Alex Kolesar Diabetes Information

Rhuna Shen Susan E Wiegers and Ruchira Glaser

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Department of Medicine, Cardiovascular Medicine Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A

Cardiovascular disease is a leading cause of death in the diabetic population, accounting for close to 80% of the mortality in diabetic patients in North America (1,2). Patients with diabetes mellitus have both a significantly higher risk for, and a higher mortality from, coronary artery disease (CAD). The diabetic patient has a two-to four-fold increase in the risk for development of coronary artery disease (2-6). Furthermore, diabetes accounts for 10% of the population attributable risk of first myocardial infarction (MI) (7).

Diabetic patients are not only over-represented among those patients with myocardial infarction, but also have a worse prognosis than non-diabetic patients with myocardial infarction (8-10). Several large studies, including the thrombolysis and angioplasty in myocardial infarction (TAMI) trial, have shown that even in the thrombolytic era, in-hospital mortality rates in diabetic patients remain 1.5 to 2 times higher than in non-diabetic patients (2,11-16). In the Finnish monitoring international cardiovascular disease (FINMONICA) trial, the one-year case fatality rate for a first myocardial infarction, including pre-hospital mortality, was 45% in diabetic men and 39% in diabetic women. These case fatality rates were significantly higher than those of non-diabetic subjects (38% and 25% for men and women, respectively) (9). In addition, many studies have demonstrated that, among survivors of myocardial infarction, diabetic patients have higher late mortality rates than do non-diabetic patients (8,10,17-22).

In addition to a higher prevalence of and mortality from symptomatic cardiovascular disease, diabetic patients also have a higher rate of asymptomatic coronary disease and coronary calcification (23,24). Diabetic patients without a history of myocardial infarction have as high a risk of myocardial infarction as do non-diabetic patients with previous myocardial infarction. In a Finnish population cohort study, the seven-year incidence of both fatal and nonfatal myocardial infarction, among over one thousand non-diabetic patients without prior history of myocardial infarction was 3.5%. In those non-diabetic patients with a prior history of myocardial infarction, the incidence was 18.8%. This incidence was comparable to that of diabetic patients without any prior history of myocardial infarction (20%) (25). These data underscore the need for screening asymptomatic diabetic patients in a manner similar to that of non-diabetic patients with previous infarction.