ST-elevation myocardial infarction (NSTEMI)
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Guidelines
- Standards of care in diabetes - 2023
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Patient leaflets
Diabetes type 2: should I take insulin?
Diabetes type 2: what treatments work?
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Diabetic cardiovascular disease

Summary

Definition

History and exam

Key diagnostic factors

Other diagnostic factors

Risk factors

Diagnostic investigations

1st investigations to order

Investigations to consider

Treatment algorithm

acute myocardial infarction or unstable angina

highly significant coronary artery disease: without acute myocardial infarction or unstable angina

diabetic cardiovascular disease: stable and/or after intervention

Contributors

Authors

Mohamed Al-Kazaz, MD

Disclosures

Acknowledgements

Disclosures

Peer reviewers

Irfan Moinuddin, MD

Disclosures

David Leehey, MD

Disclosures

Differentials

Guidelines

Patient leaflets

Log in or subscribe to access all of BMJ Best Practice

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