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INTRODUCTION
The prevention and adequate treatment of the
risk factors (RF) predictive for mortality in diabetes
mellitus (DM) through lifestyle changes (medical
education, daily physical activity, smoking cessation,
an appropriate diet), an improved glycemic control
checking, blood pressure (BP) and dyslipidemia
treatment contribute to the decrease of morbidity and
cardiovascular mortality.
1
ABSTRACT
REZUMAT
PREDICTIVE MORTALITY RISK FACTORS IN DIABETES
MELLITUS
Corina Marcela Hogea
1
, Viorel Serban
2
, Mihaela Rosu
2
, Romulus Timar
2
The principal cause of death in patients with diabetes mellitus (DM) is cardiovascular as these subjects display a plurality of risk factors (RF). Even after
adjustment for the other RF, diabetics are left with an excess of risk for CVD of 75-90%., thus suggesting that DM is an independent RF for cardiovascular
diseases (CVD). Cardiovascular risk determined by the classical RF is enhanced by DM, and this has an additional effect on mortality. The failure to obtain
a proper glycemic control, added to the other RF, has lead to the impossibility of reducing cardiovascular morbidity and mortality in diabetes patients, as
numerous studies show. Very often, the increased risk of atherosclerosis is held responsable for the high mortality in diabetes patients, though solely the
existence of the atheroma plaque is not suffcient, the process being much more complex, contributing to the appearance of acute cardiovascular events
like an instable angina and myocardial infarction. The prevention and adequate treatment of the risk factors predictive for mortality in DM, through lifestyle
changes, an improved glycemic control, normalization of blood pressure and lipid levels contribute to a decreased cardiovascular morbidity and mortality
in this group of patients.
Key Words: diabetes mellitus, cardiovascular risk factors, mortality, atherosclerosis
Principala cauz de deces la pacienii cu diabet zaharat (DZ) este de natur cardiovascular, acetia prezentnd un conglomerat de factori de risc (FR).
Chiar dup ajustarea pentru ceilali FR, diabeticii rmn cu un exces de risc pentru BCV de 75-90%., ceea ce sugereaz c DZ este un FR cardiovascular
independent. Riscul cardiovascular indus de FR clasici este accentuat de DZ i aceasta are un efect adiional pe mortalitate. Insuccesul n obinerea unui
control glicemic adecvat, adugat altor FR, face imposibil reducerea morbiditii i mortalitii cardiovasculare la pacienii diabetici, aa cum au artat
numeroase studii. Foarte adesea, riscul crescut de ateroscleroz este incriminat n augmentarea mortalitii la pacienii diabetici, dei simpla existen
a plcii de aterom nu este sufcient, procesul find mult mai complex, contribuind la apariia evenimentelor cardiovasculare acute, cum ar f angina
instabil i infarctul miocardic. Prevenia i tratamentul adecvat al factorilor de risc predictivi pentru mortalitatea n DZ, prin modifcarea stilului de via,
ameliorarea controlului glicemic, normalizarea tensiunii arteriale i a lipidelor serice contribuie la reducerea morbiditii i mortalitii cardiovasculare la
aceti pacieni.
Cuvinte cheie: diabet zaharat, factori de risc cardiovascular, mortalitate, ateroscleroz
Received for publication: Mar. 14, 2012. Revised: May 29, 2012.
1
Diabetes Clinic, Clinical Emergency County Hospital, Timisoara,
2
Department of Diabetology and Metabolic Disease, Victor Babes
University of Medicine and Pharmacy, Timisoara
Correspondence to:
Dr. Corina Marcela Hogea, Diabetes Clinic, Clinical Emergency County
Hospital, 10 Iosif Bulbuca Blvd, Timisoara, Tel. +40-749-276215.
Email: [email protected]
The principal cause of death in patients with DM
is of cardiovascular nature, studies indicating as major
factors for cardiovascular disease (CVD) smoking, high
blood pressure and dyslipidemia. Cardiovascular risk
(CVR) induced by these RF is enhanced in DM, and
this has an additional effect on mortality. The failure
of obtaining a proper control, over RF, has lead to the
impossibility of reducing morbidity and cardiovascular
mortality in diabetes patients, as numerous studies
show.
2,3
Very often, the increased risk of atherosclerosis
(ATS) is considered the major culprit for the high
risk of mortality in DM patients, though only the
existence of the atheroma plaque is not suffcient, the
process being much more complex, contributing to
the appearance of acute cardiovascular events such as
unstable angina and myocardial infarction (MI).
Persons suffering from DM show a plurality of
RF, the excess of adjusted risk being greater, compared
to that of nondiabetics, what suggests that DM is an
independent RF for CVD.
4,5
Even after adjustment
REVIEW ARTICLES
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Corina Marcela Hogea et al 31
to the other RF, diabetics are left with an excess of
risk for CVD of 75-90%.6 Not all cardiovascular
RF (smoking, arterial hypertension, increased total
cholesterol, low HDLc) are also predictive factors of
mortality, a statement which is also upheld by a Finnish
study, conducted in elderly persons with DM as well as
by the Verona study.
7,8
Predictive RF of mortality in patients suffering
from DM are classical or specifc.
9
(Table 1)
Table 1. Risk factors that predict mortality in DM.
9

CLASSICAL RF
Age greater than 45 in men and above 55 in
women is the most important predictive mortality;
moreover the risk is much higher between 65 and
74 years.
10
After menopause the CV mortality is
higher, thus suggesting the protective part played by
the female sexual hormones in the development of
ATS.
1
Dyslipidemia
The UKPDS has established the RF involved
in the appearance of CVD: high LDL cholesterol
(LDLc); a high total cholesterol (TC), a low HDL
cholesterol (HDLc), high blood glucose values, arterial
hypertension and smoking. The lipid profle of a
diabetic person is described as follows:
11,12
- The TC concentrations similar to that of non
diabetics, but having a different HDLc composition,
with a lower concentration of the big antiatherogenic
particles;
- An important factor in the appearance of ATS,
a marker of CVR, is the high level of cholesterol,
especially of that which is part of the lipoproteins
with low density (LDLc);
- The value of over 60 mg/dl of HDLc is a
protecting factor against ATS, its low value being an
important cardiovascular RF in DM;
- High concentrations of tryglicerides; their role in
the appearance of ATS is debatable, they are present in
the composition of lipoproteins with very low density
(VLDL) which supply very aterogene remnants. There
are also opinions supporting the role of TG as a
marker for ATS.
In patients who have suffered a MI, the TC
values, as well as those of LDLc, are RF for recurrent
coronary events.
13
The frst intention of the treatment of dyslipidemia,
in all patients with DM and CVD, are statins because
they reduce TC and LDLc, and increase HDLc. The
Scandinavian Simvastatin Survival Study (4S) and
Cholesterol and Recurrent Events Study (CARE) show
that, in diabetics, the benefts of statines are similar, or
even greater than in non diabetics.
14,15
The mortality in
diabetic patients was 43% lower compared with 29%,
in the case of non diabetics (4S).
14

In the CARE study, the treatment with pravastatine
has resulted into a 24% reduction of coronary
heart disease and non fatal MI.
15
After adopting an
appropriate diet, at a TC value of 5.2 mmol/l, a statin
will be chosen; if the rising of TG continues, fbrates
will be preferred; the simultaneous rising of both TC
and TG, needs an association of statin and fbrate.
Large clinical studies uphold that, the administration
of statines, in case of a TC smaller than 6.2 mmol/l,
has no benefts on the consecutive CV events or an
CV mortality.
Watching 35 years the evolution of the RF and
their infuence on CV morbidity and mortality (the
Framingham study), lead to the conclusion that, there
is a greater tendency of LDLc reduction in diabetics,
as compared to nondiabetics, as a consequence of
the growing number of treated patients, though the
percentage of those who have achieved the targeted
objectives was very low (the same results are revealed
also in former studies, e.g NHANES).
16
Arterial hypertension is a RF for CVD, the rise
of the risk is connected to the increase of the BP
values; the mortality and stroke in DM patients falls, if
BP values are controlled.
1,17
When patients with CVD
suffered an MI, the presence of a arterial hypertension
represents a major RF for the appearance of other
consecutive CV events.
18
According to ADA, the BP treatment target
in DM patients is 130/80 mm Hg, and even lower
in patients with altered kidney function.
19,20
Many
studies indicate, as frst choice, ACE inhibitors, very
benefcial in patients with DM, both because of their
neutral metabolic effect (no effect on carbohydrate
and lipid metabolism), and because of their CV
benefts: an effcient lowering of BP, reduce the risk
of the appearance and development of microvascular
complications in diabetics, and promote a higher
survival period in patients with CVD.
21-23
At the
same time, ACE inhibitors hinder the development
and progression of renal excretion of abumine, thus
contributing to reducing CVR.

0IassIcaI 8ecIfIc fer 0.M.

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Obesity is a RF for DM and a vast array of cancers
and it is associated with a reduced life expectation.
Obesity, especially the abdominal one form, is an
important RF for DM, strongly connected to the other
cardiovascular RF (hypertension, dyslipidemia).
1
The
relationship between the body mass index (BMI) and
mortality is represented by a curve, with the lowest
mortality at a BMI under 25 kg/m
2
; the risk rises
with a BMI over 25 kg/m
2
and, over 30 kg/m
2
the
curve becomes very steep.
25
The lowering of the BMI
leads to a better glycaemic control, also a better BP
an associate dyslipidemia, thus resulting into a reduced
general risk of the diabetic patients.
1
Comparing persons with normal body weigh with
obese persons of the same age and sex, the latter (1
st
degree obesity) have a death rate 2-8 times higher,
those with 2nd degree obesity a rate 4-7 times higher,
while those with 3rd degree a rate of 9 times higher.
In the case of heart failure the link between obesity
and mortality is not yet established as there have been
controversies concerning the beneft of losing weight
in subjects with this condition. Many epidemiologic
studies have shown (among which the Framingham
study), paradoxically, a decrease in survival through the
loss of weight (a similar effect have also correction of
other RF).
24,26
After adjusting to age, sex, IMC, smoking and
other RF, the mortality rate was higher at patients who
have lost weight (with 44% in the case of men and
with 38% in women), irrespective their initial weight,
probably due to the fact that the loss of weight was
unintentional.
24
The situation is changed when the
loss of weight is intentional, the data obtained by the
American Cancer Society Prevention Study I pointing
to a 25% cut of the CV mortality and a 28% of the
CVD.
27
In the case of type 2 DM, the intentional loss
of weight determines a lower rate of mortality, by
reducing BP values, improving the lipid metabolism,
and decreasing the circulant insulin level, all of them
leading to a reduced risk of CVD and cancer, and to
lower levels of estrogen and infammatory cytokines.
Besides we can speak about a direct diminuation of
cancer risk, the improvement of thrombotic profle,
reduction of the oxidative stress and of sleep apnea.
Smoking contributes to the rise of CVR thus
being a RF for all causes of mortality, quitting is one
of the most important and approachable methods for
prevention of ATS.
1,28
It also disturbs the lipid profle,
causing the rise of CT and VLDL, the decreased
of HDLc and, the alteration of the sensitivity to
insulin.
29
In patients with DM, smoking (through a yet
unknown mechanism) worsens the glycemic control;
the risk of micro and macrovascular complications
grows; in patients with type 1 DM, smoking rise
urinary albumin excretion (after banning smoking,
the albumin level is that of nonsmokers, also through
the improvement of the glycemic control), as well as
the risk of nonproliferative diabetic retinopathy; the
risk of diabetic neuropathy grows, a persistent effect
also after giving up smoking; it hastens the risk of
progression towards end stage diabetic renal disease;
with patients on dyalisis, the persistence in smoking
reduces the survival period.
30-34
The mortality combined by associating smoking
and DM is much greater than their sum or even
multiplied.
35,36
. The mortality risk of smoking is equal
or even greater than that produced by DM. A new
concept, called the equivalent in glucose of smoking
is under discussion now, with a view to giving a
prevailing place to stopping this harmful habit, within
the clinical management of DM.
35
In a multinational WHO study, the authors
evaluated the reduction of the death risk of any kind,
dependind on the period which has elapsed since
smoking was stopped: the highest risk was observed
in long-term smokers (1.7 RR), then in those who had
recently abandoned smoking (1. 5RR), compared with
those who had abandoned smoking 10 years before
(1.2 RR), and with the non-smokers (1 RR).
35
Changing life-style through a large consumption
of fruits and vegetables, avoidance of alcohol excess,
doing physical activities at the tolerated level (walking,
jogging, swimming, cyclism) are essential means to
reduce mortality.
CVR is higher in person who have, in their family
history, frst degree relatives who have been diagnosed
with precocious CD, men earlier than 55 of age,
women than 65.
1

DIABETES MELLITUS SPECIFIC RISK
FACTORS
The duration of DM
The improvement of the glycemic control
(evaluated by the value of HbA1c, fasting and
postprandial glycemia), has reduced the risk of
appearance of microvascular complications.
17
Milestone studies performed on patients with type
1 DM (DCCT) and type 2 DM (UKPDS) have
proved the benefcial effect of bettering the glycemic
control, on microvascular complications (retinopathy,
nephropathy, neuropathy).
17,36-39
On the other hand,
the worsening of the glycemic control, not only
determines a higher risk of complications, but it
also amplifes the effect of other RF, such as DM
duration and microalbuminuria.
7,40
Some studies have
_____________________________
Corina Marcela Hogea et al 33
pointed out the growing importance of postprandial
glycemia, as opposed to the fasting blood glucose, as a
cardiovascular RF, and its role in the growing number
of CV events.
41
Many epidemiological studies have tried to
establish a glycemic threshold for the increased CVR,
showing that the risk of macrovascular complications
progresses with the glycemic values, even within
limits, which are under the values which justify a DM
diagnosis. Though the improvement of the glycemic
control has reduced atherothrombosis and CV events,
the above mentioned studies have not proved a
signifcant impact on the CV complications. DCCT
has confrmed the very important part the glycemic
control plays in reducing major CV events,and
UKPDS asserts the improvement of the outcome of
type 2 DM patients, by reducing complications and
CV accidents.
17,39
In Stockholm Diabetes Intervention
Studies, an intense glycemic control has reduced the
thickness of the intima of the carotid artery, a marker
of arteriosclerosis risk.
42
There are also contradictory
data which show that the improvement of glycemic
control does not infuence CV mortality and
morbidity.
43,44
In the time interval between the biological and the
clinical DM onset, the mortality in future patients is
higher, compared to the mortality in already diagnosed
patients, treated for DM.
45
If we do not take into
consideration the benefcial infuence of the applied
treatment on the reduction of the mortality risk, the
duration of DM is a RF, which raises this risk.
45
The
Wisconsin study has shown that, irrespective of the
patientage, the risk of death, especially of CV cause,
is correlated to the HbA1c increase.
46
It has been
established that, on a long-term basis, the degree of
metabolic control expressed by the variation coeffcient
of the fasting glycemia (CV=DS/averagex1000) is
correlated much better with mortality than the average
of the fasting glycemia.
47
The antidiabetic treatment is a marker of the
disease and of the mortality risk, many studies trying
to correlate the type of treatment and this risk. It
seems that patients who have been treated by diet, have
a lower mortality rate, as compared to those on oral
antidiabetic drugs.
45,47,48
An appropriate diet implies
the consumption of the large quantities of vegetables
and fruits, mono- and polinesaturated fats, which
provide vitamins, minerals and biofavonides and
reduce the ingestion of saturated and transnesaturated
lipids, which raise the ATS risk. At the same time,
sedentarism must be avoided (a factor favoring CVD)
through moderate physical effort.
UKPDS has shown that metformin has
considerably reduced mortality caused by MI,49 by
lowering the insulin-resistance, improving associated
RF (atherothrombosis risk profle, BP) and, by its
effect on excessive body weight.
50
A subject long discussed, and still controversed,
is the role of insulin in promoting atherogenesis,
some epidemiologic data showing the existence of
a link between the plasma level of insulin and CD
in nondiabetic, a hypothesis which has not been
confrmed in diabetics.
51-53
At the same time, some
studies have found a higher mortality in those treated
on insulin, but its increase was not parallel to the dose
of insulin (consequently, the relationship cause-effect
could not have been proved).
10,54
The predictive RF of atherogenesis and, implicitly,
of CVR are: the infammation markers (reactive C
protein and fbrinogen) which in high concentrations
are s associated with a risk of CVR (proved by
clinical studies); a high Lp(a) with atherogenic role;
hyerhomocisteinemia, a marker with a low predictive
value and incompletely evaluated; the markers of
the fbrinolitic function (PAI-1); insulin-resistance;
microalbuminuria, a marker of generalized endothelial
disfunction, continual, an independent RF of ATS,
causing a 2-4 times increase of CV and general mortality;
the emotional stress, which produces a growth in the
oxygen consumption of the myocardis, by stimulating
SNS, contributes to the triggering of acute vascular
events; toxic factors- high intake of ethanol enhances
the risk of CV mortality; the atmospheric pollution,
through the particles resulting from burning, has
direct toxic and proinfammatory effect, leading to a
rise of CVR; the sleep apnea syndrome, leads to type
2 DM, hypertension, acute MI and stroke; diabetic
retinopathy, associated with coronary subclinical
pathology.
55-58
Its presence in patients with type 2 DM
raises the risk of CVD, independent of other RF,
supporting the role of the microvascular disease in the
CVD pathogenesis in diabetics.
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