Cardiovascular disease and diabetes

Atherosclerotic vascular disease is the major cause of morbidity and mortality in people with diabetes
mellitus.

Diabetes is associated with a two to three-fold increased risk of coronary heart disease in men and a four to
five-fold increase in pre-menopausal women.

The risk conferred by diabetes is independent of and additional to the other major risk factors:

Smoking

Hypertension

Hyperlipidaemia

Microalbuminuria or proteinuria

Obesity

Adverse family history
It should then be split into the following links:
Management of very high risk patients
Therapeutic interventions for very high risk patients
Primary prevention of CHD in Type 1 & 2 diabetes
Screening criteria for CHD in diabetes
Calculating CHD risk
Aspirin
Management of very high risk patients
This includes patients with:

Coronary heart disease

Peripheral arterial disease

Cerebrovascular disease

Diabetic nephropathy (proteinuria)

Those with calculated coronary heart disease risk >30% over 10 years
Therapeutic interventions for very high risk patients

Smoking cessation

Aspirin – 75 mg per day. Clopidogrel 75 mg/day should be considered in aspirin-intolerant patients
and should be added in aspirin-treated patients with a past history of coronary artery disease presenting
with acute coronary syndromes.

Statin therapy - unless contraindicated. The cholesterol targets are:
Total cholesterol 25% reduction from baseline or <5 mmol/l (whichever is lower)
LDL cholesterol <3 mmol/l

Glycaemic control – See Section 11 - Targets for glycaemic control

Blood pressure control – See Section 18 - Blood pressure

Beta blockade – following myocardial infarction – SIGN guideline No 55

Weight reduction

ACE inhibition – unless contraindicated
Primary prevention of coronary heart disease in type 2 diabetes
Statin and Aspirin therapy should be considered for all patients with Type 2 diabetes. Where the
calculated coronary heart disease risk is >15% and total cholesterol >5 or LDL >3, statin and Aspirin
(75 mg per day) therapy should be offered in the absence of contraindications.
Primary prevention relates to all patients with Type 2 diabetes not included in Section 21.1.
Primary prevention of coronary heart disease in type 1 diabetes
In the absence of contraindications, statin and Aspirin (75 mg per day) therapy should be considered
for all patients with Type 1 diabetes of greater than 10 years duration who are over 40 years of age,
or in younger patients if coronary heart disease risk exceeds 15% in 10 years.
Primary prevention relates to all patients with Type 1 diabetes not included in section 21.1.
Screening criteria for coronary heart disease in diabetes
Who
All people with diabetes aged over 25
When
Annually
By whom
Any member of the diabetes care team
How
The following should be addressed annually and the overall coronary heart disease risk
calculated
Outcome

History and examination as appropriate. Consider ECG.

Smoking – see Smoking and Diabetes

Blood pressure – See Blood Pressure

Measurement of urinary albumin - see Screening for diabetic renal disease

Lipid profile – see Lipids and Diabetes

Obesity and diet – see Major dietary messages for all types of Diabetes Mellitus

Glycaemic control – see Targets for glycaemic control
For primary prevention - See Primary prevention of coronary heart disease in type 1& 2
diabetes
For secondary prevention - See Therapeutic interventions for very high risk patients
Calculating coronary heart disease risk
The coronary heart disease risk is determined on the basis of certain pre-existing conditions or by the use of
risk factor tables. For the purposes of this document the Joint British Societies’ Coronary Risk Prediction
Charts have been used (See BNF or SIGN Guideline 40 - Lipids and the Primary Prevention of Coronary
Heart Disease22 and the SIGN 40 Quick Reference Charts). See also electronic risk calculator
www.gpct.grampian.scot.nhs.uk/grampintranet/ggmp/diabetes/risk.xls
The risk calculated should be increased as shown for each of the following additional risks:
Risk Factor
Multiplication
Factor
Family history of CHD
(1st degree relative with cardiovascular disease <55 years – male and <65 years – female)
1.5
Microalbuminuria
1.5
Indian subcontinent ethnicity
1.5
Type 1 diabetes mellitus
1.5
Aspirin
All patients with Type 2 diabetes and a calculated 10 year coronary heart disease risk >15% and Type 1
patients aged over 40 with greater than ten years duration of diabetes, who have no contraindications,
should take 75 mg Aspirin per day. Clopidogrel 75 mg daily is an alternative for patients intolerant of
Aspirin.
In 'primary' prevention before starting Aspirin therapy aim to reduce systolic blood pressure to 145 mmHg
or below.