tend to be localized distally; unstable plaques are frequent.
The most frequent complications of myocardial infarction in diabetes mellitus are left ventricular dysfunction, congestive heart failure, cardiogenic shock, arrhythmias, and sudden death [311–313]. Silent infarction is frequent and seems to be more closely related to the severity of the coronary artery disease than to cardiac autonomic neuropathy [314–316].
The prognosis depends on age, acute metabolic control, and duration of diabetes [317–319]. Early and late mortality is increased 1.5- to 2.5-fold in men and four-fold in women [29,320]. Recently one-year mortality was reduced by infusion of glucose with insulin and potassium [321]. The benefit of thrombolytic therapy is debated [322,323]. A considerable reduction of late mortality has been achieved by surgical therapy [324]. The indication for interventional therapy of myocardial infarction in diabetes is the same as in the general population. In most studies the early mortality associated with percutaneous transluminal coronary angioplasty, stent implantation, and coronary bypass surgery was no higher than in nondiabetic subjects, but long-term survival is still lower [325–330].
In addition to coronary artery disease, diabetic subjects may have cardiac problems even when the coronary arteries are intact. They have been attributed to diabetic cardiomyopathy and microvascular dysfunction characterized by reduced coronary flow reserve [331,332].
Prevention
Since diabetes mellitus has taken on epidemic dimensions, with an incidence that continues to rise, prevention is indispensable if we are to gain control of this disease. In the etiology of both types of diabetes, genes and environmental factors complement one another. Genes will most likely not become the target of preventive measures in the foreseeable future. However, environmental factors could offer the chance for successful intervention.
At present we do not know the environmental factors involved in the pathogenesis of type 1 diabetes mellitus. Ongoing prevention studies are aiming at the elimination of potential triggers of the autoimmune process and intervention studies at the level of the insulitis, or the basic mechanisms of autoimmunity [43,333,334]. The results remain to be seen.
In type 2 diabetes mellitus the determination factors are known (Table 1.6). Only early detection and treatment of the metabolic syndrome will reverse the epidemic trend of type 2 diabetes and its major complications. Among the factors that can be influenced, adverse life style, obesity, and physical inactivity are highly significant [53–56,335–338]. Their correction is the best prevention and causal treatment of type 2 diabetes mellitus.
Societies with increasing prevalence of type 2 diabetes seem to be characterized by a Western life style that includes little physical activity and in which overeating is common. Therefore, prevention of type 2 diabetes should start with population-wide awareness campaigns and counseling about a healthy life style. The management of “civilization-dependent” diseases is not just a medical problem but also a cultural one. The particular situations in different geographic regions must be taken into account. Voluntarily changing a life style which people have found comfortable and pleasant is a life-long task. It is not enough to face people with rational arguments. They need to be offered emotional rewards as well. The ideal would be to make healthy life style fashionable [339].
Various strategies have been proposed in the past [340]. Holistic approaches have been the most promising [337,338].They have proved to be effective under study conditions, but the epidemic trend has not yet been reversed. One reason for the failure may be that intervention is usually targeted at adults, whereas a life style is often shaped in childhood and prevention should be started at that age.
Treatment
Treatment Aims
The primary goals of treatment are identical for all types of diabetes mellitus (Table 1.15).
The impact of diabetes both on the affected subjects and their families and on the health services is important. Mortality is increased. Although recent studies have shown that the prognosis can be improved, it appears to be difficult to replicate the study experiences in the diabetic population in general. For economic reasons this will be impossible in developing regions of the world.
Quality of life is decreased. Reduced life expectancy and the risk of disabling complications frighten many diabetic people, even though their fear may remain unconscious. It is a strain for many diabetic people tointegrate regular self-management into their daily lives. It is burdensome to have to abstain from certain social activities and pleasures, to accept the limitation of fitness and working capacity, and to realize that society tends to consider people with diabetes less reliable and fit for use. Being diabetic may also impair one's chances of employment, and the cost of health insurance may be higher than normal. Psychological problems, both obvious and hidden, and social discrimination are important causes of reduced quality of life.
Table 1.15 Primary goals of diabetes management
| Relief of symptoms |
|---|
| Improvement of quality of life |
| Prevention of acute and chronic complications |
| Reduction of mortality |
| Treatment of accompanying disorders |
| Prevention of discrimination |
| Prevention of psychological, social and economic problems |
Chronic complications of diabetes are a major burden. This is evident in respect of loss of vision, renal failure, or diabetic neuropathies
