Protecting Your Heart: Cardiovascular Care for Diabetes

Heart disease is the most common cause of death for people living with diabetes. It affects the way the heart and blood vessels work, causing problems like atherosclerosis, high blood pressure, and coronary artery disease.

Let’s take a look at how diabetes affects the cardiovascular system, how heart health is monitored in people with diabetes, and what you can do to keep your heart healthy.

Diabetes affects the heart in two main ways:

First, it leads to accelerated atherosclerosis in the arteries that supply the heart (coronary arteries).

Atherosclerosis refers to fat deposits that narrow the lumen (opening) of blood vessels, compromising their ability to transport blood. As the blood supply to the heart gradually reduces, it becomes weaker, a condition called congestive heart failure.

In case a fat deposit ruptures, patients experience an abrupt blockage of the heart’s blood supply, causing parts of it to die. This is called a myocardial infarction, which leads to heart attack.

Unfortunately, many people with diabetes can’t feel the classic chest pain associated with heart attacks. That’s because diabetes also damages nerve fibers, impairing their ability to feel pain in their limbs. As a result, people with diabetes can experience “silent heart attacks”, which are more dangerous because they come to attention later, after they've done a lot of damage.

The second way diabetes affects heart health is via its associated conditions. People with type 2 diabetes usually have high blood pressure and cholesterol levels. Both of these are independent risk factors for atherosclerosis.

There are three ways doctors monitor heart health in patients with diabetes. These are:

Two general measures are recommended for all diabetes patients, whether or not they have heart symptoms. These include:

• Checking the blood pressure (BP) at every clinic appointment and encouraging patients with elevated BP to measure it at home. Elevated blood pressure is defined as a systolic blood pressure higher than 140 and a diastolic blood pressure higher than 90.

• Obtaining a lipid panel at the time of diabetes diagnosis and repeating every five years for patients under 40 years. This is a blood test that shows your cholesterol levels, which are important to keep in control if you have diabetes.

These measures not only help prevent developing heart disease but also other macrovascular complications, such as stroke and peripheral arterial disease.

Keep in mind that conducting heart-specific tests — such as an electrocardiogram (ECG) — is not recommended for diabetes patients without any heart symptoms.

Healthcare providers should also calculate an atherosclerotic cardiovascular disease (ASCVD) risk score for all diabetes patients. This can start as early as 20 years of age, with reassessment every four to six years. If you’re over 40, your doctor will conduct more frequent reassessments.

This score tells:

• The 10-year ASCVD risk for individuals aged 40–79 years

• Lifetime ASCVD risk for individuals aged 20–59 years

This helps your specialist know how likely you are to experience a heart attack down the line and helps guide diabetes treatment.

Heart studies are done in only those diabetes patients who show heart symptoms. These symptoms include:

• Cold hands and feet

• Swelling of the hands or feet

• Shortness of breath on exertion

• Difficulty breathing when you lie straight

• Waking up during the night due to shortness of breath

• Chest pain that worsens with activity and resolves with rest

The first test for these patients is often an ECG, which can help understand whether the blood supply to any heart area is compromised.

The next step is to calculate a pretest probability (PTP) of cardiac disease by taking into account the age, sex, and symptoms of the patients.

Patients with a low PTP are unlikely to experience heart complications due to diabetes, so no further testing is done.

For those with high PTP, a coronary angiogram is conducted, which helps visualize heart blood vessels and see if any of them are affected by fat deposits.

Once your risk of heart disease is determined, there are six measures you can take to lower it. These include:

Healthy weight reduction allows for reduced blood pressure and cholesterol levels. It also makes the body more sensitive to insulin, allowing for better blood glucose control. These factors combine to reduce the risk of heart disease.

In type 2 diabetes patients, the minimum weight loss recommended is 5% . The more weight you can lose, the lower your chances of heart disease will be.

Doctors also assess the body mass index (BMI) of diabetes patients every year. It tells whether the weight of a person is appropriate for their height. For those with a BMI greater than 27 kg/m2, weight-reducing drugs are recommended. These include:

• Lipase inhibitors: (Orlistat) These prevent dietary fat from getting absorbed in the intestine

• Anti-opioid drugs: (naltrexone/bupropion) These suppress appetite

• GLP-1 agonists : (liraglutide and semaglutide) These make you feel full quicker and are especially beneficial for diabetes type 2 patients.

For patients with a BMI greater than 30, bariatric surgery is an option. The goal is to either reduce stomach size or bypass a small section of the small intestine to limit nutrient absorption.

People with diabetes should see a registered dietitian for a proper diet plan. But general dietary recommendations to reduce the risk of heart disease include:

• A high-fiber diet . According to a review of meta-analyses published in the journal Nutrients, populations who consumed the highest dietary fiber intake had a significantly reduced occurrence of heart disease. Foods with the highest fiber content include lentils, split peas, black beans, pinto beans, and artichoke hearts.

• Eating non-starchy vegetables . These vegetables have a lower carbohydrate content, meaning they don’t raise blood glucose levels. Examples include spinach, kale, collard greens, tomatoes, and carrots.

• Avoiding refined sugar . It’s found in a wide range of foods, including ketchup, soda, cakes, ice cream, and most processed foods. These are all foods a person with diabetes should avoid .

These can be tried out for three to six months in patients with mild hypertension and include:

• Weight loss , which is the most effective measure. You can expect a 1 mmHg reduction in blood pressure for every kilogram you lose.

• Dietary Approaches to Stop Hypertension (DASH) diet . It’s rich in fruits, vegetables, and whole grains but low in saturated and trans fats. Patients following this diet can experience up to an 11 mm Hg blood pressure reduction.

• Exercise . The most effective type for hypertension is 90-150 minutes of aerobic exercise per week, which can lead to a five to eight mmHg blood pressure reduction.

Medications are recommended when:

• Your BP is more than 130/80 mmHg and you show clinical signs of peripheral arterial disease (such as cool extremities or leg pain while walking), coronary heart disease, heart failure, or a history of stroke

• Your BP is more than 140/90 mmHg

The first-line hypertension drugs in diabetes patients include:

• Angiotensin-converting enzyme inhibitors (ACE inhibitors) , such as lisinopril, enalapril, and captopril. These also protect the kidneys, so they’re beneficial for patients with diabetic kidney disease.

• Angiotensin receptor blockers (ARBs) , such as losartan. Some patients develop swelling and long-term cough on ACE inhibitors, which is where ARBs come in. They have the same benefits but with a better side effect profile.

• Thiazide diuretics , such as chlorthalidone. These are preferred in patients of African origin.

Statins are drugs that stop the production of cholesterol in the liver, making it less likely to deposit in blood vessels and cause a heart attack.

Diabetes patients between 40 and 75 years of age are prescribed a low-dose statin whether or not they have high blood cholesterol levels. Some patients are also given high-dose statins , including:

• Those with type 2 diabetes for more than 10 years

• Those with type 1 diabetes for more than five years

• Those with an albumin-to-creatinine ratio of more than 30 mg/g, which means they’re losing proteins in the urine. These proteins normally prevent blood clots from forming, so patients who lose them in the urine are at a high risk of a heart attack.

Common side effects of statins include muscle pain, headache, and constipation or diarrhea. But they can, in rare cases, cause extreme muscle damage — a condition called rhabdomyolysis — which is an important side effect to be aware of.

Glucagon-like peptide-1 (GLP-1) agonists are believed to be cardioprotective, meaning they can improve heart failure symptoms and reduce the risk of death from heart disease. But they can cause nausea, vomiting, diarrhea, and inflammation of the pancreas. Examples of these drugs include saxagliptin, sitagliptin, and linagliptin.

Drugs that block angiotensin (such as ACEis or ARBs) are the first-line hypertension treatment for diabetic patients. Angiotensin normally constricts blood vessels, so these drugs lead to blood vessel dilatation. This also leads to good blood flow to the kidney — people with diabetes already have a high chance of kidney disease, so these drugs are beneficial.

Smoking cessation, weight reduction, physical activity, dietary changes, blood pressure management, and potential statin therapy are all important measures for reducing the risk of heart disease in diabetes.

But remember that the real cause of heart problems in diabetes is high blood sugar. So the most important step for protecting your heart is ensuring good blood sugar control, whether it’s by sticking to your oral hypoglycemic drug regimen or taking regular insulin injections.

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