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The mainland is a big country with diabetes, and the number of diabetic patients is huge. It should not be overlooked that cardiovascular disease, especially coronary heart disease, is the main cause of morbidity and mortality in patients with type 2 diabetes. In the face of this severe disease situation, clinicians are paying more and more attention to the treatment and management of patients with diabetes mellitus and coronary heart disease, in order to improve the clinical outcomes and quality of life of patients with type 2 diabetes. This article will focus on the diagnosis, characteristics and drug treatment of patients with diabetes mellitus and coronary heart disease for the benefit of readers.
Diabetes mellitus is a group of metabolic disorders characterized by hyperglycemia due to multiple etiologies and is caused by defects in insulin secretion and/or utilization [1]. As of 2021, the mainland has the highest incidence of diabetes in the world, with a prevalence of 12.8% and 141 million people, equivalent to 1 in 8 people with diabetes [2]. Cardiovascular disease is the leading cause of death and disability in type 2 diabetes, with more than one-third of patients with diabetes comorbiditive cardiovascular disease, and about 75 percent of patients with diabetes ultimately die from cardiovascular disease [3]. Coronary heart disease has the highest proportion of cardiovascular diseases in patients with type 2 diabetes in China [4], and the prognosis of patients with diabetes is worse when cardiovascular disease occurs. In addition, diabetes mellitus combined with coronary heart disease is not simply the sum of the two diseases, and when they coexist, they have a "1+1>2" synergistic effect in increasing cardiovascular events and mortality. Therefore, the coexistence of diabetes and coronary heart disease brings a heavy burden to patients, their families, and even society. The early diagnosis and management of diabetes mellitus complicated with coronary heart disease is very important in clinical practice. So, how should patients with diabetes mellitus and coronary heart disease be managed clinically?
How to diagnose patients with diabetes mellitus and coronary heart disease?
1. Identify typical myocardial ischemia: pain, stuffiness, compression, tightness or shortness of breath located in the precordial area, which may be accompanied by discomfort in the left shoulder and arm; triggers are physical activity or emotional agitation; It is relieved within 1~5 min of rest or nitroglycerin[5].
2. If typical symptoms can be induced by slight exertion, or repeated episodes within a few hours, unstable angina pectoris or acute myocardial infarction may be present, and any stress testing is not recommended, and it is recommended to be transferred to a cardiologist for invasive coronary angiography (CAG) or coronary CT angiography (CCTA) to confirm the diagnosis [5].
3. If the typical symptoms are induced by moderate or higher exertion, it is recommended to have resting electrocardiogram (ECG) and echocardiography (UCG) first, and if UCG excludes left ventricular outflow tract obstruction and severe mitral stenosis, then further ischemic burden test is done to assist in diagnosis [4].
4. If the typical symptoms occur in a resting state, especially in the early hours of the morning, a 12-lead Holter is recommended, and if symptom-related ischemic ST-T dynamic changes are found to diagnose coronary spastic angina, further CAG or CCTA is recommended to determine whether and how much coronary fixed stenosis exists [5].
5. Regular ECG and UCG are recommended for patients with atypical or asymptomatic symptoms but at very high risk of coronary artery disease [5].
What are the characteristics of patients with diabetes mellitus and coronary heart disease?
1. Women are significantly higher than men, and the prognosis is worse
The proportion of women with diabetes mellitus and coronary artery disease is significantly higher than that of men, and the prognosis for women who undergo coronary angioplasty or bare stenting is worse [6].
2. Early occurrence and high risk of cardiovascular events
In general, patients with type 2 diabetes mellitus often have coronary heart disease around the age of 50 [7]; Compared with patients with non-type 2 diabetes, patients with diabetes mellitus and coronary heart disease are at higher risk of hypertension, dyslipidemia, acute myocardial infarction, and heart failure. Clinical studies suggest that type 2 diabetes is associated with a nearly three-fold increase in the risk of death from coronary heart disease and a 1.5-fold increase in the risk of major adverse cardiovascular events (MACE) [8].
3. Coronary artery involvement is extensive and the degree of stenosis is more severe
Compared with the non-diabetic group, the diabetic group had a significantly higher number of three-vessel coronary lesions, complex lesions, and vascular stenosis, and the number of stents implanted was relatively small and long [9].
What are the commonly used drugs for patients with diabetes mellitus and coronary heart disease?
Drug therapy for patients with diabetes mellitus and coronary artery disease includes the following classes of drugs [5,10,11]:
1. Antiplatelet therapy
Patients with chronic coronary syndrome (CCS) are treated with long-term low-dose aspirin, and clopidogrel can be considered for replacement if they cannot be tolerated; Dual antiplatelet therapy (aspirin + clopidogrel/ticagrelor) is recommended for at least 12 months after acute coronary syndrome (ACS) or percutaneous coronary intervention (PCI).
2. Blood lipid management
Moderate-intensity statins are preferred, with low-density lipoprotein cholesterol (LDL-C) < 1.4 mmol/L as the primary goal and non-high-density lipoprotein cholesterol < 2.0 mmol/L as the secondary goal.
3.肾素血管紧张素醛固酮(RAAS)抑制治疗
Angiotensin-converting enzyme inhibitors (ACE inhibitors) or angiotensin II receptor blockers (ARBs) are recommended.
4. Anti-myocardial ischemia therapy
These include drugs such as β blockers, nitrates, calcium antagonists, nicorandil and trimetazidine hydrochloride. Among them, β-blockers can improve both myocardial ischemia symptoms and patient outcomes.
5. Blood sugar management
Including sodium-glucose cotransporter 2 inhibitor (SGLT2i), glucagon-like peptide-1 receptor agonist (GLP-1RA), metformin, insulin sensitizer and other drugs.
6. Traditional Chinese medicine treatment
Traditional Chinese medicine, which is characterized by holistic regulation, has shown many advantages in the treatment of coronary heart disease, and is very useful in patients with diabetes mellitus and coronary heart disease, such as Musk Baoxin pills and other drugs.
Musk Baoxin Pill is a commonly used aromatic Wentong Chinese patent medicine in mainland China, which has the effects of dilating coronary arteries, improving vascular endothelial function, inhibiting inflammation of blood vessel wall, and promoting therapeutic angiogenesis [12], which can improve myocardial ischemia, improve glucose and lipid metabolism, and protect insulin β cell function, making it an ideal drug for the treatment of diabetes mellitus and coronary heart disease [13]. A network meta-study of 45 randomized controlled trials [14] involved 4727 patients with type 2 diabetes mellitus and angina pectoris, including 2431 in the experimental group and 2296 in the control group (conventional treatment group). Seven kinds of oral Chinese patent medicines were included, including 8 articles of compound Danshen Dripping Pill, 8 articles of Musk Baoxin Pill (421 patients in the experimental group and control group), 4 articles of Yixinshu Capsules, 10 articles of Yindan Xinnaotong Soft Capsules, 3 articles of Naoxintong Capsules, 9 articles of Tongxinluo Capsules, and 3 articles of Qishen Yiqi Dripping Pills, aiming to evaluate the efficacy of 7 different oral Chinese patent medicines in the treatment of type 2 diabetes mellitus complicated with coronary heart disease angina. The results showed that compared with conventional treatment with Western medicine alone, Musk Baoxin Pill + conventional treatment with Western medicine could significantly reduce the incidence of adverse cardiovascular events (P<0.05). In addition, the results of a randomized controlled study of 102 patients with diabetes mellitus and coronary heart disease [15] showed that compared with the control group (conventional treatment), the total effective rate of the Musk Baoxin Pill group (Musk Baoxin Pill + conventional treatment) was significantly better than that of the control group (P<0.05), and the number and duration of angina pectoris attacks in the Musk Baoxin Pill group were significantly shorter than those in the control group (P<0.05) (Table 1).
Table 1.Comparison of treatment effect and the number and duration of angina pectoris attacks between the two groups
summary
Diabetes mellitus with coronary heart disease is a common group of patients in clinical practice, and such patients have a higher incidence of cardiovascular events and a worse prognosis, and more comprehensive treatment measures are urgently needed. Traditional Chinese medicine has a long history in the treatment of coronary heart disease and has good application value. Evidence-based medical studies have confirmed that as an effective supplement to the standard treatment of patients with diabetes mellitus and coronary heart disease, Musk Baoxin Pill can significantly reduce the incidence of adverse cardiovascular events, reduce the number and duration of angina pectoris, and can bring more clinical benefits to patients, which is worthy of clinical application.
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