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Diabetes and Heart Disease: A Dangerous Duo

Diabetes is a common silent metabolic abnormality, manifested by elevated blood sugar levels, which causes significant cardiovascular disease and death without appropriate treatment. Similar to other risk factors such as abnormal cholesterol levels and hypertension, which in most cases are without symptoms, diabetes can occur for long periods of time in an individual, undetected and unrecognized. This disregard may result in the individual developing serious, life-threatening complications on the heart, kidney, brain, eyes and peripheral arteries over time.

Truly, diabetes (similar to hypertension) is a “silent killer”, an “ominous timebomb”. Early detection through screening is imperative for its early management, limiting disease progression and thereby reducing the ever-growing cardiovascular disease epidemic in the country.

How does diabetes cause heart disease?
Diabetes is a major risk factor for atherosclerosis, the process of building up cholesterol plaques and/ or blood clots within blood vessel walls. Significant plaques developing in the coronary*, cerebral* and renal* arteries cause heart attacks, strokes and kidney failure, respectively. Elevated blood sugar directly and indirectly damage the lining of blood vessels, resulting to atheroma formation. Indirect damage results from high blood sugar, the cholesterol abnormalities and blood pressure elevation inherent in the diabetic state.

Why screen heart disease in diabetic patients?
Diabetics with heart disease have a very poor long term prognosis. Heart attacks and failure are the most common cause of death among diabetics. Compared to their non-diabetic counterparts, patients with diabetes have coronary arteries which are more diffusely and severely obstructed resulting to premature heart attacks, heart failure and other complications.

As a life-saving strategy, diabetics with heart disease eventually will need costly revascularization procedures, like bypass grafting or coronary stenting,to improve their heart condition, despite maximal medical therapy. This is the problem when the diabetic patient develops heart disease. Without intensive treatment, heart ailment will be severe and progressive, resulting to debilitation and death in a few years.

Thus, diabetic patients should be routinely screened for heart disease. Cardiovascular screening can be done through performance of rest and stress electrocardiogram and 2D echocardiogram. (Please see Common Heart Tests.) The decision to do any of these procedures depends on the attending physician/cardiologist’s overall evaluation of the patient’s likelihood for heart disease.

When and how to screen?
Diabetes, being a chronic asymptomatic disease, cardiovascular complications are already present at the time of its diagnosis. Thus, early screening is needed. There are several approaches in screening. Firstly, diabetes should be screened on individuals at high risk for diabetes, such as those with symptoms and/or with family history of blood sugar abnormalities. Symptoms indicative of diabetes are the 3 P’s: excessive thirst (polydipsia), appetite (polyphagia) and urination (polyuria). Significant weight loss and weakness associated with sugary urine (urine teeming with ants) are suggestive of the disease.

Secondly, screening for diabetes should be done as part of the overall risk assessment and management of individuals with moderate to high risk for developing cardiovascular disease in the future and those already with cardiovascular disease. The former are individuals with one or more risk factors, such as cigarette smoking, hypertension, unhealthy diet, sedentary lifestyle, obesity, history of premature heart disease or diabetes.The latter are those with coronary artery disease (with history of chest pains, heart attacks and/or heart failure), with cerebral stroke (with weakness and/or paralysis of one part of the body) or with kidney failure. At present, universal screening for undiagnosed diabetes, which includes low to very low risk people, is not recommended.

Three screening tests are usually utilized to determine the presence and severity of blood sugar abnormalities: fasting plasma glucose, oral glucose tolerance test and Hemoglobin A1C.

Fasting Plasma Glucose (FPG) is the most commonly used test to screen blood glucose abnormalities. The test should be done at least 8 hours from the last meal. Normal FPG is below 100 mg/ dl (5.5 mmol/L). FPG levels within 100125 mg/dl are termed Impaired Fasting Glucose (IFG), while levels 126 mg/dl and above are classified as diabetes. Cost of procedure is P170- 240.

Oral Glucose Tolerance Test (OGTT) is used to detect the degree of hyperglycemia after food intake. In an OGTT in nonpregnant individuals, fasting plasma glucose is taken, then afterwards, a 75 gm glucose solution is ingested. Plasma glucose (PG) is then taken 1 and 2 hours after the glucose load. Normal OGTT is when FPG is below 100 mg/dl and the 2-hour post-glucose solution PG levels are 139 mg/dl and below. PG levels within 140- 199 mg/dl and 200 mg/dl and above are classified as Impaired Glucose Tolerance (IGT) and Diabetes, respectively. Cost of procedure P360- 605.

A1C (Hemoglobin A1C or Glycosylated Hemoglobin) measures glucose bound to the red blood cell. It reflects one’s average blood sugar level the past 3 months. Though it is indicative of the long-term blood glucose control of an individual, it is not routinely recommended for diagnosis at this time since diabetes is frequently missed by this test. Normal HbA1C is below 6.0%. Cost of procedure P450- 850.

Definitely heart disease confers a poor long-term prognosis in individuals with diabetes. Their coexistence necessitates more aggressive and intensive management of both diseases with much stricter target levels of blood glucose, blood pressure and cholesterol levels, compared to those without the other disease. Routine screening of heart disease in most patients with diabetes may be necessary for optimal risk assessment and management. Such strategy should be borne in mind by physicians and other health care providers to provide optimum cardiovascular care to diabetic patients.

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