Early Detection and Prevention: Screening Is Key for Diabetes: One of the main points emphasized in the new guidelines is the importance of screening for undiagnosed diabetes, Dr. Ryden said. Considerable improvement has been made in the treatment of cardiovascular disease "but the diabetic patient has not improved to the same extent. Cardiologists don't understand the metabolic treatment of CHD [coronary heart disease] and they need to gain skills in treating this part of the condition," he added.
Estimates suggest that 195 million people around the world have diabetes, and this will increase up to 330 or perhaps even 500 million by 2050. Up to 50% of all patients with type 2 diabetes remain undiagnosed for many years because they have no symptoms. "We want to alert people to the concept of pre-diabetes," Dr. Ryden notes.

The recommendations suggest that patients with coronary artery disease should have an oral glucose tolerance test if their diabetic status is unknown. "Diabetes or prediabetes is painless and remains undetected if not looked for," he adds. "Certain people are at higher risk than others (family history, overweight, previous gestational diabetes to mention a few). Thus we need to screen for elevated glucose (prediabetes) and prevent the progress at an early stage." This point is emphasized and the methods for screening are outlined in the guidelines, he notes.

"Diabetic patients, for various reasons, still do not receive optimal management when they have various cardiovascular disease manifestations," Dr. Ryden adds, noting that there is a lot of information on optimized management in the new guidelines.
"The treatment targets are much more precise and strict than previously outlined (lower blood pressure target and lower blood lipid targets for example)," and strict glucose control is stressed to protect patients from falling ill, or to prevent relapses.
The recommendations also advise that every patient with diabetes should be screened for CAD, Dr. Ryden notes, adding that diabetes specialists do not understand coronary heart disease.

The other co-chair of the task force Eberhard Standl, MD, of the Munich Schwabing Hospital in Munich, Germany, said, "We are dealing with two sides of the same coin: diabetes on one side and cardiovascular diseases on the other. The great merit of these guidelines is that they recognize this. We hope they will improve the management and care of millions of patients who have both cardiovascular and metabolic diseases in common."

Practice Pearls
· Diabetes should be treated to certain targets, including a glycated hemoglobin level of 6.5% or below, a blood pressure of 130/80 mm Hg or lower, and a low-density lipoprotein cholesterol level of approximately 70 mg/dL or lower in the presence of concomitant cardiovascular disease. Diabetic patients with atrial fibrillation should receive warfarin with a target international normalized ratio of 2 to 3.

· Treatment of coronary heart disease is generally similar among patients with and without diabetes. Both groups of patients may benefit from similar doses of aspirin and beta-blockers. Clopidogrel and angiotensin-converting enzyme inhibitors can augment protection against further cardiovascular events among diabetic with coronary heart disease.
Eur Heart J. 2007;28:88-136.

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