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• W2110361452 abstract "The number of diabetics will increase almost 70% in developed countries during the next 20 years: peripheral arterial disease is a common and costly complication. The incidence of cardiovascular disease (mortality and morbidity) due to atherosclerosis, is higher among patients with diabetes than in those without diabetes. Intensive management of diabetes, including glycaemic control, treatment of hypertension and dyslipidemia, as well as nonpharmacological interventions, decreases both micro- and macrovascular complications. Aspirin and clopidogrel have less antiplatelet effect in patients with diabetes. Metformin therapy is considered a risk factor for lactic acidosis if not withdrawn 2 days before angiography, but this risk is extremely low in patients with normal renal function. Peri-operative hyperglycaemia and large fluctuations in plasma glucose increase postoperative mortality and morbidity and careful measures are required to minimise these effects. The number of diabetics will increase almost 70% in developed countries during the next 20 years: peripheral arterial disease is a common and costly complication. The incidence of cardiovascular disease (mortality and morbidity) due to atherosclerosis, is higher among patients with diabetes than in those without diabetes. Intensive management of diabetes, including glycaemic control, treatment of hypertension and dyslipidemia, as well as nonpharmacological interventions, decreases both micro- and macrovascular complications. Aspirin and clopidogrel have less antiplatelet effect in patients with diabetes. Metformin therapy is considered a risk factor for lactic acidosis if not withdrawn 2 days before angiography, but this risk is extremely low in patients with normal renal function. Peri-operative hyperglycaemia and large fluctuations in plasma glucose increase postoperative mortality and morbidity and careful measures are required to minimise these effects. The global prevalence of diabetes mellitus has increased continuously and it has been predicted that the number of adult diabetics will double within 30 years. Almost 250 million people, nearly 6% of adults in the world, have diabetes.1Mayor S. Diabetes affects nearly 6% of the world's adults.BMJ. 2006; 9: 1191Crossref Scopus (16) Google Scholar Patients with diabetes have an average reduction in life expectancy of 5–10 years, mainly because of premature cardiovascular disease (CVD).2Marshall S.M. Flyvbjerg A. Prevention and early detection of vascular complications of diabetes.BMJ. 2006; 2: 475-480Crossref Scopus (149) Google Scholar In Finland, 90% of the total health care costs of diabetes are due to the complications of the disease. The treatment of type II diabetes alone cost 370€ per person annually, but the cost of complications increases this to 8900€ per person.2Marshall S.M. Flyvbjerg A. Prevention and early detection of vascular complications of diabetes.BMJ. 2006; 2: 475-480Crossref Scopus (149) Google Scholar, 3Finnish Diabetes Association Developement program for prevention of type 2 diabetes. Population Strategy 2003–2010. Hermes Oy, Tampere2003Google Scholar The onset of complications reduces the quality of life, particularly when both microvascular and macrovascular disease are present.4Jonsson B. CODE-2 Advisory Board. Revealing the cost of Type II diabetes in Europe.Diabetologia. 2002; 45: S5-S12Crossref PubMed Scopus (340) Google Scholar, 5Kulzer B. Diabetes mellitus: how important is it to measure the quality of life?.Dtsch Med Wochenschr. 2006; 131: S259-S263Crossref PubMed Scopus (5) Google Scholar Multiple modifiable risk factors, including hyperglycaemia, hypertension, and dyslipidemia, increase the risk of poor outcome.6Adlerberth A.M. Rosengren A. Wilhelmsen L. Diabetes and long-term risk of mortality from coronary and other causes in middle-aged Swedish men. A general population study.Diabetes Care. 1998; 21: 539-545Crossref PubMed Scopus (82) Google Scholar, 7Muntner P. He J. Astor B.C. Folsom A.R. Coresh J. Traditional and nontraditional risk factors predict coronary heart disease in chronic kidney disease: results from the atherosclerosis risk in communities study.J Am Soc Nephrol. 2005; 16: 529-538Crossref PubMed Scopus (381) Google Scholar Excess mortality from cardiovascular disease (CVD) compared to general population can be seen in all age groups, especially in young people with type 1 diabetes. Macrovascular disease, which usually is diffuse and distal affecting many vessels, is the main cause of death in type 1 and type 2 diabetes.6Adlerberth A.M. Rosengren A. Wilhelmsen L. Diabetes and long-term risk of mortality from coronary and other causes in middle-aged Swedish men. A general population study.Diabetes Care. 1998; 21: 539-545Crossref PubMed Scopus (82) Google Scholar The prevalence and mortality from all forms of CVD is 2–8 fold higher in the presence of diabetes.6Adlerberth A.M. Rosengren A. Wilhelmsen L. Diabetes and long-term risk of mortality from coronary and other causes in middle-aged Swedish men. A general population study.Diabetes Care. 1998; 21: 539-545Crossref PubMed Scopus (82) Google Scholar, 7Muntner P. He J. Astor B.C. Folsom A.R. Coresh J. Traditional and nontraditional risk factors predict coronary heart disease in chronic kidney disease: results from the atherosclerosis risk in communities study.J Am Soc Nephrol. 2005; 16: 529-538Crossref PubMed Scopus (381) Google Scholar Diabetes increases the risk of asymptomatic peripheral arterial disease (PAD) (Odds Ratio (OR) 3.8).8Eason S.L. Petersen N.J. Suarez-Almazor M. Davis B. Collins T.C. Diabetes mellitus, smoking, and the risk for asymptomatic peripheral arterial disease: whom should we screen?.J Am Board Fam Pract. 2005; 18: 355-361Crossref PubMed Scopus (37) Google Scholar, 9Norgren L. Hiatt W.R. Dormandy J.A. Nehler M. Harris K.A. Fowkes F.G.R. on behalf of the TASC II Working Group Inter-Society Consensus for the Management of Peripheral Arterial Disease.Eur J Vasc Endovasc Surg. 2007; 33: S1-S75Abstract Full Text Full Text PDF PubMed Scopus (2347) Google Scholar The Epidemiology of Diabetes Interventions and Complications study compared carotid intima-media thickness in subjects with and without diabetes: after 6 years, intima-media thickness was greater in those with diabetes.10Nathan D.M. Lachin J. Cleary P. Orchard T. Brillon D.J. Backlund J.Y. Diabetes Control and Complications Trial Epidemiology of Diabetes Interventions and Complications Research Group et al.Intensive diabetes therapy and carotid intima-media thickness in type 1 diabetes mellitus.N Engl J Med. 2003; 5: 2294-2303Google Scholar During an 11-year follow-up study, almost a quarter (31/131) patients with type 2 diabetes, aged at 58 at entry, developed PAD during follow-up and 21/29 deaths were attributed to CVD.11Kallio M. Forsblom C. Groop P.H. Groop L. Lepäntalo M. Development of new peripheral arterial occlusive disease in patients with type 2 diabetes during a mean follow-up of 11 years.Diabetes Care. 2003; 26: 1241-1245Crossref PubMed Scopus (91) Google Scholar In patients with diabetes, for every 1% increase in hemoglobin A1c (HbA1c) there is a corresponding 26–28% increase risk of PAD.12Selvin E. Marinopoulos S. Berkenblit G. Rami T. Brancati F.L. Powe N.R. et al.Meta-analysis: glycosylated hemoglobin and CVD disease in diabetes mellitus.Ann Intern Med. 2004; 21: 421-431Crossref Scopus (1169) Google Scholar Insulin resistance is a risk factor for PAD even in subjects without diabetes, increasing the risk by about 50%.13Muntner P. Wildman R.P. Reynolds K. Desalvo K.B. Chen J. Fonseca V. Relationship between HbA1c level and peripheral arterial disease.Diabetes Care. 2005; 28: 1981-1987Crossref PubMed Scopus (90) Google Scholar About half of all lower extremity amputations are related to diabetes.9Norgren L. Hiatt W.R. Dormandy J.A. Nehler M. Harris K.A. Fowkes F.G.R. on behalf of the TASC II Working Group Inter-Society Consensus for the Management of Peripheral Arterial Disease.Eur J Vasc Endovasc Surg. 2007; 33: S1-S75Abstract Full Text Full Text PDF PubMed Scopus (2347) Google Scholar, 14Eskelinen E. Lepäntalo M. Hietala E.M. Sell H. Kauppila L. Mäenpää I. et al.Lower limb amputations in Southern Finland in 2000 and trends up to 2001.Eur J Vasc Endovasc Surg. 2004; 27: 193-200Abstract Full Text Full Text PDF PubMed Scopus (73) Google Scholar Although the majority of diabetic ulcers are neuropathic, almost 60% also have an ischaemic component, with 10% being solely ischaemic.15Oyibo S.O. Jude E.B. Voyatzoglou D. Boulton A.J.M. Clinical characteristics of patients with diabetic foot problems: changing patterns of foot ulcer presentation.Pract Diabetes Int. 2002; 19: 10-12Crossref Scopus (24) Google Scholar Atherosclerosis is probably present in all patients with long-duration diabetes.16Jude E.B. Boulton A.J.M. Diabetic foot.in: Beard J. Gawes P. Vascular and Endovascular Surgery. 3rd edn. Elsevier Saunders, 2006: 118-137Google Scholar In critical limb ischemia (CLI), PAD impairs blood flow so that the nutritive requirements of the tissue cannot be met.9Norgren L. Hiatt W.R. Dormandy J.A. Nehler M. Harris K.A. Fowkes F.G.R. on behalf of the TASC II Working Group Inter-Society Consensus for the Management of Peripheral Arterial Disease.Eur J Vasc Endovasc Surg. 2007; 33: S1-S75Abstract Full Text Full Text PDF PubMed Scopus (2347) Google Scholar This is usually caused by multilevel arterial occlusive disease.9Norgren L. Hiatt W.R. Dormandy J.A. Nehler M. Harris K.A. Fowkes F.G.R. on behalf of the TASC II Working Group Inter-Society Consensus for the Management of Peripheral Arterial Disease.Eur J Vasc Endovasc Surg. 2007; 33: S1-S75Abstract Full Text Full Text PDF PubMed Scopus (2347) Google Scholar Patients with diabetes comprise 45–70% of those undergoing bypass surgery for CLI.14Eskelinen E. Lepäntalo M. Hietala E.M. Sell H. Kauppila L. Mäenpää I. et al.Lower limb amputations in Southern Finland in 2000 and trends up to 2001.Eur J Vasc Endovasc Surg. 2004; 27: 193-200Abstract Full Text Full Text PDF PubMed Scopus (73) Google Scholar, 17Virkkunen J. Heikkinen M. Lepäntalo M. Metsänoja R. Salenius J.P. Finnvasc Study Group Diabetes as an independent risk factor for early postoperative complications in critical limb ischemia.J Vasc Surg. 2004; 40: 761-767Abstract Full Text Full Text PDF PubMed Scopus (72) Google Scholar, 18Chung J. Bartelson B.B. Hiatt W.R. Peyton B.D. McLafferty R.B. Hopley C.W. et al.Wound healing and functional outcomes after infrainguinal bypass with reversed saphenous vein for critical limb ischemia.J Vasc Surg. 2006; 43: 1183-1190Abstract Full Text Full Text PDF PubMed Scopus (84) Google Scholar The metabolic and haemodynamic abnormalities of diabetes both contribute to the development of complications. Microvascular complications are strongly associated with CVD. The primary defect in PAD is atherothrombotic occlusion of large vessels and microangiopathy is not seen as a primary factor in the development of tissue ischemia in patients with diabetes. However, microvascular dysfunction can be observed in the skin, which could render this organ more susceptible to a reduction in perfusion pressure.19Houben A.J. Nieuwenhuijzen Kruseman A.C. Bouhouch E. Slaaf D.W. Schaper N.C. Peripheral macro- and microcirculation in short-term insulin-dependent diabetes mellitus: the role of prostaglandins in early haemodynamic changes.Eur J Clin Invest. 1993; 23: 662-667Crossref PubMed Scopus (10) Google Scholar In addition, diabetic neuropathy, in both type 1 and 2 diabetic patients, results in increased shunting of blood flow and an impaired inflammatory response to various stimuli.20Flynn M.D. O'Brien I.A. Corrall R.J. The prevalence of autonomic and peripheral neuropathy in insulin-treated diabetic subjects.Diabet Med. 1995; 12: 310-313Crossref PubMed Scopus (30) Google Scholar Endothelial function, which is impaired by most cardiovascular risk factors, eg hypercholesterolemia, smoking appears to be a useful marker of diabetic control.21Fowler B. Jamrozik K. Norman P. Allen Y. Prevalence of peripheral arterial disease: persistence of excess risk in former smokers.Aust N Z J Public Health. 2002; 26: 219-224Crossref PubMed Scopus (64) Google Scholar Recent reports indicate that an improved metabolic control in diabetes, whatever the treatment used, is associated with near normalization or restoration of normal endothelial function.22Guerci B. Bohme P. Kearney-Schwartz A. Zannad F. Drouin P. Endothelial dysfunction and type 2 diabetes. Part 2: altered endothelial function and the effects of treatments in type 2 diabetes mellitus.Diabetes Metab. 2001; 27: 436-447PubMed Google Scholar In both type 1 and type 2 diabetes, the lower the glycated haemoglobin achieved the lower the risk of microvascular complications.23The Diabetes Control and Complications Trial Research Group The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus.N Engl J Med. 1993; 30: 977-986Google Scholar, 24UK Prospective Diabetes Study (UKPDS) Group Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33).Lancet. 1998; 12: 837-853Google Scholar, 25Gaede P. Vedel P. Larsen N. Jensen G.V. Parving H.H. Pedersen O. Multifactorial intervention and cardiovascular disease in patients with type 2 diabetes.N Engl J Med. 2003; 30: 383-393Crossref Scopus (3700) Google Scholar In Diabetes Control and Complication Trial (DCCT), conventional therapy of type 1 diabetes consisted of 1–2 insulin injections per day. Intensive therapy aimed to achieve blood glucose values as close to the normal range as possible with 3 or more daily insulin injections or with insulin pump.23The Diabetes Control and Complications Trial Research Group The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus.N Engl J Med. 1993; 30: 977-986Google Scholar During the mean follow-up of 6.5 years, patients in the intensively treated group had significantly less microvascular complications, nephropathy and retinopathy. When major cardiovascular events and peripheral vascular events were combined, intensive therapy reduced the risk of macrovascular disease by 41%, although this was not statistically significant. The prevalence and amount of arterial calcification, 7–9 years after the trial, were significantly lower in the intensive treatment group compared with the conventional therapy group despite, even though there was no difference in HbA1c between the groups at late follow-up.26Cleary P.A. Orchard T.J. Genuth S. Wong N.D. Detrano R. Backlund J.Y. DCCT/EDIC Research Group et al.The effect of intensive glycemic treatment on coronary artery calcification in type 1 diabetic participants of the Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications (DCCT/EDIC).Study. Diabetes. 2006; 55: 3556-3565Crossref PubMed Scopus (210) Google Scholar However mean HbA1c level during the study period was significantly lower in the intensive treatment group. In the UK Prospective Diabetes Study (UKPDS), the relation between exposure to glycaemia over time and the risk of macrovascular or microvascular complications in patients with type 2 diabetes were determined in 3600 patients. Each 1% reduction in updated mean HbA1c was associated with reductions in risk of 21% for any end point related to diabetes (P<0.0001), 21% for deaths related to diabetes (P<0.0001), 14% for myocardial infarction (P<0.0001), and 37% for microvascular complications (P<0.0001). The lowest risk was in those with HbA1c values in the normal range (<6.0%).27Stratton I.M. Adler A.I. Neil H.A. Matthews D.R. Manley S.E. Cull C.A. et al.Association of glycaemia with macrovascular and microvascular complications of type 2 diabetes (UKPDS 35): prospective observational study.BMJ. 2000; 12: 405-412Crossref Scopus (6560) Google Scholar Current evidence suggests best therapy for diabetes is associated with the targets in Table 1. If the vascular surgeon identifies that these targets are not being met or approached a patient with diabetes, the diabetologists should be requested to optimise therapy for the patient.Table 1Hemoglobin A1c (HbA1c), cholesterol, blood pressure targets and other important factors for patients with DM to prevent or slow cardiovascular diseaseHbA1c (%)≤6.5 mmol/lFasting<6.0 mmol/lPost-prandial (peak)Individuals with type 1 diabetes <7.5 mmol/lIndividuals with type 2 diabetes 7.5–9.0 mmol/lCholesterolLDL: Individuals without CVD <2.6 mmol/l Individuals with CVD <1.8 mmol/lTriglycerides<1.7 mmol/lHDL: Men >1.0 mmol/l1.0 mmol/l Women>1.2 mmol/lBlood pressureSystolic blood pressure <130 mmHgDiastolic blood pressure < 80 mmHgOther important factorsAspirin therapySmoking cessationRegular physical exercise (>35–45 min/day)Weight controlDietary habitsThese goals are for patients in general and have to be adjusted for an individual patient taking all aspects in consideration, for example age (very young children or older adults may need modifications), history of severe hypoglycemia (HbA1c recommendation higher), renal impairment, limited life expectancy and other comorbid conditions.Modified from the European Guidelines for Cardiovascular disease prevention and American Diabetes Association, Standards of medical cari in diabetes 2007.70De Backer G. Ambrosioni E. Borch-Johnsen K. Brotons C. Cifkova R. Dallongville J. et al.Third Joint Task Force of the European and other Societes. European Guidelines on Cardiovascular Disease Prevention.Eur J Cardiovasc Preven Rehab. 2003; 10: S1-S78PubMed Google Scholar, 71American Diabetes Association Standards of Medical Care in Diabetes 2007.Diabetes Care. 2007; 30: S4-S41Crossref PubMed Scopus (1492) Google Scholar Open table in a new tab These goals are for patients in general and have to be adjusted for an individual patient taking all aspects in consideration, for example age (very young children or older adults may need modifications), history of severe hypoglycemia (HbA1c recommendation higher), renal impairment, limited life expectancy and other comorbid conditions. Modified from the European Guidelines for Cardiovascular disease prevention and American Diabetes Association, Standards of medical cari in diabetes 2007.70De Backer G. Ambrosioni E. Borch-Johnsen K. Brotons C. Cifkova R. Dallongville J. et al.Third Joint Task Force of the European and other Societes. European Guidelines on Cardiovascular Disease Prevention.Eur J Cardiovasc Preven Rehab. 2003; 10: S1-S78PubMed Google Scholar, 71American Diabetes Association Standards of Medical Care in Diabetes 2007.Diabetes Care. 2007; 30: S4-S41Crossref PubMed Scopus (1492) Google Scholar Smoking cessation is a particular advantage to patients with diabetes and peripheral arterial disease. The highest relative risk associated with PAD is current smoking of 25 or more cigarettes daily (OR=7.3, 95% confidence interval (CI) 4.2–12.8).21Fowler B. Jamrozik K. Norman P. Allen Y. Prevalence of peripheral arterial disease: persistence of excess risk in former smokers.Aust N Z J Public Health. 2002; 26: 219-224Crossref PubMed Scopus (64) Google Scholar Both hyperglycemia and smoking can result in the formation of advanced glycation end products and in enhanced oxidative stress within the vessel wall, suggesting that these process might play a central role the development or progression of PAD.28Baynes J.W. Thorpe S.R. Role of oxidative stress in diabetic complications: a new perspective on an old paradigm.Diabetes. 1999; 48: 1-9Crossref PubMed Scopus (2085) Google Scholar Diabetes combined with smoking has high positive predictive value for asymptomatic PAD (15%), when both are lacking, rates for predicting asymptomatic PAD is low (1%).8Eason S.L. Petersen N.J. Suarez-Almazor M. Davis B. Collins T.C. Diabetes mellitus, smoking, and the risk for asymptomatic peripheral arterial disease: whom should we screen?.J Am Board Fam Pract. 2005; 18: 355-361Crossref PubMed Scopus (37) Google Scholar The weight of evidence also suggests that smoking adversely influences the success of bypass surgery. By the age of 45 about 40% of patients with type 2 diabetes are hypertensive, the proportion increasing to 60% by the age of 75.29Hypertension in Diabetes Study (HDS): I. Prevalence of hypertension in newly presenting type 2 dia-betic patients and the association with risk factors for cardiovascular and diabetic complications.J Hypertens. 1993; 11: 309-317Crossref PubMed Scopus (453) Google Scholar This combination provides additive increases in the risk of major cardiovascular events. Aggressive blood pressure control may be the most important factor in preventing major cardiovascular events in patients with type 2 diabetes.30Strippoli G.F. Craig M. Craig J.C. Antihypertensive agents for preventing diabetic kidney disease.Cochrane Database Syst Rev. 2005; 19 (CD004136)Google Scholar, 31Domanski M. Mitchell G. Pfeffer M. Neaton J.D. Norman J. Svendsen K. MRFIT Research Group et al.Pulse pressure and cardiovascular disease-related mortality: follow-up study of the Multiple Risk Factor Intervention Trial (MRFIT).JAMA. 2002; 22-29: 2677-2683Crossref Scopus (235) Google Scholar, 32UK Prospective Diabetes Study Group Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38.BMJ. 1998; 12: 703-713Crossref Google Scholar In a Cochrane review, a reduction in systolic blood pressure of 10 mmHg was associated with a 13% reduction in risk of microvascular events and an 11% reduction for myocardial infarction.30Strippoli G.F. Craig M. Craig J.C. Antihypertensive agents for preventing diabetic kidney disease.Cochrane Database Syst Rev. 2005; 19 (CD004136)Google Scholar In the Multiple Risk Factor Intervention Trial Diabetic Cohort, cardiovascular mortality was increased by 2–4 fold and the association between systolic blood pressure and complications had no threshold value.31Domanski M. Mitchell G. Pfeffer M. Neaton J.D. Norman J. Svendsen K. MRFIT Research Group et al.Pulse pressure and cardiovascular disease-related mortality: follow-up study of the Multiple Risk Factor Intervention Trial (MRFIT).JAMA. 2002; 22-29: 2677-2683Crossref Scopus (235) Google Scholar In UKPDS, reductions in risk in the group assigned to tight blood pressure control (achieved 144/82) compared with the group assigned to less tight blood pressure control (achieved 154/87) were significant, reductions of 32% in deaths related to diabetes (p=0.019), 44% in strokes (p=0.013) and 37% in microvascular endpoints (p=0.0092) after mean follow-up of 8.4 years.32UK Prospective Diabetes Study Group Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38.BMJ. 1998; 12: 703-713Crossref Google Scholar Since diabetes is an important cardiovascular risk factor, a lower target value for those with diabetes (130/85 mmHg) than for others (140/90 mmHg) has been proposed.33Morgensen C.E. New treatment guidelines for a patient with diabetes and hypertension.J Hypertens Suppl. 2003; 21: S25-S30Google Scholar All classes of antihypertensive agents are effective in reducing blood pressure in diabetes, with evidence of a concomitant reduction in cardiovascular risk. Hypertensive patients have a significantly increased risk for development of type 2 diabetes, which is dependent on the class of anti-hypertensive drug used. Diuretics and beta-blockers have a prodiabetic effect, but angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers may prevent diabetes more effectively than the metabolically neutral calcium channel blockers. The metabolic abnormalities that cluster in patients with type 2 diabetes and the metabolic syndrome are all independent risk factors for atherogenesis and dyslipidemia is an important, modifiable risk factor for CVD. Two placebo-controlled trials have shown, that treatment with statins reduces the risk of a major cardiovascular event by 37% in patients with type 2 diabetes without clinically apparent CVD.34Heart Protection Study Collaborative Group MRC/BHF Heart Protection Study of cholesterol lowering with simvastatin in 20,536 high-risk individuals: a randomised placebo-controlled trial.Lancet. 2002; 6: 7-22Google Scholar, 35Colhoun H.M. Betteridge D.J. Durrington P.N. Hitman G.A. Neil H.A. Livingstone S.J. et al.CARDS investigators. Primary prevention of cardiovascular disease with atorvastatin in type 2 diabetes in the Collaborative Atorvastatin Diabetes Study (CARDS): multicentre randomised placebo-controlled trial.Lancet. 2004; 21-27: 685-696Abstract Full Text Full Text PDF Scopus (3132) Google Scholar In a meta-analysis of randomized controlled trials, lipid lowering drug treatment was at least as effective in diabetic patients as in non-diabetic patients.36Costa J. Borges M. David C. Vaz Carneiro A. Efficacy of lipid lowering drug treatment for diabetic and non-diabetic patients: meta-analysis of randomised controlled trials.BMJ. 2006; 13: 1115-1124Crossref Scopus (245) Google Scholar For primary prevention, the risk reduction for major coronary events was 21% (95% CI 11%–30%) and 23% (12%–33%) in patients with and without diabetes respectively. For secondary prevention, the corresponding risk reductions were 21% (10%–31%) and 23% (19%–26%). All those aged 40 years with diabetes and younger patients with diabetes at particularly high risk (microvascular or macrovascular complications, hypertension, metabolic syndrome or a strong family history for CVD) should be offered statins. Neuropathy with subsequent loss of protective sensations, muscular weakness and structural deformity as well as autosympathectomy is the main cause for diabetic foot ulceration. Ischaemia alone is the cause only in 10%,15Oyibo S.O. Jude E.B. Voyatzoglou D. Boulton A.J.M. Clinical characteristics of patients with diabetic foot problems: changing patterns of foot ulcer presentation.Pract Diabetes Int. 2002; 19: 10-12Crossref Scopus (24) Google Scholar whereas inadequate tissue often perfusion prevents healing. Neuropathy causes reulceration in case of inappropriate offloading. Therefore continuous education of patients regarding skin care, foot hygiene, off-loading, and proper footwear is crucial to reducing the risk of an injury that can lead to ulceration. A careful foot examination that tests for neuropathy and arterial insufficiency can identify legs at risk and should be a routine to the diabetic patient. If foot ulcer has not shown any evidence for healing in two weeks, careful examination of the lower limb circulation with subsequent vascular reconstruction as appropriate is indicated. These measures decreased first amputations in Finland 1988–2002 from 924 to 387 per 100000 patients with diabetes.37Winell K. Niemi M. Lepäntalo M. The National Hospital Discharge Register data on lower limb Amputations.Eur J Vasc Endovasc Surg. 2006; 32: 66-70Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar Type 2 diabetes is increasingly common, primarily because of increases in the prevalence of a sedentary lifestyle and obesity. In about half of patients with recently diagnosed type 2 diabetes, life-style interventions such as weight reduction and increased physical activity may reverse the diabetes.38Gilis-Januszewska A. Szurkowska M. Szybinski K. Glab G. Szybinski Z. Spodaryk K. et al.The efficacy of non-pharmacological intervention in obese patients with newly diagnosed diabetes mellitus type II.Pol Arch Med Wewn. 2001; 106: 853-860PubMed Google Scholar, 39Tuomilehto J. Lindstrom J. Eriksson J.G. Valle T.T. Hamalainen H. Ilanne-Parikka P. et al.Finnish Diabetes Prevention Study Group. Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance.N Engl J Med. 2001; 3: 1343-1350Crossref Scopus (8025) Google Scholar In the Finnish Diabetes Prevention Study (FDPS), 522 middle-aged, overweight subjects with impaired glucose tolerance were randomly assigned to either the intervention group or the control group. Each subject in the intervention group received individualized counselling aimed at reducing weight, total intake of fat, and intake of saturated fat and increasing intake of fibre and physical activity.39Tuomilehto J. Lindstrom J. Eriksson J.G. Valle T.T. Hamalainen H. Ilanne-Parikka P. et al.Finnish Diabetes Prevention Study Group. Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance.N Engl J Med. 2001; 3: 1343-1350Crossref Scopus (8025) Google Scholar The cumulative incidence of diabetes after four years was 11% (95% CI 6%–15%) in the intervention group and 23% (17%–29%) in the control group, a 58% risk reduction in the intervention group (P<0.001). After a median of 4 years of active intervention period, participants who were still free of diabetes were further followed up for a median of 3 years, with median total follow-up of 7 years. Beneficial lifestyle changes achieved in the intervention group were maintained after the discontinuation of the intervention, and the corresponding incidence rates of diabetes during the post-intervention follow-up were 4.6 and 7.2 (p=0.0401), indicating 36% reduction in relative risk.40Lindstrom J. Ilanne-Parikka P. Peltonen M. Aunola S. Eriksson J.G. Hemio K. et al.Finnish Diabetes Prevention Study Group. Sustained reduction in the incidence of type 2 diabetes by lifestyle intervention: follow-up of the Finnish Diabetes Prevention Study.Lancet. 2006; 11: 1673-1679Abstract Full Text Full Text PDF Scopus (1275) Google Sch" @default.
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• W2110361452 title "Diabetes Care for Patients with Peripheral Arterial Disease" @default.
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• W2110361452 doi "https://doi.org/10.1016/j.ejvs.2007.01.012" @default.
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