Major Vascular Disease

Although microvascular disease is a major concern in diabetic patients, it should be emphasized that most patients with long-term type 1 DM and most patients with type 2 DM will die because of cardiovascular disease. Diabetic patients, particularly females, have an excess mortality owing to coronary artery disease compared with the non-diabetic control population. There is also an increased mortality due to peripheral vascular disease. Diabetic patients account for around 50% of all lower-limb amputations. Atheromatous lesions in diabetic patients are histologically identical to those in the non-diabetic population, but are more severe and widespread. Coronary artery disease may progress more quickly and hence present at a younger age. Although thrombolysis is effective, diabetic patients have a higher acute and delayed mortality after acute myocardial infarction mostly as a result of left ventricular failure. The Diabetes Mellitus Insulin GLucose infusion in Acute Myocardial Infarction (DIGAMI) study has suggested that the use of a glucose-insulin infusion and subsequent insulin treatment may significantly reduce 1-year mortality. Diabetes may also cause a specific cardiomyopathy in the absence of coronary artery disease.

Although risk factors for microvascular disease that pertain to the general population are also relevant to diabetic patients, hemostatic abnormalities (for example, decreased fibrinolysis or increased fibrinogen levels), hypertension and hyperlipidemia are particularly important in the latter. There is continuing debate over the atherogenic role of hyperinsulinemia and its relationship to the elevated levels of plasminogen activator inhibitor type 1 (PAI-1) described in diabetes.

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