J Korean Med Assoc.  2005 Aug;48(8):721-734. 10.5124/jkma.2005.48.8.721.

Management of the Patients with Diabetes Mellitus and Macro- and Microvascular Complications

• Park Y

• KMID: 2064938
• DOI: http://doi.org/10.5124/jkma.2005.48.8.721

Abstract

The chronic, mainly vascular complications of diabetes mellitus involve many organs and are responsible for the majority of morbidity and mortality associated with the disease. The vascular complications of diabetes are divided into microvascular and macrovascular complications. Although some macrovascular complications may precede the development of diabetes, they frequently co-associate and present together. The increasing prevalence of diabetes and its association with macrovascular disease have become serious public health concerns. Patients with diabetes who have underlying coronary artery diseases have a different, more complex pathophysiology and a worse prognosis. Optimal management of these patients requires a comprehensive multifactorial approach to prevent microvascular and macrovascular events. In the setting of an acute myocardial infarction (aMI), immediate management should focus on limiting the infarct size using fibrinolytic agents, primary percutaneous intervention, or glycoprotein IIb/IIIa inhibitors. Drug-eluting stents may have an important role in patients with diabetes, who have a higher rate of post-intervention coronary restenosis than in nondiabetic individuals. All patients with aMI should be given aspirin, nitrates, beta-blockers, and angiotensin-converting enzyme inhibitors. Lipid-lowering agents as well as glycemic control have been shown to be effective in decreasing long-term mortality. Despite advances in the management of the vascular complications, the mortality rates of patients with diabetes remain 1.5-to 2-fold greater than those of individuals without diabetes. Maximizing the use of lifesaving therapies proved effective, and a tight metabolic control can further decrease mortality rates. However, many of these lifesaving therapies are underused in patients with diabetes because of the misconception that potential adverse effects may outweigh their benefits. New programs aimed at improving post-infarction quality of care in patients with diabetes, based on guidelines and expert recommendations, have shown promising. However, more efforts should be devoted to the improvement of outcomes related to these public health problems.

Keyword

Diabetes mellitus; Vascular complication; Coronary artery disease; Management

MeSH Terms

Angiotensin-Converting Enzyme Inhibitors
Aspirin
Coronary Artery Disease
Coronary Restenosis
Diabetes Complications
Diabetes Mellitus*
Drug-Eluting Stents
Fibrinolytic Agents
Glycoproteins
Humans
Mortality
Myocardial Infarction
Nitrates
Prevalence
Prognosis
Public Health
Angiotensin-Converting Enzyme Inhibitors
Aspirin
Fibrinolytic Agents
Glycoproteins
Nitrates

Reference

1. UK Prospective Diabetes Study Group. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet. 1998. 352:837–853.

2. American Diabetes Association. Clinical practice recommendations 2005. Diabetes Care. 2005. 28:Suppl 1. 1–79.

3. American Heart Association. Heart Disease and Stroke Statistics. 2003. Dallas: TX: 2004 Update.

5. The Writing Team for the Diabetes Control and Complication Trial/Epidemiology of the Diabetes Intervention and Complications Research Group. Effect of intensive therapy on the microvascular complications of type 1 diabetes mellitus. JAMA. 2002. 287:2563–2572.

6. Beckman JA, Creager MA, Libby P. Diabetes and atherosclerosis: epidemiology, pathophysiology, and management. JAMA. 2002. 287:2570–2581.

7. Neil HA, Seagroatt V, Betteridge DJ, Cooper MP, Durrington PN, Hunphries SE, et al. Established and emerging coronary risk factors in patients with heterozygous familial hypercholesterolaemia. Heart. 2004. 90:1431–1437.

9. Hochman JS, McCabe CH, Stone PH, Becker RC, Cannon CP, Braunwald E, et al. Outcome and profile of women and men presenting with acute coronary syndromes: a report from TIMI IIIB. Thrombolysis in Myocardial Infarction. J Am Coll Cardiol. 1997. 30:141–148.

10. Gu K, Cowie CC, Harris MI. Diabetes and decline in heart disease mortality in US adults. JAMA. 1999. 281:1291–1297.

11. Haffner SM, Lehto S, Ronnemaa T, Pyorala K, Laakso M. Mortality from coronary heart disease in subjects with type 2 diabetes and in nondiabetic subjects with and without prior myocardial infarction. N Engl J Med. 1998. 339:229–234.

12. Malmberg K. Prospective randomised study of intensive insulin treatment on long term survival after acute myocardial infarction in patients with diabetes mellitus. Br Med J. 1997. 314:1512–1515.

13. Malmberg K, Ryden L. Myocardial infarction in patients with diabetes mellitus. Eur Heart J. 1988. 9:259–264.

14. Stone PH, Thompson B, Anderson HV, Kronenberg MW, Gibson RS, Braunwald E, et al. Influence of race, sex, and age on management of unstable angina and non-Q-wave myocardial infarction: the TIMI III registry. JAMA. 1996. 275:1104–1112.

15. Sprafka JM, Burke GL, Folsom AL, McGoven PG, Hahn LP. Trends in prevalence of diabetes mellitus in patients with myocardial infarction and effect of diabetes on survival. Diabetes Care. 1991. 14:537–543.

16. Hammoud T, Tanguay JF, Bourassa MG. Management of coronary artery disease: therapeutic options in patients with diabetes. J Am Coll Cardiol. 2000. 36:355–365.

17. Jokl R, Klein RL, Lopes-Virella MF, Colwell JA. Release of platelet plasminogen activator inhibitor 1 in whole blood is increased in patients with type II diabetes. Diabetes Care. 1995. 18:1150–1155.

18. Steinberg HO, Chaker H, Leaming R, Johnson A, Brechtel G, Baron AD. Obesity/insulin resistance is associated with endothelial dysfunction: implications for the syndrome of insulin resistance. J Clin Invest. 1996. 97:2601–2610.

19. Brownlee M, Vlassara H, Cerami A. Nonenzymatic glycosylation and the pathogenesis of diabetic complications. Ann Intern Med. 1984. 101:527–537.

20. Moreno PR, Murcia AM, Palacios IF, Leon MN, Bernardi VH, Fallon JT, et al. Coronary composition and macrophage infiltration in atherectomy specimens from patients with diabetes mellitus. Circulation. 2000. 102:2180–2184.

21. Goraya TY, Leibson CL, Palumbo PJ, Weston SA, Killian JM, et al. Coronary atherosclerosis in diabetes mellitus: a population-based autopsy study. J Am Coll Cardiol. 2002. 40:946–953.

22. Kip KE, Faxon DP, Detre KM, Yeh W, Kelsey SF, Currier JW, Roger VL. Coronary angioplasty in diabetic patients: the National Heart, Lung, and Blood Institute Percutaneous Transluminal Coronary Angioplasty Registry. Circulation. 1996. 94:1818–1825.

23. Weiner DA, Ryan TJ, Parsons L, Fisher LD, Chaitman BR, Tristani FE, et al. Significance of silent myocardial ischemia during exercise testing in patients with diabetes mellitus: a report from the Coronary Artery Surgery Study (CASS) Registry. Am J Cardiol. 1991. 68:729–734.

24. Valensi P, Sachs RN, Harfouche B, Lormeau B, Paries J, Attali JR, et al. Predictive value of cardiac autonomic neuropathy in diabetic patients with or without silent myocardial ischemia. Diabetes Care. 2001. 24:339–343.

25. Ceriello A. Coagulation activation in diabetes mellitus: the role of hyperglycaemia and therapeutic prospects. Diabetologia. 1993. 36:1119–1125.

26. Mak KH, Moliterno DJ, Granger CB, Miller DP, White HD, Topol EJ, et al. Influence of diabetes mellitus on clinical outcome in the thrombolytic era of acute myocardial infarction. J Am Coll Cardiol. 1997. 30:171–179.

27. Roffi M, Chew DP, Mukherjee D, Bhatt DL, White JA, Topol EJ, et al. Platelet glycoprotein IIb/IIIa inhibitors reduce mortality in diabetic patients with non-ST-segment-elevation acute coronary syndromes. Circulation. 2001. 104:2767–2771.

28. Gheorghiade M, Goldstein S. Incomplete versus complete myocardial infarction. Henry Ford Hosp Med J. 1991. 39:263–264.

29. Fibrinolytic Therapy Trialists(FTT) Collaborative Group. Indications for fibrinolytic therapy in suspected acute myocardial infarction: collaborative overview of early mortality and major morbidity results from all randomised trials of more than 1000 patients. Lancet. 1994. 343:311–312.

30. Grines C, Patel A, Zijlstra A, Weaver WD, Granger C, Simes RJ. Primary coronary angioplasty compared with intravenous thrombolytic therapy for acute myocardial infarction: six-month follow up and analysis of individual patient data from randomized trials. Am Heart J. 2003. 145:47–57.

31. Stone GW, Grines CL, Cox DA, Garcia E, Tcheng JE, Lansky AJ, et al. Comparison of angioplasty with stenting, with or without abciximab, in acute myocardial infarction. N Engl J Med. 2002. 346:957–966.

32. Gaede D, Vedel P, Larsen N, Jensen GVA, Parving HH, Pedersen O. Multifactorial intervention and Cardiovascular dress in patients with type 2 diabetes. N Engl J Med. 2003. 348:383–393.