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Matthew J. Budoff, Not all diabetics are created equal (in cardiovascular risk), European Heart Journal, Volume 29, Issue 18, September 2008, Pages 2193–2194, https://doi.org/10.1093/eurheartj/ehn368
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Current guidelines continue to recommend all persons with diabetes be considered at high risk and treated accordingly. For example, National Cholesterol Education Panel Guidelines state ‘Persons with type 2 diabetes should be managed as a coronary heart disease (CHD) risk equivalent. Treatment for low density lipoprotein (LDL) cholesterol should follow Adult Treatment Panel III recommendations for persons with established CHD’.1 This remains an important tenet, as up to 80% of persons with diabetes will suffer a cardiovascular event. This has led some to conclude that further risk stratification in persons with diabetes is neither warranted nor useful.
However, persons with diabetes are not all at equal risk. The data from PREDICT,2 as well as previous coronary artery calcium (CAC) studies, demonstrate that persons with diabetes will have widely varied cardiovascular risk. While many persons with diabetes do have increased cardiovascular risk compared with the general population, there is a defined subset who have a very low cardiovascular risk and an equally large subset who are at extremely high risk. These groups cannot be discerned on the basis of HbA1c levels, duration of diabetes, age, gender or cardiovascular risk factors. Clearly, coronary calcium scanning (CCS) is not only becoming widely accepted in intermediate risk patients, such as those with several cardiovascular risk factors3,4 but data continue to accumulate indicating that presumed high-risk patients may actually benefit from further risk stratification. Increasing evidence that lower LDL-cholesterol values are warranted in persons with extremely high cardiovascular risk (with targets proposed as low as 1.8 mmol/L or 70 mg/dL). Despite this, there will be times when clinicians may need evidence to decide which patients warrant the highest doses of lipid-lowering therapy (some require dual or triple cholesterol-lowering therapies) to achieve these targets. Identifying diabetic persons with 10-, 20- or 30-fold increased risk of cardiovascular events will be important to justify these therapies to both the clinician and patient.
