2018, Volume 25, Supplement 2: Management of cardiovascular disease in the patient with diabetes

It is estimated that there are well over four million people living with type 2 diabetes in the UK at present, with many more undiagnosed. Diabetes imposes considerable premature vascular risks on individuals. In this supplement, the well-established concept of multiple risk factors leading to excess diabetes risk is acknowledged, with confirmation of considerable successes in reducing cardiovascular disease (CVD) risks (non-fatal more than fatal) in diabetes. However, we also discuss age differentials in risk, whereby younger-onset type 2 diabetes is shown to be much more pathogenic, and is better highlighted with a call for better management in these groups, and more trials....

Diabetes mellitus imposes considerable premature vascular risks on individuals. In this short review, the well-established concept of multiple risk factors leading to excess diabetes risk is acknowledged, with confirmation of considerable successes in reducing cardiovascular disease (non-fatal more than fatal) risks in diabetes. However, the less well appreciated age differentials in risk, whereby younger-onset type 2 diabetes is shown to be more pathogenic, is better highlighted with a call for more aggressive management in these groups....

Diabetes affects at least 415 million people worldwide, this epidemic disproportionately affects certain ethnicities, like South Asians (SA), more than others. The risk of developing diabetes is between two to six times higher in SA when compared with white Europeans in the UK. The current estimations are that there are nearly 400,000 people with diabetes of SA heritage living in the UK, which makes them one-fifth of the total UK diabetes population. The United Kingdom Asian Diabetes Study (UKADS) showed SAs tend to have early onset of diabetes (57.0 vs. 64.8 years), for longer duration (7.8 vs. 6.3 years), with individuals of lower body mass index (BMI) (28.6 vs. 31.0 kg/m2), lower waist (101.7 vs. 105.5 cm), lower systolic blood pressure (140.1 vs. 143.9 mmHg), lower high-density lipoprotein (HDL) (1.3 vs. 1.5 mmol/L) but relatively higher total cholesterol (4.7 vs. 4.3 mmol/L), higher triglycerides (2.5 vs. 2.0 mmol/L) and higher glycosylated haemoglobin (HbA1c) (8.2% vs. 7.2%) when compared with white Europeans. Diabetes in SAs increases their risks for coronary heart disease (perhaps more non-fatal), diabetic renal disease and diabetic retinopathy with a significantly lower duration of diabetes. The increased prevalence of diabetes in UK SAs with increased risk of complications is multi-factorial with both usual risk factors and unknown elements contributing. The role of genetic and epigenetic factors, low foetal birth weight, lifestyle factors that include diet and less physical activity, along with low socio-economic status, cultural barriers, language barriers, fatalistic attitude and cultural ‘taboos’, are speculated but variably proven. Although there is an emerging research in some of the areas, more well-designed randomised-controlled trials are needed to study these cardiometabolic risks and devise better management strategies for diabetes in this high-risk ethnic group....

Cardiovascular (CV) disease is a cause of significant morbidity and mortality in patients with type 2 diabetes. While lowering glucose levels is central to the management of diabetes, the relationship between glycaemia and CV disease is not straightforward, with both hyper- and hypoglycaemia contributing to vascular risk. Moreover, the type of hypoglycaemic agent may determine predisposition to CV events, adding another layer of complexity to patient management. Over the past decade, newer hypoglycaemic therapies have been forced to undergo rigorous randomised-controlled trials (RCTs) to confirm vascular non-inferiority and investigate possible superiority. This has provided an unprecedented wealth of data and demonstrated that inhibitors of dipeptidyl peptidase are CV neutral, whereas agents in the sodium-glucose co-transporter family offer CV protection and reduce heart failure risk. Some glucagon-like peptide-1 analogues have also shown vascular protection. In contrast to newer agents, metformin and agents in the sulfonylurea (SU) group have not been investigated in high-quality RCTs. Current evidence, derived from meta-analyses and observational studies, suggests that metformin is either CV neutral or offers vascular protection in some patients, yet to be fully characterised. SUs, on the other hand, may increase vascular risk, although concrete evidence for this is lacking. Interestingly, agents in the same class may have different vascular effects, as has been the case with rosiglitazone and pioglitazone, creating difficulties with guidelines and treatment recommendations. Ongoing and future RCTs, together with appropriate mechanistic studies, will further help to optimise hypoglycaemic therapy to maximise vascular benefits in patients with diabetes....

Over the last few years, there has been a growing interest in the role of antihyperglycaemic agents in cardiovascular disease prevention. Although clearly of interest, the weight of evidence suggests the mainstay of risk reduction is still focused on lifestyle interventions, control of hypertension and dyslipidaemia. This review will consider the relative merit of aggressive lifestyle intervention, establishing appropriate blood pressure targets and choice of agents to achieve this target in the population with diabetes, and the interventions to improve dyslipidaemia beyond statin therapy. Finally, consideration will be given to novel therapeutic targets that may be incorporated into future treatment algorithms....