Management of Cholesterol in Diabetes - A Review

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Abstract

Diabetes is considered to be equivalent to coronary artery disease in terms of cardiovascular risk. Therefore, aggressive management of cardiovascular risk factors, especially dyslipidemia, is warranted in patients with diabetes. Although diabetes is associated with a specific lipid pattern (increased triglycerides, reduced high-density lipoprotein [HDL] cholesterol, and presence of small dense low-density lipoprotein [LDL] particles), LDL cholesterol lowering remains the primary target of lipid management. Lifestyle intervention should be the first-line therapy in dyslipidemia management, and a statin should be considered early on, aiming not only at reaching target LDL cholesterol levels (<70mg/dl in patients with and <100mg/dl in patients without concomitant cardiovascular disease), but more importantly at slowing the progression of atherosclerosis and reducing the rate of cardiovascular events. Combination therapy for optimal LDL reduction and achievement of other lipid goals (triglyceride reduction and HDL increase) can be considered in patients with diabetes who are at extremely high cardiovascular risk.

Disclosure
The authors have no conflicts of interest to declare.
Correspondence
Mohit Gupta, MD, Los Angeles Biomedical Research Institute at Harbor-UCLA, 1124 W Carson St Bldg E5, Torrance, CA 90502. E: mohit_gupta13@yahoo.com
Received date
25 June 2010
Accepted date
07 July 2010
Citation
US Cardiology - Volume 7 Issue 2;2010:7(2):20-24
Correspondence
Mohit Gupta, MD, Los Angeles Biomedical Research Institute at Harbor-UCLA, 1124 W Carson St Bldg E5, Torrance, CA 90502. E: mohit_gupta13@yahoo.com

Pages

Diabetes and Cardiovascular Disease

Diabetes has long been recognized as a major risk factor for cardiovascular disease and is widely regarded as a ‘coronary disease equivalent,’1,2 as diabetes and established coronary heart disease indicate a similar absolute risk for cardiovascular death in both men and women.3–5 Cardiovascular complications of diabetes have traditionally been regarded as either microvascular (retinopathy, nephropathy, and neuropathy) or macrovascular (coronary,6 cerebrovascular,7 peripheral,8 and renal9 atherosclerosis); the latter have been held responsible for up to 70% of diabetes-associated mortality.10,11 Not only is cardiovascular disease more common in patients with diabetes, it also occurs at a younger age, presents with more atypical symptoms, and has a less favorable course: diabetic survivors of a myocardial infarction have a higher short- and long-term mortality rate and are more likely to develop heart failure than non-diabetics.12,13 The pathophysiology of diabetes-promoted atherosclerotic disease is complex and multifactorial. It comprises a direct influence of diabetes on vascular structure and function14 as well as a complex interplay of traditional and novel (especially inflammatory and hemostatic) cardiovascular risk factors with diabetes-associated metabolic derangements as a likely source of interaction—the cardiometabolic syndrome.15–19 Among these risk factors, diabetic dyslipidemia is probably the most exhaustively studied and has been traditionally recognized as both a significant co-factor in the development of and a pivotal therapeutic target in the fight against cardiovascular diseases in diabetes.

Diabetic Dyslipidemia

Also referred to as atherogenic dyslipidemia,16 diabetic dyslipidemia is characterized by a triad of lipid derangements: moderate elevation of triglyceride levels, decreased high-density lipoprotein (HDL) cholesterol levels, and presence of small dense (oxidation-prone and thus extremely atherogenic) low-density lipoprotein (LDL) particles.20 According to data from the Framingham cohort, 19% of men and 17% of women with diabetes (as opposed to only 9 and 8% of men and women without diabetes, respectively) have triglyceride levels above the 90th percentile of the general population, and similarly twice as many participants with diabetes than those without (21 versus 12% in men and 25 versus 10% in women) have HDL levels below the 10th percentile; conversely, high total and LDL cholesterol levels affect those with and those without diabetes to the same extent.21

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