Macrovascular disease : pathogenesis and risk assessment

Abstract

Type 2 diabetes mellitus is characterized by obesity and insulin resistance. Macrovascular (cardiovascular) disease (CVD) encompasses myocardial infarction, stroke and peripheral arterial disease. It is caused by atherosclerosis, a complex pathological process that is accelerated in people with diabetes and therefore causes premature morbidity and mortality. Risk is modified by established factors including hypertension and dyslipidaemia (which are linked to underlying insulin resistance), and microalbuminuria/renal impairment as well as cigarette smoking. Hyperglycaemia is a relatively weak risk factor for CVD once diabetes is established but is the key driver of microvascular complications. Other ‘novel’ predictors include elevated B-type natriuretic peptide, obstructive sleep apnoea, non-alcoholic fatty liver disease, hypoadiponectinaemia and testosterone deficiency, as well as chronic periodontitis and collagen vascular disorders. Early identification of cases and prompt management of risk factors is important in improving long-term outcome. Smoking cessation is a neglected area that requires urgent attention. Relative cardiovascular risk is similarly high in type 1 diabetes, even in younger individuals, and is also an important area for research.