Materia Medica Malaysiana

Health: Beware the deadly link

PEOPLE who have diabetes are two to four times more likely to suffer from cardiovascular disease, be it heart attack or stroke.

The risk of heart failure for them is two to three times greater than for non-diabetic people, while stroke occurs twice as often in people with diabetes and high blood pressure, compared with those who only have high blood pressure.

Professor S.P. Chan, president of Malaysia Diabetes Association, says that many people tend to be unaware of the link between diabetes and cardiovascular diseases. For diabetics, this lack of awareness can be dangerous.

“People are generally more worried about their heart, but do not realise that a heart attack or stroke is highly predisposed to those with diabetes,” says Chan, an endocrinologist and diabetologist at Universiti Malaya Medical Centre who has more than 20 years’ experience in the field.

“Therefore, if one is a diabetic, one should also be treated for cardiovascular diseases.”

Chan says the Collaborative Atorvastatin Diabetes Study (CARDS), which was presented recently at the annual meeting of the American Diabetes Association, plays an important role in reducing the risk and burden of diabetes and cardiovascular-related deaths.

CARDS, the largest endeavour specifically designed to study the effects of statin (a cholesterol-fighting drug) in diabetes patients, ended almost two years earlier than expected due to the emergence of significant findings.

Through the study, more than 2,800 people with Type 2 diabetes, no history of heart disease and relatively low levels of cholesterol, were found to have notable reduction in heart attacks and strokes after being treated with atorvastatin 10mg, a cholesterol-lowering medication. Patients treated with this drug had a 37 per cent reduction in major cardiovascular diseases, which included heart attacks, strokes and cardiac resuscitation, among others.

CARDS, which was initiated in Britain and Ireland, is a collaboration between Pfizer, University College London, Diabetes United Kingdom and the British Department of Health. This second landmark atorvastatin study ended early due to a significant cardiovascular benefit seen in patients.

Type 2 growing at epidemic rate

Says Chan: “Type 2 diabetes or non-insulin dependent diabetes is increasing at epidemic proportions worldwide, and an estimated 170 million people worldwide suffer from diabetes, which is a leading risk factor for cardiovascular disease. The majority of people with diabetes, roughly 65 per cent, will suffer a heart attack or stroke, a rate that is up to four times higher than adults without diabetes.”

Of the estimated 1.2 million diabetic cases in Malaysia, 98 per cent have Type 2 or non-insulin-dependent diabetes, a situation where the body is unable to make enough or properly utilise insulin.

“To make it worse, most diabetics were not aware that they had the disease, as half of them do not show any classical symptoms of diabetes. It comes as a big shock to them to learn that they have diabetes,” says Chan.

“Cardiovascular complications also occur at an earlier age in people with diabetes. More than half of all the diabetic patients have high blood pressure or elevated total cholesterol levels, and many have both these conditions.”

The scenario is worsened by the fact that cardiovascular disease is responsible for between 50 and 80 per cent of deaths in people with diabetes. Chan says the majority of the global burden of diabetes is due to an increased risk of cardiovascular risk.

“In 2002, heart disease and related diseases of pulmonary circulation was the second principal cause of death in government hospitals, making up some 15 per cent. The majority of heart patients in Malaysia are in their 40s and 50s, while in other parts of the world, it is 50 and above. We are seeing a trend in Malaysia where younger people are becoming diabetics, and experts are attributing this growth to genetics, obesity and lack of exercise.

“Besides that, 70 to 75 per cent of diabetics die due not to kidney failure or limb amputations, but to a heart attack or stroke. I think the urgency in preventing diabetes and keeping it at bay has not sunk in with the general public. There is no realisation that diabetes and heart attack are connected. Diabetes is one of the main reasons why diabetics develop cardiovascular diseases.”

Chan says that over the years, she has found more cases of younger people becoming diabetics.

“The focus has to be on preventing diabetics from suffering cardiovascular complications. If you have diabetes, do not overlook the risk factors like hypertension and lipid disorder. It is crucial that they be treated aggressively to prevent diabetics from developing malignant complications,” she says.

“The wrong emphasis has resulted in diabetics ignoring the risk factors. They get so worried about wanting to look after their heart that they forget that it is the diabetes that has caused the heart problem. Diabetes is insidious and it can take five to seven years before it surfaces and is detected.”

Lifestyle, says Chan, is an obvious factor that determines the development of diabetes.

“People are more and more sedentary in their lifestyles, and many are underestimating their individual risk in contracting diabetes. Because they do not think they are at risk, they therefore do nothing to prevent diabetes,” says Chan.

“And our achievement-oriented approach to life is not helping. Instead of looking after our health, people are spending long hours at work and children too are no longer going out to play. If this goes on, the greatest worry is that we will see a further increase in Type 2 diabetes, especially among the young.”

Benefits of using statins

National Heart Institute senior consultant cardiologist and Cardiology Department head, Datuk Seri Dr Robaayah Zambahari, said the CARDS data has added to the growing evidence that supports the early and significant benefits of treating patients with statins.

“We now have the option to treat high-risk patients at an earlier stage and hence, better the chances of preventing a heart disease or stroke,” she says.

“The CARDS results have shown that cholesterol-lowering treatment such as atorvastatin is beneficial to patients with diabetes.”

The National Heart Institute had been administering the atorvastatin drug in its heart patients for almost six years now.

“We look at the heart patient’s cholesterol level because different statins have different strengths. Atorvastatin is the most potent of the statins, but not all patients will need it. A patient with a mildly elevated cholesterol level can do with a mild statin but a patient with a high cholesterol level will require the most potent statin and in bigger doses, together with a combination of other medication.

“I believe we should look at the quality of life. We advise patients to cut down on high cholesterol in their food and if they cannot achieve the targeted cholesterol level, then they can use a statin. It is very safe.”