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78 Cardio Diabetes Medicine 2017

with ACE inhibitors. In the EPHESUS randomized trial ies consistently demonstrating a substantial gap be-
in post-MI patients, superior efficacy of eplerenone tween the accumulated evidence and its application
was observed in the diabetes subset of 2122 pa- in patients with diabetes. Second, continued investi-
tients, similar to that in the overall trial. On the basis gation into specific therapies and strategies targeting
of these results, eplerenone is recommended for all the unique risks for CVD associated with diabetes
patients with diabetes and acute MI with decreased remains a critical global public health imperative.
ejection fraction, except in the presence of contra-
indications. Beta blockers and diuretic medications References :
significantly reduce incident HF among patients with 1. American Diabetes Association: Standards of medical care in diabe-
diabetes. Carvedilol may offer advantages in diabetic tes-2013. Diabetes Care 36(Suppl 1):S11, 2013.17. Buse JB, Ginsberg
patients because of its favorable effects on insulin HN, Bakris
sensitivity and plasma lipid profiles, but the clinical 2. Heart Outcomes Prevention Evaluation Study Investigators: Effects of
relevance of these observations remains uncertain. ramipril on cardiovascular and microvascular outcomes in people with
Poor glycemic control is associated with risk of HF diabetes mellitus: Results of the hope study and micro-hope substudy.
in diabetes, with the association stronger in women Lancet 355:253, 2000
than in men.Drugs with a propensity to precipitate 3. Braunwald’ Heart Disease,Chapter 61,Diabetes and the Cardiovascular
hypoglycemia, especially sulfonylureas and exog- System ,Darren K. McGuire
enous insulin administration, should be used with 4. Hurst’s Heart, Chapter 91,Diabetes and Cardiovascular Disease ,Michael
some caution, as the stress response to hypoglyce- E. Farkouh, Elliot J. Rayfield, and Valentin Fuster
mia stimulates the neurohormonal axis implicated
in the clinical complications of HF. Thiazolidinedione
medications have a propensity to increase plasma
volume and to precipitate incident or worsening HF;
their use requires caution in patients with any degree
of HF, and they are contraindicated in patients with
NYHA class III or IV HF.

Cardiomyopathy:
The Framingham Heart Study showed that men with
diabetes are twice as likely to develop congestive
heart failure compared with their nondiabetic coun-
terparts and females with diabetes had a five-fold
increase in the rate of congestive heart failure. The
spectrum of heart failure ranges from asymptomatic
to overt systolic failure. Diabetes complicated by hy-
pertension represents a particularly high-risk group
for the development of congestive heart failure.27
Diastolic dysfunction is exceedingly common (>50%
prevalence in some studies) and may be linked to
diabetes without the presence of concomitant hyper-
tension. The etiology of impaired left ventricular func-
tion may involve any of the following mechanisms: (1)
coronary atherosclerotic disease, (2) hypertension, (3)
left ventricular hypertrophy, (4) obesity, (5) endothe-
lial dysfunction, (6) coronary microvasculature dis-
ease, (7) autonomic dysfunction, and (8) metabolic
abnormalities.
Overall, diabetes increases risk for virtually all CVD
complications and, most notably, atherosclerotic vas-
cular disease and HF. Further progress requires con-
tinued efforts in two domains: First, increased and
optimal application of the existing evidence for CVD
risk reduction is of paramount importance, with stud-

GCDC 2017