Prediabetes and diabetes are largely influenced by cardiovascular complications. Approximately 2/3 of patients with diabetes die from cardiovascular complications. Although there has been some improvement in reducing cardiovascular-disease, diabetes is still considered to be a coronary risk equivalent. This risk extends far beyond the diabetes threshold and is already present in prediabetic stages.
The Silent-Diabetes-Study analysed patients with coronary-artery-disease (CAD) undergoing angiography without pre-diagnosed diabetes. An oral glucose-tolerance-test was performed. It was demonstrated that the proportion of newly-diagnosed patients with impaired-glucose-tolerance or diabetes increased with the extent of CAD. This emphasises the need for early cardiological intervention.
In acute settings of myocardial-infarction (MI), it has been demonstrated that diabetic patients benefit more from an intensification of early interventions than non-diabetic patients. Intensification of therapeutic strategies in diabetic patients with acute MI enabled a substantial reduction in hospital-mortality comparable to rates of non-diabetic patients.
There is significant evidence that diabetic patients have a high benefit from reducing lipid- and blood pressure-levels.
Strategies beyond glucose-lowering (e.g. SGLT-2-inhibitors, GLP-1-receptor-agonists) appear to be associated with significant cardiovascular risk reduction, as evidenced by recent cardiovascular outcome trials. Cardiovascular risk reduction, which is achieved by the pure effect of glucose-lowering may also result in lower rates of cardiovascular events even though it might take up to a decade, until significant results become visible.
Overall the evidence for an early initiation of cardiovascular interventions in diabetes is strong. Due to the potential to rapidly lower the increased cardiovascular risk, it is recommended to treat cardiovascular-disease first.