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Brief description/objective

• Diabetes-associated deaths, over 2/3 of them being cardiovascular, are on an exponential rise following the diabetes “epidemics” observed in Western countries.
• Diabetes confers an equivalent cardiovascular risk to ageing 15 years.
• Coronary artery disease is more prevalent, more severe, and occurs at younger age in patients with diabetes. Chronic hyperglycemia, dyslipidemia, and insulin resistance have been associated with an accelerated form of atherogenesis, characterized by a prothrombotic state, enhanced inflammation, and endothelial dysfunction.
• Diabetic patients undergoing coronary revascularization have worse outcomes compared with nondiabetic individuals, both in the setting of PCI and CABG. Subgroup analyses of randomized trials and registries have suggested that CABG is superior to PCI in diabetic patients with multivessel disease. Ongoing randomized trials focusing for the first time on diabetic patients may settle the controversy.
• Diabetic patients with both non-ST-elevation ACS and STEMI have higher short- and long-term morbidity and mortality rates than nondiabetic counterparts. This finding is explained partly by a higher baseline risk profile, partly by a lesser degree of adherence to evidence-base therapies in this patient population. At the same time however, diabetic patients derive a grater benefit that nondiabetic individuals from aggressive management, including early invasive strategy, GP IIb/IIIa inhibition, and possibly primary angioplasty.
• The association between aggressive glucose-lowering strategies and reduction in diabetes-related adverse outcomes has been established in clinical trials for micro- but not macrovascular complications. Nevertheless, optimization of the glucose level remains a main goal in diabetes treatment.
• Aggressive modification of additional risk factors, including blood pressure and cholesterol level control, cigarette smoking cessation, weight loss, and exercise is key cardiovascular prevention.
• Metabolism modulation with thiazolidinediones has been associated in ex vivo studies with anti-inflammatory and thrombus-reducing properties. In addition, rosiglitazone has been shown to prevent diabetes in individuals with impaired glucose metabolism. However, thus far a reduction of cardiovascular events associated with these agents has not been convincingly demonstrated.
• Currently, two areas of research/clinical application are hot in the field of diabetes and cardiovascular disease. First, optimization of blood glucose control either by continuous insulin therapy and glycemic monitoring (closed loop) or by new therapeutic agents such as glucagons-like peptide 1 agonists and dipeptyl-peptidase-IV-inhibitors. Second, endocannabinoid receptor antagonists have been shown to improve obesity and overall cardiovascular risk profile. However, it remains to be determined whether these strategies may lead to a reduction macrovascular or microvascular complications in diabetes.
• The ultimate goal in diabetes care remains the cure of the disease by regeneration of beta-cell mass and/or beta-cell function. The role of pluripotent cells in this setting needs to be defined.