Therapy of Type 2 Diabetes Mellitus in Patients with Heart Disease

Patients with diabetes mellitus have amarkedly increased risk for myocardial infarction (3-5fold), heart failure and atrial fibrillation. All patients who have survived a myocardial infarction should be tested for the diagnosis of diabetes mellitus. In patients with diabetes, effects of therapy with antihypertensive drugs and statins on macrovascular endpoints are much more prominent than effects of intensive blood glucose lowering. Intensive glycemic control mainly improves microvascular outcomes. HbA1c as a measure of glycemic control must be set individually in each patient. The decision has to be based on duration of diabetes, life expectancy, psychosocial factors, risk of severe hypoglycemia, organ complications and comorbidities. Antihyperglycemic therapy with metformin reduces major cardiac events in obese diabetic patients. This is has not been shown conclusively for insulin and sulfonylurea drugs. These drugs show positive effects on microvascular endpoints. For newer antidiabetic drugs, results from endpoint trials are not available at the moment. They should be used only in case of contraindications against standard drugs or in case glycemic goals cannot be attained with standard drugs. Intensive blood glucose lowering does not affect incidence and outcome of heart failure in diabetic patients. During treatment of acute coronary syndrome blood glucose should be lowered moderately. It has not been shown that intensive glucose lowering affects outcomes of acute coronary syndrome.