Complications
Autonomic dysfunction occurs in 40% to 50% of patients with diabetes.[19] This may result in sympathovagal imbalance, which lowers the threshold for life-threatening arrhythmias.[19] Patients who have diabetes and AF have a substantially increased risk of all-cause mortality, cardiovascular (CV) mortality, stroke, kidney disease, and heart failure.[6]
Patients with arrhythmias should be monitored and referred for appropriate treatment. Opportunistic screening for AF, by pulse taking or ECG, is recommended in European guidelines for all patients with diabetes ages under 65 years; systematic screening should be considered for those ages 75 years and over or at high stroke risk.[6]
When indicated by risk stratification (e.g., CHA₂DS₂-VASc score), long-term oral anticoagulant therapy is used in patients with AF for reduction of ischemic stroke and other ischemic events. A bleeding risk score should also be used to identify and address potential bleeding risk factors, for example, concomitant use of antiplatelet agents.[6]
Joint American Heart Association and American College of Cardiology guidelines recommend that all patients with history or physical exam findings suggestive of peripheral arterial disease (PAD) should have a resting ankle-brachial index (ABI), with or without ankle pulse volume recordings and/or Doppler waveforms.[28] Screening with resting ABI is also considered reasonable in patients with any of the following characteristics: age ≥65 years or older; age 50 to 64 years with risk factors for atherosclerosis (e.g., diabetes, smoking history, dyslipidemia, hypertension), chronic kidney disease (CKD), or family history of PAD; age <50 years with diabetes and one additional risk factor for atherosclerosis; patients with known atherosclerotic disease in another vascular bed (e.g., coronary, carotid, subclavian, renal, mesenteric artery stenosis, or abdominal aortic aneurysm).[28] The American Diabetes Association recommends screening for PAD using ABI in asymptomatic people with any of the following characteristics: age ≥50 years; diabetes with duration ≥10 years; comorbid microvascular disease; clinical evidence of foot complications; or any end-organ damage from diabetes.[29] ABI results: 1.0 to 1.4 is normal; 0.91 to 0.99 is borderline; ≤0.9 is abnormal.
Diabetes is associated with an increased risk of dementia. Etiologic factors include vascular factors (cerebrovascular disease, cardiovascular risk factors, atherosclerosis, and peripheral arterial disease) and nonvascular factors (hyperglycemia leading to excess formation of advanced glycated end-products, disturbed neuronal signaling leading to cerebral amyloidosis).[415]
The prevalence of depressive disorders is twice as high in patients with diabetes compared with those without diabetes. Depression is also common in patients with coronary disease, particularly after acute infarction. It is associated with worse health behaviors and possibly worse cardiovascular outcomes.[416]
Evidence on the cardiac effects of depression treatment is limited, but it is reasonable to screen patients and treat as indicated.[320][321][417]
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