Many people with diabetes develop at least mild cardiovascular disease. Therefore, treatment consists of a strong program for preventing further damage to the heart and blood vessels, coupled with specific therapies for problems that already exist. Whether plaque build-up affects the arteries of the heart, legs, brain or other organs, effective prevention and treatment are likely to involve lifestyle changes, such as diet, exercise, stress management and quitting smoking; medications to control blood sugar, blood pressure and cholesterol levels; and possibly daily aspirin to ward off unwanted blood clots.
In the case of severe plaque build-up, treatment may involve catheter-based interventions, such as stenting to widen the diseased artery and hold it open. In some cases, surgery may be needed to bypass the blockage and re-route blood flow through a new vessel or - in the case of the arteries that supply blood to the brain - to scrape and remove the plaque from the artery wall, restoring adequate blood flow.
The best way to prevent cardiovascular disease is to take good care of yourself and keep your diabetes under control. Read on for information about how to manage your diabetes and cardiovascular health.
Revascularization (procedures to restore blood flow)
The ABCs of Diabetes Management
To keep your diabetes under control, you can start with the ABCs of diabetes management:
A is for A1C. The A1C test gives your doctor important insight into your blood glucose levels over the previous two to three months. It's a good idea to check your A1C level twice a year. For most people who have diabetes, the goal is an A1C of less than 7 percent. Your physician will advise you on your target A1C.
B is for blood pressure. When a person with diabetes also has high blood pressure, the risk for cardiovascular disease doubles. High blood pressure forces the heart to work harder to circulate blood, and can lead to a heart attack, stroke, and kidney damage. Studies have also shown that there is a link between high blood pressure and resistance to insulin by the body's cells. For people with diabetes, the goal is a blood pressure of less than 130/80 mmHg.
C is for cholesterol. In people with diabetes, LDL, or "bad" cholesterol, tends to build up and clog the arteries. Triglycerides, another form of fat that can cause atherosclerosis, also tend to be abnormally high in diabetes. HDL, or "good" cholesterol, helps keep the arteries healthy by removing cholesterol from the body. In diabetes, HDL levels tend to be lower than normal. This combination of abnormal lipid levels is often seen in people with premature heart disease.
For most people, target blood levels of these lipids are
- Total cholesterol, less than 200 mg/dL
- LDL cholesterol, less than 100 mg/dL (below 70 mg/dL for those who already have, or are at high risk for, heart disease)
- Triglycerides, less than 150 mg/dL
- HDL cholesterol, greater than 40 mg/dL for men and greater than 50 mg/dL for women
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Lifestyle Changes and Medication
Inaddition to the ABCs of diabetes care, there are many steps you can take to stay healthy.
Diet. The great thing about a heart-healthy diet is that it's good for everyone, including people with diabetes. In general, your diet should be nutritionally balanced, high in fiber, low in fat (especially saturated fat) and moderate-to-low in salt. Load up with vegetables; choose lean meats, chicken and fish - and prepare them by baking or broiling; choose low-fat or fat-free dairy products; avoid high-sodium processed foods and limit how much salt you add to food; and enjoy some fresh fruit every day. As for how much you should eat of starchy foods like bread, pasta, potatoes and rice, follow the advice of your doctor and dietitian. Finally, watch the calories. Too much of any food can cause you to gain weight, and that will make it hard to control your diabetes.
Alcohol. If you choose to drink alcohol, limit it to one drink for women and two drinks for men per day. (One drink is a 12-ounce beer, a 4-ounce glass of wine, or 1.5 ounces of distilled alcohol.) Keep in mind that alcohol has a lot of calories. In addition, it tends to raise blood levels of triglycerides.
Exercise. Increasing your physical activity is one of the best ways to reduce the risk for heart attack and stroke. Exercise can help you to lose weight, prevent or delay the onset of Type 2 diabetes, reduce blood pressure, and relieve stress. It also helps make the body's cells more responsive to insulin. The goal for most people is at least 30 to 60 minutes of exercise on most days of the week.
Smoking. Cigarette smoke is not only bad for the lungs, it's toxic to the blood vessels and increases the risk of heart attack and stroke People with diabetes are especially vulnerable to the bad effects of smoking. Quitting smoking is difficult, but it is well worth the effort. Talk with your doctor about getting help with smoking cessation.
Body weight. Obesity is not only a major risk factor for cardiovascular disease, it plays a central role in insulin resistance and has been linked to high blood pressure. If you are overweight, losing those extra pounds will reduce your risk of heart attack and stroke, improve your sensitivity to insulin and help you to control your blood sugar levels.
Medications. People with diabetes know how important it is to take insulin or oral anti-diabetic medications. It's just as essential to take medications to prevent or treat cardiovascular disease, if your doctor has prescribed them. Depending on your individual health needs, you may need to take the following:
- Blood pressure medication. Anyone who has both diabetes and high blood pressure should be treated with medication to bring the blood pressure down to 130/80 mmHg or less. Many doctors will prescribe a type of medication known as an ACE inhibitor (or a related medication known as an ARB). These medications not only control the blood pressure, they appear to protect the heart and kidneys, so they are especially helpful in people with diabetes. If you need more than one medication to keep your blood pressure under control, your doctor may also prescribe a thiazide diuretic, a beta blocker, or a calcium-channel blocker.
- Cholesterol-lowering medication. If your LDL cholesterol is high, your doctor may prescribe a statin. If your triglycerides are high, it may be necessary to take niacin or a fibrate medication.
- Aspirin. Low-dose aspirin (75 to 162 mg daily) is recommended for people who know they have coronary artery disease (e.g., someone who has had a heart attack in the past). But for those who want to prevent cardiovascular disease from developing, aspirin's role is less clear. The American Diabetes Association, American Heart Association and American College of Cardiology recently released joint recommendations that address this question. The recommendations reflect a balance between aspirin's moderate benefit in reducing the risk for cardiovascular disease and its potential to increase the risk of bleeding from the stomach and gastrointestinal tract. Current recommendations for the prevention of vascular disease state:
- Low-dose aspirin is reasonable for adults with diabetes who are not at increased risk for gastrointestinal bleeding but are at increased risk for cardiovascular disease (i.e., older than age 50 for men and age 60 for women PLUS at least one major heart disease risk factor).
- Low-dose aspirin might be considered for adults with diabetes who are at intermediate risk for cardiovascular disease (i.e., younger patients with one or more risk factors, or older patients with no risk factors).
- Aspirin is not recommended for adults with diabetes at low risk for cardiovascular disease (men under age 50 and women under age 60 with no major risk factors).
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If you develop cardiovascular disease, you may eventually need a revascularization procedure. The term revascularization simply means to restore blood flow to the heart or another organ after the arteries have become clogged with cholesterol plaque. In the case of the heart, this can be accomplished either coronary artery bypass graft surgery with or angioplasty and stenting. Angioplasty and stenting are minimally invasive catheter procedures that together are known as PCI (percutaneous coronary intervention).
Revascularization for Coronary Artery Disease (CAD)
Whether people with diabetes fare better with CABG surgery or PCI is an ongoing controversy. That's because there haven't been many clinical studies that focused specifically on how to treat narrowed coronary arteries in people with diabetes. In addition, cardiovascular disease is different - and more severe - in people with diabetes. For example, people with diabetes often have widespread atherosclerosis affecting many arteries, not just a single blockage. Plaque deposits are often longer and affect smaller blood vessels in patients with diabetes. And after an angioplastyprocedure, it is more common in people with diabetes to find that the artery has become obstructed again, this time by an overgrowth of scar tissue. Known as restenosis, this complication explains why patients with diabetes are more likely to need repeat procedures after angioplasty and stenting when compared to non-diabetic patients.
For many years it was believed that CABG was the best choice for people with diabetes, mostly because early studies showed that long-term survival was better with surgery than with PCI. But more recent studies have started to change the way people think. Now that drug-eluting stents are available, many interventional cardiologists believe that angioplasty and stenting is a good option for certain people with diabetes, depending on how widespread the coronary artery disease is and how complex each cholesterol plaque is.
Revascularization for Peripheral Artery Disease (PAD)
If you have peripheral artery disease (PAD), treatment will include medication and lifestyle changes, just as with coronary artery disease. Getting more exercise and quitting smoking are especially important. Depending on how severe your PAD is and how you respond to initial therapy, you may also need revascularization to make sure your legs and feet are getting enough blood flow. Whether the best treatment is surgery or a minimally invasive catheter procedure will depend on the specific type of blockage and which artery is involved.
Revascularization for Carotid Artery Disease
You may also need revascularization because of plaque build-up in a carotid artery, which supplies blood to the brain. For now, most patients are treated with a surgical procedure known as carotid endarterectomy (CEA).This procedure involves opening the artery, cutting or scraping away the plaque and removing it.
However, for years, researchers have been conducting clinical studies to determine which types of patients and which types of plaques could be safely and effectively treated with a minimally invasive catheter procedure known as carotid artery stenting (CAS). Growing evidence supports the use of CAS in an increasingly wide range of patients with carotid artery disease, though not in all patients. Recommendations and guidelines are being revised on an ongoing basis as new evidence becomes available.
The bottom line is, whether you have heart disease, PAD, or carotid artery disease, the choice between surgery and catheter-based interventions like angioplasty and stenting must take into account your medical history and individual preferences, and should be made after a careful discussion with your physician.
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