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Canadian Journal of Cardiology

Diabetes for Cardiologists: Practical Issues in Diagnosis and Management

      Abstract

      Diabetes mellitus (DM), a chronic metabolic disease characterized by hyperglycemia, is a profound cardiovascular (CV) risk factor. It compounds the effects of all other risk factors, leads to premature micro- and macrovascular disease, facilitates development of heart failure, worsens the clinical course of all CV diseases, and shortens life expectancy. Established DM, unrecognized DM, and dysglycemia that may progress to DM are all commonly present at the time of presentation of overt CV disease. Thus, CV specialists and trainees frequently treat patients with dysglycemia. The traditional and proven role of cardiologists in reducing the risk of macrovascular events in this population is through aggressive lipid and blood pressure treatment. However, a more proactive role in the detection and management of DM is likely to become increasingly important as the prevalence continues to increase and therapies continue to improve. The latter include antihyperglycemic therapies with proven cardiovascular safety profiles and CV event reduction properties not yet fully elucidated and not necessarily related to glycemic control. Accordingly, the purpose of this article is to (1) expand the interest of cardiologists in earlier stages of the natural history of DM, when prevention or early detection might help achieve greatest benefit; (2) highlight principles of optimal glycemic management, with an emphasis on add-on choices showing promising reduction of CV events and lacking CV adverse effects; and (3) encourage cardiologists to become proactive partners in the multidisciplinary care needed to ensure optimal lifelong vascular health in patients with, or who are at risk of, DM.

      Résumé

      Le diabète sucré (DS), une maladie métabolique chronique caractérisée par une hyperglycémie, est un facteur de risque cardiovasculaire (CV) sérieux. Il aggrave les effets de tous les autres facteurs de risque, conduit prématurément aux maladies microvasculaires et macrovasculaires, facilite le développement de l’insuffisance cardiaque, aggrave l’évolution clinique de toutes les maladies CV et raccourcit l’espérance de vie. Le DS établi, le DS non diagnostiqué et la dysglycémie qui peuvent progresser vers le DS sont généralement tous présents au moment du tableau clinique de la maladie CV patente. Par conséquent, les spécialistes et les résidents dans le domaine des maladies CV traitent fréquemment les patients atteints de dysglycémie. Le rôle traditionnel et avéré des cardiologues dans la réduction du risque d’événements macrovasculaires dans cette population passe par le traitement énergique des lipides et de la pression artérielle. Cependant, un rôle plus proactif dans la détection et la prise en charge du DS promet de devenir de plus en plus important alors que la prévalence continue d’augmenter et les thérapies continuent de s’améliorer. Ces dernières comprennent les traitements antihyperglycémiques dont les profils d’innocuité cardiovasculaire prouvée et les propriétés de réduction des événements CV qui ne sont pas encore complètement élucidés et nécessairement liés à la régulation de la glycémie. En conséquence, le but de cet article est : 1) d’accroître l’intérêt des cardiologues quant aux étapes préliminaires de l’évolution naturelle du DS, lorsque la prévention ou la détection précoce aiderait à obtenir de plus grands avantages; 2) de mettre en lumière les principes de la prise en charge optimale de la glycémie en insistant sur les choix supplémentaires qui démontrent une réduction prometteuse des événements CV et l’absence d’effets CV indésirables; 3) d’encourager les cardiologues à devenir des partenaires proactifs dans les soins multidisciplinaires nécessaires pour assurer une santé vasculaire optimale tout au long de la vie des patients atteints du DS ou qui sont exposés au risque d’en être atteints.
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