According to the U.S. Centers for Disease Control (CDC), a staggering 65 percent of people with diabetes die from heart disease or stroke, yet few people with diabetes are aware of their increased cardiovascular risks.

Bringing blood glucose, blood pressure, and LDL cholesterol levels down is the best way to combat diabetes-related cardiovascular complications. The National Diabetes Education Program (NDEP) and the Department of Health and Human Services (HHS) recommend following the “ABCs” of diabetes treatment to maintain optimal heart health.

For patients with a poor cholesterol profile, dietary adjustments (i.e., lowering intake of saturated fat) and increased exercise are recommended. If these don't provide sufficient improvement, or if LDL and/or triglyceride levels are significantly elevated to begin with, drugs called statins — such as Crestor (rosuvastatin), Lipitor (atorvastatin), Pravachol (pravastatin), or Zocor (simvastatin) — may be prescribed.

In some cases, your physician may recommend a statin drug as a preventive measure, even if your lipid profiles are normal.

ABCs of Diabetes Treatment

A	A1C	<7 percent
B	Blood pressure	<130/80 mmHg
C	Cholesterol	LDL <100 mg/dl

Atherosclerosis and CAD

Atherosclerosis, more commonly known as hardening or clogging of the arteries, is caused by a buildup of fatty material (also called plaque or cholesterol), which restricts blood flow. If arteries become completely blocked, tissue death can occur. For patients with arterial obstructions, medications such as nitroglycerin, beta-blockers, and angiotensin-converting enzyme (ACE) inhibitors may be prescribed.

Blockage to the arteries that feed the heart is called coronary artery disease (CAD). What makes CAD particularly dangerous is that symptoms don't typically appear until vessels are significantly blocked. Symptoms of CAD include the following:

• Chest pain (angina)

• Pain in the left arm or shoulder (referred pain)

• Neck or jaw pain

• Chest tightness or pressure

• Shortness of breath

• Nausea

• Perspiration

• Irregular heartbeat (arrhythmia)

An electrocardiogram (ECG), echocardiogram, and/or stress test may be helpful in diagnosing blocked arteries. If CAD is left untreated or if treatment is ineffective, the artery may become completely blocked. When blood flow is restricted to the heart, a myocardial infarction (heart attack) may occur. Without oxygen from the blood, the affected area of heart muscle dies.

Symptoms of a heart attack are the same as those described previously for CAD, except the pain is considerably more intense. However, in people with diabetes who suffer from autonomic neuropathy, pain symptoms may not be felt at all, resulting in a “silent heart attack.”

In cases of stroke or heart attack, where restoring blood flow is critical to prevent tissue death and damage, clot-dissolving or “clotbusting” (fibrinolytic or thrombolytic) drugs may be administered, such as Activase (alteplase), Streptase (streptokinase), Abbokinase (urokinase), Eminase (anistreplase), or Retavase (reteplase).

You may also require an angioplasty, a procedure in which a catheter is inserted into the artery and an attached balloon is expanded to clear the blockage. Often, a device called a stent, which is expanded inside the artery to hold the vessel open, is used. Atherectomy, a procedure that strips fatty blockages out of the artery, may also be performed.

Studies have indicated that coronary bypass surgery may have better long-term outcomes than angioplasty for people with diabetes. Bypass involves rerouting the circulation by grafting a healthy piece of artery on to the obstructed blood vessel and around the blockage.

Peripheral Vascular Disease (PVD)

Like CAD, peripheral vascular disease (also called peripheral arterial disease, or PAD) involves atherosclerosis. Unlike CAD, PVD affects the extremities — most commonly the legs. Signs of PVD include the following:

• Calf and leg cramps or aching, usually when walking (intermittent claudication)

• Smooth, shiny, hairless skin on the shins

• Chronically cold feet and legs

• Numb legs or feet

• A bluish or reddish cast to the skin of the feet and/or legs

• Sores or ulcers on the legs that won't heal

The treatment of PVD is similar to that of CAD. Weight loss, cholesterol improvement through diet or drug therapy, appropriate exercise, and medication may all be recommended. Good foot care, important for everyone with diabetes, is especially essential to those people who develop PVD.

Hypertension

Another leading complication on the diabetes hit parade is hypertension, or high blood pressure. It occurs in up to 65 percent of people with diabetes, and is also closely linked with both diabetic kidney disease and CAD, making it a complex yet critical-to-manage condition.

The ADA recommends that non-pregnant adults with diabetes age 18 years and older aim for a blood pressure goal of less than 130 mmHg systolic and less than 80 mmHg diastolic (commonly expressed as 130/80 or “130 over 80”). A patient is considered hypertensive if she has a blood pressure reading greater than or equal to 140/90 mmHg. Weight loss, smoking cessation, exercise, and dietary adjustments such as lowering sodium and cholesterol intake may all be part of your recommended treatment program if your blood pressure is elevated. The fact that these are largely all goals of your diabetes management program to begin with may make them easier to accomplish.

If lifestyle modifications don't bring down your blood pressure, medications such as angiotensin-converting enzyme (ACE) inhibitors, diuretics, and angiotensin receptor blockers (ARBs) are effective options for some people. ACE inhibitors have also been shown to have the added benefit of delaying the progression of kidney disease, and may be a preferred therapy in patients who also have renal impairment. Your doctor can tell you more about these drugs and if they may be right for you.

Stroke

Another potential cardiovascular complication of diabetes is ischemic stroke. Ischemic stroke occurs when an artery leading to the brain becomes blocked and blood flow is cut off. Symptoms of stroke hit suddenly and include the following:

• Weakness or numbness of the arm, face, or leg (typically one-sided)

• Mental confusion

• Difficulty speaking

• Dizziness and/or problems with balance

• Visual problems

• Severe headache

Because of the complex relationships between diabetes and all the systems of the body, many diabetic complications are interrelated. For example, University of Wisconsin research (the Atherosclerosis Risk in Communities Study) found that middle-aged people who had never experienced a stroke but suffered from retinopathy displayed poorer cognitive function that those who didn't have retinopathy. The finding suggests that cerebral microvascular disease (which is at the root of diabetic retinopathy) may contribute to the development of cognitive impairment, even when stroke doesn't occur.