Type-2 diabetes mellitus related cardiovascular risk: new options for interventions to reduce risk and treatment goals.
Diabetes represents a state of accelerated cardiovascular risk with data from longitudinal studies suggesting that in patients with well established diabetes the risk is equivalent to those with existing cardiovascular disease. In addition, the prognosis of patients with diabetes who suffer cardiovascular disease (CVD) is much worse. There are therefore dual imperatives for all physicians, particularly those in primary care, to focus on strategies to reduce vascular risk in their patients with diabetes. There are, in parallel, background issues that make this risk modification in diabetes a priority, with the rising prevalence of disease, driven at least in part by the rising tide of obesity, and the rising cost (42% of total expenditure) of treating CVD in diabetics. Evidence for interventions that modify the CVD risk in diabetes is now strong, with unequivocal data to support multifactorial risk modification, particularly for the effective targeting of glycaemia and blood pressure (with primary evidence for bp targets below standard care) from studies such as Steno2 and UKPDS, and lipid modification through the use of statins in both secondary (HPS) and primary (CARDS) prevention of CVD in diabetes. Knowledge of these interventions is high in primary care, but implementation is variable. This is probably at least in part because primary care physicians appear to consider risk factor modification within single risk strategies, rather than adopting lifestyle and therapeutic interventions that influence multiple risks in a systematic package of care and patient follow up.