Macrovascular disease: pathogenesis and risk assessment

Type 2 diabetes mellitus is characterized by obesity and insulin resistance (IR). Macrovascular (cardiovascular) disease (CVD) encompasses myocardial infarction, stroke and peripheral artery disease. It is caused by atherosclerosis, a complex pathological process that is accelerated in people with diabetes and therefore accounts for a higher proportion of total mortality. Risk is modified by established factors including hypertension and dyslipidaemia (which are linked with underlying insulin resistance), and microalbuminuria/renal impairment. Hyperglycaemia is a relatively weak risk factor for CVD once diabetes is established. Potential ‘novel’ predictors include elevated B-type natriuretic peptide, hypoadiponectinaemia, vitamin D and testosterone deficiencies, as well as chronic periodontitis and collagen vascular disorders. Early identification of cases and prompt management of risk factors is important in improving long-term outcome. Smoking cessation is a neglected area that requires urgent attention. Relative cardiovascular risk also remains high in type 1 diabetes, particularly in younger patients, and is also an important area for future research.