Thursday, September 06, 2007

Heart Attack, the Diabetes Equivalent

We all know that diabetes has often been call a CAD equivalent, obviously because diabetes cause many of their morbidity and mortality by their micro-vascular and macro-vascular effects. In the good (or not so good) old days, diabetics died from hyperglycemic effects. With insulin and many of the aggressive medical regimes, ketosis and acidotic comas are rare now. So many diabetics now die from CVS disease, heart attacks, strokes and the like.

A recent study by the Italians and reported in the 25th August issue of Lancet, showed that many patients after having suffered from a heart attacks, develop frank diabetes or IFG (impaired fasting glucose).Over a five-year period, Mozaffarian and colleagues tracked new-onset diabetes or the development of impaired fasting glucose (IFG) in a cohort of more than 8000 nondiabetic men and women who had experienced a recent AMI at baseline. Study participants were were part of the GISSI-Prevenzione trial, one of the first studies to establish the benefits of a Mediterranean diet, high in n-3 polyunsaturated fatty acids. The investigators also collected information on body-mass index (BMI), cardiovascular risk factors, diet, lifestyle, and medication use at baseline and over the follow-up period. Mozaffarian and colleagues showed that after an average followup of 3.2 years, 33% of the study cohort developed frank diabetes, and 62% of them had fasting blood glucose in excess of 5.6Mmols/L, against a rate of 3.7% and 27.5% respectively, in the general study cohort. The comparative annual diabetic rates for the general population is 1.8% and 1.6% respectively. The data shows clearly that after you have a heart attacks, you are obviously at risk of developing diabetes.

I suppose the next question that clinicians will ask is, "Is there a good explanation?". I am not sure. Obviously, more work needs to be done. I suppose, a heart attack is a great stress, and stress may precipitate a diabetic state in those likely to develop diabetes. What is even more interesting is that those on a mediterranean diet and a diet also lower in saturated fats and carbohydrates, have a lower risk of diabetes. The study did not study the effects of ACE-I or ARBs in this setting. Perhaps ACE-I and ARBs in this setting will show an even more diabetes protective effect. How interesting, Diabetes is a CAD equivalent and now it seems likely that CAD maybe a diabetes equivalent.

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