Cardiovascular Complications In Diabetes

Diabetes plays a powerful role in the development of cardiovascular diseases (810). The incidence of cardiovascular disease is two times higher in men with diabetes and three times higher in women with diabetes than nondiabetic subjects (10). Haffner et al. (11) reported that the risk of developing a myocardial infarction in type 2 diabetic patients without a previous history of myocardial infarction is similar to that of nondiabetic patients who have had a prior myocardial infarction.

Diabetic patients have a twofold increase in the prevalence of hypertension compared with nondiabetic subjects (5). Hypertension is even more common in certain ethnic groups with type 2 diabetes. Almost twice as many African Americans and three times as many Hispanic Americans as compared with white non-Hispanic subjects have coexistent diabetes and hypertension (5). The coexisting hypertension and diabetes continue to rise dramatically in western countries as the overall population ages and as obesity and sedentary lifestyles become more prevalent.

The coexistence of diabetes and hypertension causes a very high risk for the development of macrovascular and microvascular complications. In patients with diabetes, 30 to 75% of complications can be attributed to hypertension (12). Risk for cardiovascular disease increases significantly when hypertension coexists with diabetes mellitus (13,14). Moreover, hypertension has a greater impact on cardiovascular diseases in diabetic as compared with nondiabetic subjects (15). Diabetic patients have a higher incidence of coronary artery disease, congestive heart failure, and left ventricular hypertrophy when hypertension is present. The incidence of other macrovascular complications, such as stroke and peripheral vascular disease, also increases significantly when hypertension exists in diabetic patients. Moreover, in addition to macrovascular complications, hypertension accelerates the risk of microvascular complications. Diabetic nephropathy (16,17), retinopathy (18-20), and neuropathy (21) are much more common when hyper- -o tension is found in association with diabetes.

The prevalence and natural history of hypertension differ markedly between patients with type 1 and type 2 diabetes mellitus. The prevalence of hyper- -g tension in patients with type 1 diabetes mellitus is similar to that of the general population until the onset of diabetic nephropathy. Hypertension not only develops with the onset of renal disease in these patients but also worsens with the progression of nephropathy. The hypertension in this setting is characterized by a

& u elevation of both systolic and diastolic blood pressures. In contrast, nearly 50% of patients with type 2 diabetes mellitus have hypertension at the time of diagnosis of diabetes. The prevalence of hypertension in these patients increases with age. Type 2 diabetic patients constitute more than 90% of those individuals with a dual diagnosis of diabetes and hypertension (5). Hypertension also commonly occurs in association with other components of the insulin resistance syndrome, termed ''syndrome X,'' which includes obesity, dyslipidemia, hyperuricemia, atherosclerotic cardiovascular disease, and microalbuminuria. Isolated systolic hypertension is common in patients with type 2 diabetes mellitus, suggesting decreased vascular compliance due to macrovascular disease. Hypertensive patients with type 2 diabetes also commonly have an attenuated nocturnal decline in blood pressure (i.e., they do not have the normal nighttime fall in blood pressure) (22).

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