Vascular complications of diabetes

doi:10.1136/bmj.320.7241.1062

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This article has a correction

Please see: ABC of vascular disease: Vascular complications of diabetes

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Richard Donnelly,
Alistair M Emslie-Smith,
Iain D Gardner,
Andrew D Morris

Adults with diabetes have an annual mortality of about 5.4% (double the rate for non-diabetic adults), and their life expectancy is decreased on average by 5-10 years. Although the increased death rate is mainly due to cardiovascular disease, deaths from non-cardiovascular causes are also increased. A diagnosis of diabetes immediately increases the risk of developing various clinical complications that are largely irreversible and due to microvascular or macrovascular disease. Duration of diabetes is an important factor in the pathogenesis of complications, but other risk factors—for example, hypertension, cigarette smoking, and hypercholesterolaemia—interact with diabetes to affect the clinical course of microangiopathy and macroangiopathy.

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Vascular complications of diabetes

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Risk of morbidity associated with all types of diabetes mellitus

Microvascular complications

A continuous relation exists between glycaemic control and the incidence and progression of microvascular complications. Hypertension and smoking also have an adverse effect on microvascular outcomes. In the diabetes control and complications trial—a landmark study in type 1 diabetes—the number of clinically important microvascular endpoints was reduced by 34-76% in patients allocated to intensive insulin (that is, a 10% mean reduction in glycated haemoglobin (Hb_A1c) concentration from 8.0% to 7.2%). However, these patients also had more hypoglycaemic episodes. Similarly, in the UK prospective diabetes study of patients with type 2 diabetes, an intensive glucose control policy that lowered glycated haemoglobin concentrations by an average of 0.9% compared with conventional treatment (median Hb_A1c 7.0% v 7.9%) resulted in a 25% reduction in the overall microvascular complication rate. It was estimated that for every 1% reduction in Hb_A1c concentration there is a 35% reduction in microvascular disease.

Relation between glycaemic control (Hb_A1c) and risk of progression of microvascular complications (retinopathy) and severe hypoglycaemia in patients with type 1 diabetes. Data from the diabetes control and complications trial. Dotted lines represent 95% confidence …