Preventing a heart attack
The best way to deal with a heart attack is to prevent it. The National Diabetes Education Program, which is an alliance of the National Institutes of Health and the Centers for Disease Control and Prevention, has developed the “ABCs” of cardiovascular risk reduction.
“A” is for A1c, or HbA1c, a blood value that measures control of blood sugar over time. People with diabetes should target a value below 7% to reduce their risk of heart attack and other cardiovascular problems. The impact is considerable: Studies have demonstrated that for every 1% increase in HbA1c, the risk of a cardiovascular event increases 10% to 30%.
“B” is for blood pressure, which is a cardiovascular risk factor for all people, with diabetes or not. People should strive for a blood pressure of 130/80 mm Hg or less. Every 10-point increase in systolic (the first number) blood pressure has been correlated to a 20% increase in cardiovascular risk.
“C” is for cholesterol, specifically the LDL, or “bad,” cholesterol. The target is an LDL level of less than 100 mg/dl. Data from the United Kingdom Prospective Diabetes Study demonstrated that every 39-point increase in LDL increased cardiovascular risk by 50%, and that those with levels over 151 mg/dl were 2.3 times more likely to have cardiovascular complications than people with LDL levels below 117 mg/dl.
There are a range of medicines that can help people with diabetes achieve these goals, and modifications in diet and exercise have also been shown to be very important as a first-line treatment.
In addition to controlling blood sugar, blood pressure, and cholesterol, many physicians advocate that people with diabetes take aspirin to help prevent blood clots. Diabetes both increases the tendency of blood to clot in the blood vessels and decreases the natural process that dissolves clots.
Current treatment guidelines from the ADA recommend 81–325 milligrams of aspirin each day for anyone over 30 with Type 2 diabetes at risk for heart disease. Since diabetes is now considered a “risk factor equivalent” for heart disease, many physicians recommend that all people over 30 years of age who have diabetes take aspirin.
There is still debate about how to approach control of risk factors in people with diabetes, but many physicians suggest starting aggressive management upon diagnosis or even upon diagnosis of prediabetes, a syndrome of insulin resistance and/or impaired glucose tolerance.
Michael Brownlee, MD, a researcher at Albert Einstein College of Medicine in New York, believes that aggressive drug therapy is a good idea for everyone diagnosed with diabetes, whether Type 1 or Type 2.
“The ‘triple therapy’ for Type 2 diabetes, whether you have other risk factors or not,” he notes, “is a statin drug to lower lipid levels, aspirin to help prevent clotting, and an angiotensin-converting enzyme (ACE) inhibitor to reduce blood pressure. My opinion is that people with Type 1 diabetes should be on the same therapy, early in their treatment. Given the similar metabolic abnormalities, the reality that these drugs have a low toxicity, and the protective effect of ACE inhibitors on the kidneys, it would be prudent to start treatment early.”
There is also controversy about the impact of hormone replacement therapy (HRT) on heart disease risk. HRT once was thought to help prevent heart disease in postmenopausal women, but more recent controlled trials have found no benefit. One study of particular interest to women with diabetes, published in February 2003, reported that in women with diabetes taking HRT, there was a significant increase in the risk of death from heart attack, and in fact an increased risk of death from all causes. In 2004, the American Heart Association issued updated guidelines on preventing heart disease in women; these guidelines recommended against using HRT for this purpose.