Supporting evidence is of class A

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Advanced coronary artery disease may be treated medically or surgically. However, some studies suggest that coronary artery bypass grafting (CABG) may be less effective in older patients with diabetes than in other groups, perhaps because of microvascular disease in the coronary circulation, but most likely due to the extensive nature of diffuse disease with difficulty in bypassing the number of lesions present. One study found better survival in people with diabetes with CABG than with PTCA.

Patients with type 2 diabetes have twice the average risk of suffering a stroke. It is unsure whether good glycemic control reduces this risk. However, treatment of hypertension, smoking and hyperlipidemia reduces the risk of stroke in most persons. See Annotation #11, "Set Individualized Treatment Goals" and the Blood Pressure Control algorithm.

E. Peripheral Vascular Disease - Peripheral arterial disease is commonly associated with diabetes. As many as 36 percent of patients with diabetes have lower-extremity peripheral arterial disease based on lower-extremity blood pressure readings. However, a typical history of intermittent claudication or an absent peripheral pulse is less commonly noted.

Peripheral vascular disease in combination with peripheral neuropathy places patients with diabetes at increased risk for nontraumatic amputations of the lower extremity. Peripheral vascular disease may be slowed by smoking cessation and treatment of hypertension and dyslipidemia. (See Annotation #11b, "Start or Intensify Statin Dose" and the Blood Pressure Control algorithm). Aggressive daily foot care, inspection of the feet at every office visit, early treatment of foot infections, treatment of callus, use of moisturizing lotion and proper footwear may forestall problems, including amputation. Vascular surgery may also prevent amputation in some patients with established severe peripheral vascular disease.

Treatment includes glycemic, blood pressure and lipid control, as well as smoking cessation, which may slow the progression. Proper high-risk foot management is necessary to prevent ulceration and amputation. Consider referral of patients with claudication and/or absent pedal pulses to surgery. Vascular surgery may prevent amputation in some patients with severe peripheral vascular disease. See the Glycemic Control and Blood Pressure Control algorithms.

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