Prevention of coronary heart disease in diabetes.

Cardiovascular disease (especially coronary heart disease ) is the most common complication and cause of death in patients with type 2 diabetes. CHD prevention should be the major focus in preventive care of diabetes patients. There is a solid evidence base from which to recommend aggressive control of elevated blood pressure and lipids to reduce CHD events in diabetes. Aggressive glycemic control alone will not reduce CHD events, but will prevent diabetes-specific microvascular complications. Blood pressure should be treated to a goal of at least 130/80 mm Hg, and possibly lower, using angiotensin-converting enzyme inhibitors, thiazide diuretics, or beta blockers as first-line agents. Low-density lipoprotein cholesterol should be treated with a statin to reduce the level by 30% to 40%, regardless of pretreatment level, to a goal of less than 100 mg/dL for most patients or a goal of less than 70 mg/dL in diabetes patients with CHD. Patients with high-density lipoprotein levels less than 40 mg/dL may benefit from fibrate therapy. Cigarette smoking should be actively discouraged, and prophylactic aspirin therapy should be prescribed for most patients. A regular program of physical activity and weight control should be prescribed to improve insulin sensitivity. Use of thiazolidinediones may be considered early in the course of hypoglycemic therapy, but additional research is needed to define the role of insulin sensitization as a primary means to reduce CHD risk in type 2 diabetes.