ABSTRACT
Introduction Diabetes mellitus is increasingly common. Worldwide it is predicted that the numbers of people with diabetes will double over the next 15 years.1 In the UK, it is found in at least 2% of the Caucasian population2,3 and in up to 20% of some ethnic minority groups. With the same number of patients undiagnosed at any one time,4,5 it is clear that diabetes and its management is to place an increasing burden on health care systems around the world. In the UK, diabetes currently consumes at least 9% of healthcare expenditure, with much of this being used to treat complications. In the US, over $100 billion is spent annually on diabetes. For many years the main focus of management has been directed firstly towards symptomatic control and secondly towards recognizing and treating diabetes-specific complications, particularly retinopathy, neuropathy and nephropathy. There is no doubt that interventions to reduce the incidence and impact of these complications are partially effective in both type 1 and type 2 diabetes.6-9 However, it is clear that cardiovascular disease, and particularly coronary heart disease (CHD), greatly limits the expectation and quality of life of patients with diabetes. These patients have not seen the same fall in cardiovascular mortal-
Population-based studies have suggested that, with diabetes, the relative risk of dying of CHD is 2-3 times that of the general population in men and 3-5 times that of the general population in women.11-17 The absolute risk in women is approximately the same as in men. Eighty percent of patients with diabetes will die of cardiovascular disease, with at least 50% dying of CHD. Cardiovascular disease alone is largely responsible for the reduction of life expectancy of approximately 30% at any age of diagnosis of diabetes.18 Patients with diabetes have a consistently poorer survival after a myocardial infarction (MI). Mortality is increased in-hospital, at 1 month, at 1 year and at 5 years,19-21 and may be as high as 70% at 5 years (compared to 23-50% in those without diabetes).22,23 These patients also have a much higher rate of reinfarction.22,24
In addition to increased CHD risk, patients with diabetes have a significantly increased stroke risk, with a two-to four-fold excess risk of death from cerebrovascular disease (CVD).25 Peripheral vascular disease is also more common. Claudication is seen four times more commonly in men with diabetes and six times more commonly in women with diabetes.11,26 Gangrene is 60 times more common
