Navigating cardiovascular risk in people with type 2 diabetes mellitus

The continued global increase in the prevalence of type 2 diabetes mellitus (T2DM) poses a significant challenge to the health of individuals, societies, and nations. According to the 10th edition of the IDF Diabetes Atlas, 537 million adults (20-79 years) were living with diabetes in 2021, and this number is predicted to rise to 643 million by 2030 and 783 million by 2045². Type 2 diabetes mellitus is increasingly being recognised as a significant risk factor for the occurrence of cardiovascular (CV) complications, including coronary artery disease, stroke, and peripheral artery disease. The interplay between T2DM and CV disease (CVD) is complex; understanding this risk and implementing strategies to mitigate it, is crucial for improving long-term outcomes in people with T2DM.³

Why are people with T2DM at an increased risk of CVD?
People with T2DM have accelerated atherosclerosis for many reasons, which results in the deposition of plaques (made up of fat, cholesterol, fibrin, and other substances) in the walls of blood vessels, which leads to narrowing and decreased blood flow in these vessels, thereby increasing the risk of stroke and heart attack. Over time, high blood sugar values damage the blood vessels, promoting atherosclerosis. Moreover, insulin resistance, a hallmark of T2DM, also plays a critical role in the development of CVD.⁴ Additionally, T2DM is often accompanied by obesity, high blood pressure, and elevated blood lipid values, all of which independently are a prominent risk factor for promoting atherosclerosis.⁵ Recent research suggests that abnormal fat deposition at atypical sites, such as the liver and pancreas, contributes to insulin resistance and chronic inflammation, thereby further accelerating the development of CVD.⁶

Strategies to reduce cardiovascular risk
Reducing CV risk in people with T2DM requires more than control of blood glucose values. It is essential to target blood pressure and serum lipid values as well. People with T2DM with impaired kidney function are at a very high risk of CVD, and as such, it is imperative to implement treatment strategies that safeguard kidney function.⁷

Effective management of excess weight in overweight or obese people with T2DM is essential to mitigate the risk of CVD associated with diabetes. Lifestyle modifications, behavioural strategies, pharmacological treatments, and, if necessary, surgical interventions to reduce weight in people with T2DM with obesity are crucial for reducing CV risk in this group of people.⁸
Moreover, all people with T2DM should be encouraged to quit smoking and adopt a healthy lifestyle, including a balanced diet and regular physical activity. Additional pharmacological treatments may be necessary to achieve optimal control of the associated cardiometabolic risk factors; also, one must consider using anti-diabetic mediations with proven benefits in reducing CV events in people with T2DM with established atherosclerotic CVD or in those at high risk for CVD.¹

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Conclusion

• Diabetes mellitus significantly increases the risk of cardiovascular disease through various mechanisms.

• Comprehensive risk assessment, and individualised management strategies, are crucial for mitigating this risk.

• Appropriate lifestyle changes including diet control, regular exercise, and smoking cessation are essential in reducing CVD in people with T2DM.

• Effective blood glucose control and appropriate management of additional risk factors such as obesity, high blood pressure, and elevated lipid values can significantly improve cardiovascular outcomes in people with T2DM.

• Appropriate use of anti-diabetic medications with proven benefit in reducing CV events in people with T2DM with established CVD or in those at high risk for CVD shall further reduce the burden of CVD in people with T2DM.

References:

1. Ma CX, Ma XN, Guan CH, Li D, Mauricio D, Fu SB. Cardiovascular disease in type 2 diabetes mellitus: progress toward personalized management. Cardiovasc Diabetol. 2022 May 14;21(1):74. doi: 10.1186/s12933-022-01516-6. PMID: 35568946; PMCID: PMC9107726. Accessed at this link
2. IDF Diabetes Atlas, 10th edn. Brussels, Belgium: International Diabetes Federation, 2021. Available at: Link
3. Wong ND, Sattar N. Cardiovascular risk in diabetes mellitus: epidemiology, assessment and prevention. Nat Rev Cardiol. 2023 Oct;20(10):685-695. doi: 10.1038/s41569-023-00877-z. Epub 2023 May 16. PMID: 37193856. Accessed at Link
4. DeFronzo RA. Insulin resistance, lipotoxicity, type 2 diabetes and atherosclerosis: the missing links. The Claude Bernard Lecture 2009. Diabetologia. 2010 Jul;53(7):1270-87. doi: 10.1007/s00125-010-1684-1. Epub 2010 Apr 2. PMID: 20361178; PMCID: PMC2877338.Accessed on Link
5. Petrie JR, Guzik TJ, Touyz RM. Diabetes, Hypertension, and Cardiovascular Disease: Clinical Insights and Vascular Mechanisms. Can J Cardiol. 2018 May;34(5):575-584. doi: 10.1016/j.cjca.2017.12.005. Epub 2017 Dec 11. PMID: 29459239; PMCID: PMC5953551. Accessed on Link
6. Leiu KH, Poppitt SD, Miles-Chan JL, Sequeira IR. Fatty Pancreas and Cardiometabolic Risk: Response of Ectopic Fat to Lifestyle and Surgical Interventions. Nutrients. 2022; 14(22):4873. Link Accessed on Link
7. Reduction in CV risk in people with T2DM requires more than just control of blood glucose values. It is essential to target blood pressure and serum lipid values as well. People with T2DM with impaired kidney function are at a very high risk of CVD, and as such, it is imperative to implement treatment strategies that safeguard kidney function. Accessed on – Link
8. Rothberg AE et al. Obesity Management for the Treatment of Type 2 Diabetes. 2024 May 1.: National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK); 2023-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK603314/ Accessed on – Link

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