Diabetes and peripheral vascular disease

Abstract

The risk of peripheral vascular disease (PVD) is increased in diabetic patients, occurs earlier and is often more severe and diffuse. Endothelial dysfunction, vascular smooth muscle cell dysfunction, inflammation and hypercoagubility are the key factors in diabetic arteriopathy. The presence of PVD, apart from its increased risk of claudication, ischemic ulcers, gangrene and possible amputation, is also a marker for generalized atherosclerosis and a strong predictor for cardiovascular ischemic events. However, despite the recognition that PVD is associated with increased ischemic event rates and death, particularly in diabetic patients, this specific manifestation of systemic atherosclerosis is largely underdiagnosed and undertreated. In type-1 diabetes, early intensive insulin treatment reduces both microvascular (nephropathy, retinopathy and neuropathy) and macrovascular complications of diabetes (DCCT/EDIC study). In type-2 diabetes, UKPDS showed that tight glucose control reduces micro- and macrovascular complications, when therapy is started early after diagnosis and that early intervention has long lasting protective effects. However recently published trials (ADVANCE, ACCORD and VADT) pointed out that lowering glycemic targets to nearly normal glycaemia does not further reduce cardiovascular events in individuals with longstanding type 2 diabetes and that hypoglycaemia is to be avoided in individuals with ischemic heart disease. Finally, the small but important Steno-2 trial demonstrated that to significantly reduce peripheral vascular disease, ischemic events and mortality in type-2 diabetes, intensified multifactorial treatment of all modifiable risk factors is needed. Therefore, to prevent micro- and macrovascular complications, like PVD, in type-1 and type-2 diabetes, intensive therapy, targeting glycemia and all other modifiable cardiovascular risk factors, should be initiated as soon after diagnosis as possible and maintained in a safe way throughout life.