CLINICAL
DIABETES These pages are best viewed with Netscape version 3.0 or higher or Internet Explorer version 3.0 or higher. When viewed with other browsers, some characters or attributes may not be rendered correctly. E d i t o r i a l The Complication Most Often OverIooked! Alan J. Garber, MD, PhD, Editor Of the 16 million Americans with diabetes mellitus, whether diagnosed or undiagnosed, the majority are women. Most physicians see no difference between the sexes in the microvascular complications of diabetes, such as retinopathy and nephropathy, unless of course there are differences with regard to concomitant risk factors, such as hypertension and cigarette smoking. However, physician perceptions regarding atherosclerosis are clearly a different matter. Atherosclerosis can be accurately described as the end stage of type I and type II diabetes, since the vast majority of diabetes patients will die from an atherosclerotic event. Most commonly, these events are cardiovascular in nature, although 2-25% of atherosclerotic events may be cerebrovascular or peripheralvascular. Most physicians are aware that men have approximately a threefold greater risk of coronary mortality than do women of equal age. Furthermore, it is generally accepted that diabetes increases coronary mortality by at least twofold in men with diabetes compared with those without diabetes. Since women, particularly pre-menopausal women, are generally regarded as having a low incidence rate of ischemic heart disease, the recognition that diabetes produces a greater increase in coronary event rates in women than it does in men is not commonly perceived. Indeed, women with diabetes completely lose the cardioprotection of being female and have coronary mortality rates equal to those seen in men with diabetes. These observations are equally true in women with type I or type II disease. In addition to these mortality data, morbidity data also support the concept that the cardiovascular system of women is differentially more adversely affected by diabetes than the cardiovascular system of men. For example, the incidence of congestive heart failure is approximately tenfold greater in women with diabetes than in those without diabetes. This contrasts to a sixfold increase in congestive heart failure for men with diabetes compared with men without diabetes. Further complicating the problematic nature of diabetes with regard to atherosclerosis in women is the fact that ischemic symptomatology is often atypical or even silent in patients with longstanding diabetes, perhaps in association with the presence of cardiovascular autonomic neuropathy. As much as 27% of all patients with active ischemia may have uncharacteristic and atypical symptomatology or no symptomatology whatsoever. Because most physicians do not aggressively screen women for the presence of coronary disease, particularly in asymptomatic or atypically symptomatic women, a heightened state of sensitivity often referred to as "an increased index of suspicion" must be maintained in all physicians caring for women with diabetes. Compared to other risk factors for ischemic heart disease, diabetes may be the most potent in terms of its impact, especially in pre-menopausal women. Such issues are often overlooked in the current debate over which categories of physicians and physician specialists can serve as primary care physicians for women. It seems clear that any group that undertakes primary care for women with diabetes must be skilled and knowledgeable in the assessment of atherosclerosis, particularly when its presentation is silent or atypical. Intermittent, infrequent consultation with experts may be grossly inadequate in detecting the appearance of highly atypical or subtle symptomatology suggestive of coronary disease. In patients with reduced exercise potential, as is often the case with obese patients with type II diabetes, knowledge about the specificity and accuracy of noninvasive testing for coronary disease can also be a rare commodity. Thus, continuing in-depth education about diagnosing and managing atherosclerosis is essential for any physician seeking to undertake the primary care of women with diabetes. Copyright © 1997 American Diabetes Association Last updated: 6/3/97 For Technical Issues
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