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Diabetes and Heart Disease: The Critical Link

Having diabetes raises risk of stroke and heart attack in a very big way. What you need to know

A drop of blood on a broken heart made of pure white cubes of sugar isolated on blue background.

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En español | What are your chances of having a heart attack or stroke? That was the question adults with type 2 diabetes, age 45 and older, were asked in a 2018 Harris Poll survey about their risk for cardiovascular disease. If you have diabetes, you know all about your chances of going blind from retinopathy; you’re aware of your risk for foot ulcers or amputation due to nerve damage; and you’re usually up to speed on the possibility of being on dialysis as a result of kidney disease. But cardiovascular disease? Clearly a trick question. 

Not so fast. 

“The leading cause of premature death in people with both type 1 and type 2 diabetes is cardiovascular complications,” says Om Ganda, director of the Lipid Clinic at the Joslin Diabetes Center in Boston. “Patients with diabetes are at much higher risk for cardiovascular outcomes than those without diabetes, even at similar levels of risk factors, such as cholesterol, high blood pressure and smoking. This is true for men as well as women with diabetes." 

And yet only about half of those surveyed were aware of their risk for cardiovascular disease, which, as it turns out, is pretty darn big: 

  • Men with diabetes are twice as likely to get cardiovascular disease — meaning heart disease, heart failure, heart attack and stroke — as those who don’t have diabetes. Women are three times as likely.


  • Every 80 seconds, an adult with diabetes is hospitalized for heart disease; every two minutes, an adult with diabetes is hospitalized for stroke.
  • Almost 7 in 10 people with diabetes over age 65 will die from some form of heart disease. About 1 in 6 will die of stroke.


Connecting the dots

Experts have known about the link for a while. In 1979, the seminal Framingham Heart Study provided the first significant clue showing that people with diabetes are more vulnerable to heart disease than people who don’t have diabetes. Over a span of 20 years, researchers followed thousands of men and women — among them, people with diabetes — to see if they could pinpoint the culprits leading to heart disease.

They hit upon a number of risk factors, including high blood pressure, smoking, high cholesterol levels and a family history of early heart disease. They also spotted evidence of a link with type 2 diabetes. The evidence has only mushroomed in the years since. “Diabetes is now considered the highest risk factor for cardiovascular disease — even higher than smoking, cholesterol or high blood pressure,” says Rajesh Kumar Garg, an endocrinologist and director of clinical diabetes at the University of Miami Health System.

Blame glucose levels. High blood glucose damages nerves and blood vessels, making people with diabetes more vulnerable to the long-established risk factors for cardiovascular disease: smoking, high blood pressure, abnormal cholesterol levels and triglycerides. More than 90 percent of people with diabetes have at least one of these additional risk factors.

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“What people need to know is that all these conditions — high blood pressure, high cholesterol and high blood sugar — are really one and the same,” says Joel Zonszein, director of the Clinical Diabetes Center at the University Hospital of Albert Einstein College of Medicine in New York City, and principal investigator of an ongoing National Institutes of Health-sponsored study to find the best way to manage coronary artery disease in people with diabetes. “So when we treat type 2 diabetes, we don’t just treat the blood sugar. We want to make sure the blood pressure, cholesterol and blood sugar are all normal. And we want to do that very early in the disease.”

That includes prediabetes, too. More than 1 in 3 adults in the U.S. have prediabetes, which means their blood glucose is higher than it should be but not high enough to meet the threshold for diabetes. Although they aren’t as vulnerable to heart disease as someone with full-blown diabetes is, they are still at risk. “Many large, long-term follow-up surveys have shown that those with prediabetes have about a 50 percent increased incidence for cardiovascular outcomes, compared with about 200 percent increased incidence in those with diabetes,” Ganda says. “People with prediabetes often have elevated lipids — high cholesterol, high triglycerides, low HDL [good] cholesterol, obesity and high blood pressure — for many years before diabetes may be diagnosed. This is the ideal time to start paying attention to health by improving lifestyle.”

Lower your risk

Whether you have prediabetes or full-blown diabetes, you can’t do anything about some of the major risk factors for cardiovascular disease, such as age (as you get older, your risk of heart disease and heart attack rises) and genetics (if you have a family history of early heart disease, your own risk increases). But there’s plenty you can do to combat the other factors that raise your risk for diabetic heart disease. For instance: 

1. Maintain a healthy weight. Being overweight tends to increase your blood glucose, blood pressure and blood fat levels. Even a modest 10- to 20-pound weight loss can improve your levels.

2. Exercise. Not only is regular physical activity associated with better blood glucose levels, it can also help reduce blood pressure. Aim for at least 30 minutes of moderate-intensity aerobic exercise (a brisk walk, for instance) most days of the week, and at least two strength training sessions per week.

3. Manage stress. Stress and anxiety cause arteries to tighten, raising your blood pressure and your risk of having a heart attack.

4. Don’t smoke. If you have diabetes, you’re already at risk for heart and blood vessel problems. Nicotine only exacerbates the problem by damaging and tightening blood vessels, raising blood pressure and blood glucose, and leading to unhealthy cholesterol levels.

5. Talk to your health care provider. Discuss your specific risk factors for diabetic heart disease to come up with an individualized treatment plan. If you aren’t able to lower your blood pressure and LDL (bad) cholesterol levels through lifestyle changes, your doctor will likely prescribe medication.

Several kinds of drugs treat high blood pressure, though not all of them are equally good for people with diabetes. Some raise blood glucose levels or mask some of the symptoms of low blood glucose (hypoglycemia). And you may need one or more to reach your blood pressure goals. Most people with diabetes are prescribed a statin to reduce LDL cholesterol levels. A number of new classes of drugs for type 2 diabetes also have cardiovascular benefits.

“Diabetes is a complex metabolic disease,” Garg says. Whatever the approach, “it has to be individualized.”