Diabetic dyslipidemia
Introduction
The poor cardiovascular prognosis of diabetes is reflected by the findings of a Finnish study [1]. Type 2 diabetic patients without previous myocardial infarction have the same risk of dying from cardiovascular disease within 8 years as non-diabetic patients with prior myocardial infarction.
These Finnish data were confirmed by a recent study in six different populations in different parts of the world [2]. This study also showed that diabetic patients without previous cardiovascular disease and non-diabetic patients with cardiovascular disease have a similar risk of suffering cardiovascular death or a new myocardial infarction (Fig. 1). The direct implication of this finding is that it is essential to prevent initial myocardial infarction in diabetes sufferers, in order to relieve the burden of coronary heart disease.
Section snippets
High prevalence of dyslipidemia
The most significant cardiovascular risk factor in type 2 diabetic patients is dyslipidemia. The key components of diabetic dyslipidemia are elevation of serum VLDL-triglycerides and lowering of HDL-cholesterol. LDL-cholesterol, however, is usually not increased, or only slightly.
In the UKPDS study [3], the initial triglyceride, HDL-cholesterol and LDL-cholesterol levels were not so much different in diabetic and non-diabetic people. A finding such as this may give physicians the wrong
Diabetes-specific increase in CVD risk
The influence of multiple risk factors on cardiovascular mortality was investigated in the MRFIT study [4]. A total cholesterol>5.2 mmol/l, smoking, and a systolic blood pressure above 120 mmHg were regarded as risk factors in this study. Even in diabetic people without any of these risk factors, the cardiovascular death rate was higher than in a non-diabetic cohort without other risk factors. Together with the number of risk factors, the cardiovascular death rate increased in both the diabetic
Small, dense LDL
Diabetic dyslipidemia is a complex cluster of abnormalities. In addition to high LDL-cholesterol and low HDL-cholesterol, the serum triglycerides are elevated, there is excessive postprandial lipemia, a preponderance of small, dense LDL (LDL-phenotype pattern B), and, together with a lowering of HDL-cholesterol, a preponderance of small, dense HDL.
Small, dense LDL is a strong risk factor for cardiovascular disease and is considered to be highly atherogenic. It is also associated with the high
HDL changes
In diabetic dyslipidemia, not only the concentration of HDL-cholesterol is reduced, but also its composition and distribution is changed. The electrophoretic spectrum shows a shift towards smaller HDL-particles and HDL2 is reduced [14]. Changes in HDL in type 2 diabetes are mediated via two pathways: plasma triglyceride elevation, and a reduced ratio between lipoprotein lipase and hepatic lipase. Both lead to a modulation of HDL composition with an enhanced catabolic rate of HDL in circulation.
Conclusion
Altogether, three main lipoprotein particles cause atheroma: small, dense LDL; small, dense HDL; and cholesterol-ester rich remnants resulting from elevation of triglyceride-rich lipoproteins. All these components are elevated in diabetic patients.
In addition, normal lipid concentrations are more atherogenic in diabetic patients than non-diabetic patients due to changes in the composition of lipid particles. This forms the basis for the recommendations that in diabetic patients LDL-cholesterol
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