As a systemic condition, If cardiovascular disease affects one vascular territory, others are sure to follow suit. Diabetics are at a much greater risk of developing cardiovascular disease and are at a greater risk for experiencing CV events, such as MI or stroke. While the link between diabetes and coronary artery disease (CAD) has been well studied, the connection between diabetes and peripheral arterial disease (PAD) has been less studied.
What do we know about the relationship between diabetes and PAD? We know that diabetics are at higher risk for PAD, and diabetics with PAD are much more likely to have an MI or stroke than those who only have PAD. Data from the Framingham Heart Study revealed that 20 percent of symptomatic patients with PAD had diabetes. Experts believe this number does not reflect the incidence of combined PAD and diabetes in the general population because many people (up to 50 percent) with PAD are asymptomatic.
In a study presented at the American Diabetes Association meeting this month, researchers from Emory University found that screening people for diabetes was more cost-effective than treating them once they developed symptomatic diabetes. Twenty-four percent of those screened had either diabetes or prediabetes. While the study didn’t screen for PAD, it might be worthwhile to do so, especially for the 24 percent found to have or be at risk of developing diabetes.
Although current data on diabetes' influence on PAD are sorely lacking, data will emerge as our understanding of both diseases continues to improve. In the meantime, cardiologists would do well to consider testing for PAD in those with diabetes and/or testing for diabetes in those with cardiovascular disease.
Several studies at the ADA meeting involved testing various drugs to control glucose. Aleglitazar was found to have a positive effect on lipid and glucose control, as well as weight gain, and is now moving into Phase III trials.
While in a different class of drugs than Avandia, aleglitazar shares functional similarities. The drug has so far proved to be safe, with no one experiencing congestive heart failure or related CV events. Whether the positive effect on lipid management will translate into a benefit of CV outcomes remains to be seen.
In another study, researchers from the University of North Carolina found that a once-daily regimen of liraglutide was better at controlling blood glucose than twice-daily exenatide (Byetta), the only currently approved drug in its class. Patients taking liraglutide also lost weight. Both drugs stimulate insulin production.
While these studies are encouraging, evidence for the benefit of tight glycemic control in ameliorating PAD is lacking. Some evidence suggests a microvascular benefit resulting in a reduction in adverse events, but not a significant reduction in the risk of amputation.
In addition, there is not enough direct evidence showing a benefit for patients with PAD who are also treated for dyslipidemia. Some subgroup analyses suggest the severity of claudication is reduced by lipid-lowering treatment. Nevertheless, guidelines recommend a target LDL cholesterol level of less than 100 mg/dl in diabetics, which may also slow the progression of PAD.
As more data emerge regarding PAD and diabetes, Cardiovascular Business News will cover it. I've only mentioned a few articles in this column that we are featuring in the Endovascular Portal. There are many more, clinical as well as the latest news from industry.
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Chris Kaiser, Editor