Type 2 diabetes is cardiovascular disease

Neurologists are trying to convince generalists to avoid the term cerebrovascular accident, because many of the risk factors for stroke are modifiable: to regard the condition as an act of fate encourages inertia rather than the necessary aggressive approach including rapid brain scanning and thrombolysis in selected cases.¹ Just as in myocardial infarction ‘time is muscle’, with an intracerebral event ‘time is brain’. The term ‘brain attack’ serves to remind clinicians that intervention is required long before the 24 hours required for formal definition of a stroke.²

Generalists now have to be persuaded that an equally focused and aggressive approach is required in diabetes mellitus. The day of ‘wait and see’ is past, and the term mild diabetes should be buried forever. Gaining ground is the idea that diabetes mellitus (especially type 2 diabetes) is a ‘state of accelerated cardiovascular disease that just happens to be associated with hyperglycaemia’. People with type 2 diabetes are between two and six times more likely than those without diabetes to have cardiovascular disease and are more than twice as likely to die from it.^3,4 Among diabetologists there is a widely held belief that cardiovascular risk reduction should take precedence over reduction of blood glucose.

Whereas in type 1 diabetes the diagnosis is usually made quickly, in type 2 diabetes the patient will probably have had the disorder for 4-7 years before being formally diagnosed.⁵ Moreover, at the time of diagnosis as many as one fifth will prove to have other risk factors for cardiovascular disease modifiable by lifestyle changes or pharmacological treatment or both.^7,8 There is now ample evidence that aspirin,^9,10 statins,^11,12 and angiotensin converting enzyme (ACE) inhibitors¹³ reduce the risk of death from cardiovascular disease in diabetes. Gaede and co-workers¹⁴ lately reported that, compared with ‘standard care’, an intensive combination of behavioural and pharmaceutical interventions in type 2 diabetes reduced the incidence of cardiovascular disease by 53%, nephropathy by 61%, retinopathy by 58% and autonomic neuropathy by 73% over a mean follow-up of 7.8 years. Today, when a person with diabetes is found to have any cardiovascular risk factor at all, there should be a good reason why they should not be on aspirin, a statin and an ACE inhibitor (‘aspastatapril’). Because hypertension and hypertriglyceridaemia are also widely prevalent in people with type 2 diabetes, beta blockade and fibrates may have to be added.^15,16 These results are separate from the benefits of tight blood glucose control seen in both type 1 and type 2 diabetes.^17,18 With epidemiological and interventional data showing that the lower the blood pressure or glucose the lower the morbidity and mortality from the complications of diabetes, target values for these indices are being revised downwards.^19,20

This aggressive approach is not just for primary prevention. It applies also to people who have already had a cardiovascular event, and the benefits in those with diabetes seem even more impressive than in those without.⁹ There is, of course, a down-side to this aggressive treatment. Hypoglycaemia is a hazard of intensive regimens to lower blood glucose,^17,18 aspirin can cause gastrointestinal haemorrhage, statin therapy (especially in combination with fibrates) can result in myalgias, and ACE inhibitors can impair renal function. All these risks, however, can be limited by individual tailoring of treatment and close follow-up.^13,21,22 The emerging epidemic of diabetes²³ demands a vigorous clinical counter-attack if its consequences are not to overwhelm our health systems.