Diabetes is a metabolic disease whose incidence and prevalence has significantly increased in recent decades, mainly because of an increase in type 2 diabetes, which represents almost 90% of all cases of diabetes. The World Health Organization estimates that, by 2025, there will be 300 million diabetic patients (5.4% of the world population). Older patients are most affected by diabetes, as the disease prevalence increases with age, at least up until 75 years. The progressive aging of the global population could explain about half of the predicted increase of diabetic patients in the near future.¹

Macrovascular disease (coronary artery disease, stroke, and peripheral vascular disease) is responsible for the majority of morbidity and mortality associated with type 2 diabetes. In the UK prospective diabetes study (UKPDS),² the 10 year risk of all macrovascular complications was four times that of microvascular complications. Coronary artery disease is the leading cause of death among diabetic patients, and women have a higher cardiovascular risk than men.

Diabetics have a worse prognosis after an acute coronary syndrome than non-diabetic patients. This was documented both for ST elevation and non-ST elevation acute myocardial infarction (AMI). The Framingham heart study has also shown a higher mortality rate, as well as reinfarction and heart failure rates, in diabetic patients, both during the acute phase and in the post-infarction period, even after data adjustment for other risk factors.¹ Diabetic patients may, therefore, derive a greater benefit from therapies shown to be effective in treating ischaemic heart disease.

The challenge is, therefore, to protect the heart of diabetic patients more effectively. Can we achieve this goal? To answer this question we must first understand why patients with diabetes have a higher cardiovascular risk.

MECHANISMS FOR CARDIOVASCULAR DAMAGE AND PROTECTION IN THE DIABETIC HEART

Preconditioning

Preconditioning is the mechanism by which brief periods of sublethal ischaemia can render a …