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Global Management of Type 2 Diabetes Mellitus for the

Prevention of Cardiovascular Disease


Masrul Syafri
Department Cardiology and Vascular Medicine
Faculty of Medicine Andalas University/ General Hospital M. Djamil Padang
Diabetes mellitus is a major independent risk factor for cardiovascular disease. The worldwide
prevalence of diabetes is increasing, driven primarily by the rise in the type 2 diabetes. Diabetes mellitus
is a group as the disease characterized by insufficience insulin or by the failure of the body to
appropriately respond to insulin, resulting in hyperglycemia. Vascular complication, the principle clinical
risk associated by diabetes, are classified as microvascular (diabetic retinophaty, nefrophaty, neurophaty)
and macro vascular (ischemic disease, cerebrovascular disease, peripheral vascular disease).1,2
Approximately 90% or more of cases of diabetes mellitus are characterized by relative insulin
deficiency with a back drop of insulin resisten and classified as type 2 diabetes mellitus. The etiology type
2 diabetes is multifactorial, and compassing genetic, environmental, and behavioural factors, but the exact
mechanistic underpinning has not yet been determine.3 There are several factors contributing to the
increasing incidence and prevalences of type 2 diabetes mellitus, such as obesity, diet, sedentary lifestyle,
aging population. Number of population are especially vulnerable to development type 2 diabetes. Older
person, women, and especially elderly women are particularly susceptible.2
Diabetes mellitus is a major risk factor for atherosclerosis, clinically manifested as diabetic
macrovascular complication. The risk of ischemic heart disease is two fold to four fold higher in people
type 2 diabetes compare with those without diabetes, with myocardial infarction being the number one
cause of death. 4 Approximately 70% of patient with type 2 diabetes have hypertension (more than double
the prevalence in the general population) with further increases their vascular disease. Hypertension is
also and independent risk factor for chronic kidney disease, which in term may exacerbate cardiovascular
disease risk, resulting in a vicious circle.5 People with type 2 diabetes have two fold to five fold increases
of congestive heart failure compare with those without diabetes and have worse outcome ones failure has
developed.6
Global management of type II diabetes mellitus for the prevention of cardiovascular disease
including therapeutic life style intervention, treatment of hypertension, treatment of dyslipidemia and
antiplatelet therapies.

Therapeutic lifestyle intervention


Lifestyle intervention is the corner stone of cardiovascular disease prevention in
type II diabetes. The goals of lifestyle intervention to prevent cardiovascular
complication in patient type II diabetes are improve glycemic control, reduce
dyslipidemia, and hypertension and smoking cessation.
Moderate weight loss has been shown to reduce insulin resistance, dyslipidemia,
and blood pressure. Healthy food choices, physical activity, and exercise playing an
important role in weight reduction and weight control, regular physical activity in patient
with type II diabetes may independently lower the risk cardiovascular complication.2,3

Treatment of hypertension
Hypertension adversely affect both microvascular and macrovascular risk and has
been estimated to account for between 35% and 40% of the incrementle cardiovascular
risk associated with diabetes. Frequent modest-intensity aerobic exercise, alcohol and
sodium moderation, and weight reduction or markedly contribute improve blood
pressure. A number of randomized trial have proven the efficacy of several classes of anti
hypertensive medication, including angiotensin converted (ACE) inhibitor, angiotensin
reseptor blocker (ARB), calcium channel blocker, thiazide diuretic and beta blocker.1,5
Targets for patient with diabetes of < 130/80 mmHg have been endorsed by a
number of professional guidelines. ACE-Inhibitor should be considered first line therapy
(ARB for those in tolerance ACE inhibitor), independent of blood pressure, for all
diabetic patient aged> 55 years with additional cardiac risk factor or younger if
prevalence CVD is present, especially in the context of their incremental benefit on renal
outcomes.5

Treatment of dyslipidemia
This a common among patient in type 2diabetes, most commonly manifested as
characteristic pattern consisting of elevated triglyceride level, decrease HDL level, and
only modest elevation of LDL. Several pharmacologic agent are especially effective at
modifying this spectrum of abnormality, including niacin, and fibric acid derivated but

the CVD clinical effect remain uncertain. In contrast the statin drug, have a robust CVD
clinically outcome and are the primary drug advocated for use in patient with diabetes. 1,6
The recommended LDL therapeutic targets are as follows: LDL < 100 mg/dl in
the absent underlying CVD; LDL < 70 md/dl in the setting of prevalence CVD; and, at
maximal tolerated statin dose, at least 30% to 40% reduction from base line LDL
consentration. For the treatment of patient who have persistently elevated triglyscerid
level (>200 mg/dl) after achieving therapeutic LDL target consensus opinion advocated
that the principle secondary lipid target should be non HDL, with target level 30 mg/dl
higher than the individual patients;for responding LDL target.6

Antiplatelet therapies
Insulin resistance in type 2 diabetes are associated with myriad abnormalities in
platelet structure, life spent, activation, aggregation, yielding a prothrombotic state. The
evidence basis for the use of aspirin to reduce CVD risk in the setting of prevalence CVD
is well established, were as the role of aspirin for primary CVD risk prevention is much
less well defined. The routine use of aspirin at doses ranging from 75 to 162 mg daily
remains widely recommended for contemporary guideline for primary CVD risk
prevention for most adult patient with diabetes, including those age > 40 years or younger
with additional CVD risk factors.7

References:
1. Wild S, Roglic G, Green A, et al: Global prevalence of diabetes: estimates fot the year
2000 and projections for 2030. Diabetes Care 27:1047, 2004.
2. American Diabetes Association: Diagnosis and Classification of Diabetes Mellitus.
Diabetes Care 32:S62, 2009.
3. World Health Organization: Diabetes, fact sheet N 312, 2008.
4. Preis SR, Hwang SJ, Coady S, et a;: Trends in all-cause and cardiovascular disease
mortality among women and men with and without diabetes mellitus in Framingham
Heart Study, 1950 to 2005. Circulation 199: 1728, 2009.
5. Turnbull F, Neal B, Algert C, et al: Effects of different blood pressure lowering regimens
on major cardiovascular events in individuals with and without diabetes mellitus. Arch
Intern Med 165:1410, 2005
6. Adiels M, Olofsson SO, Taskinen MR, et al: Diabetic dyslipidemia. Curr Opin Lipidol
12: 238, 2006.
7. Baigent C, Blackwell L, Collins R, et al: Aspirin in the primary and secondary prevention
of cardiovascular disease: collaborative meta-analysis of individual participant data from
randomized trial. Lancet 373: 1849, 2009.