Management of the Patients with Diabetes Mellitus and Macro- and Microvascular Complications

ABSTRACT

The chronic, mainly vascular complications of diabetes mellitus involve many organs and are responsible for the majority of morbidity and mortality associated with the disease. The vascular complications of diabetes are divided into microvascular and macrovascular complications. Although some macrovascular complications may precede the development of diabetes, they frequently co-associate and present together. The increasing prevalence of diabetes and its association with macrovascular disease have become serious public health concerns. Patients with diabetes who have underlying coronary artery diseases have a different, more complex pathophysiology and a worse prognosis. Optimal management of these patients requires a comprehensive multifactorial approach to prevent microvascular and macrovascular events. In the setting of an acute myocardial infarction (aMI), immediate management should focus on limiting the infarct size using fibrinolytic agents, primary percutaneous intervention, or glycoprotein IIb/IIIa inhibitors. Drug-eluting stents may have an important role in patients with diabetes, who have a higher rate of post-intervention coronary restenosis than in nondiabetic individuals. All patients with aMI should be given aspirin, nitrates, beta-blockers, and angiotensin-converting enzyme inhibitors. Lipid-lowering agents as well as glycemic control have been shown to be effective in decreasing long-term mortality. Despite advances in the management of the vascular complications, the mortality rates of patients with diabetes remain 1.5-to 2-fold greater than those of individuals without diabetes. Maximizing the use of lifesaving therapies proved effective, and a tight metabolic control can further decrease mortality rates. However, many of these lifesaving therapies are underused in patients with diabetes because of the misconception that potential adverse effects may outweigh their benefits. New programs aimed at improving post-infarction quality of care in patients with diabetes, based on guidelines and expert recommendations, have shown promising. However, more efforts should be devoted to the improvement of outcomes related to these public health problems.