With a few exceptions, the treatment of CHD and stroke is the same for people with diabetes as for the general population. High blood pressure and high cholesterol levels are initially treated with diet and other lifestyle measures in an effort to get these conditions under control without medication.
Many of these lifestyle measures—for example, diet, weight loss, and exercise—are the same as the ones recommended by the American Diabetes Association for everyone with diabetes. Medication is needed when elevated blood pressure or blood cholesterol persists despite making the necessary lifestyle changes.
Blood pressure control
American Diabetes Association guidelines recommend that people with diabetes have their blood pressure checked at every doctor's visit. If your blood pressure is higher than 130/80 mm Hg, you need drug treatment in addition to lifestyle measures. People with diabetes often need two or more blood pressure–lowering drugs to achieve blood pressure control. The guidelines recommend using drugs such as ACE inhibitors, angiotensin II receptor blockers, beta-blockers, diuretics, and calcium channel blockers.
An ACE inhibitor is one of the best drugs for lowering high blood pressure in people with diabetes. These drugs decrease production of angiotensin II, a hormone that increases blood pressure. ACE inhibitors also help to prevent or delay progression of kidney damage (nephropathy). If an ACE inhibitor cannot be used, the best substitute is an angiotensin II receptor blocker. Diuretics can raise blood glucose levels and reduce serum potassium levels, and beta-blockers can reduce the warning symptoms of hypoglycemia, so extra caution is needed with these medications.
If you haven't been taking an ACE inhibitor or a beta-blocker and you have a heart attack, studies show that immediately starting treatment with these drugs can significantly reduce your risk of dying.
If your LDL cholesterol is not at the target of less than 100 mg/dL (or less than 70 mg/dL if you have had a heart attack), the American Diabetes Association recommends treatment with a statin drug. Several large studies have shown a significant reduction in heart attacks and strokes in people with diabetes who took statin drugs to lower their LDL cholesterol. Six statins are available: atorvastatin (Lipitor); fluvastatin (Lescol); lovastatin (Mevacor); pravastatin (Pravachol); rosuvastatin (Crestor); and simvastatin (Zocor).
The American Diabetes Association recommends niacin (nicotinic acid) for people with diabetes who have low levels of HDL cholesterol (less than 40 mg/dL in men or 50 mg/dL in women) and fibrate drugs (Lopid, Lofibra, Tricor) for elevated levels of triglycerides (more than 200 mg/dL). Since niacin can increase blood glucose levels, your doctor will monitor you while you are using the drug.
Other cholesterol-lowering drugs are available, including bile acid sequestrants (Colestid, Questran, Welchol), ezetimibe (Zetia), and a combination of ezetimibe and simvastatin (Vytorin).
Blood clot prevention
Diabetes produces changes in your blood that make it more prone to clotting, which increases your risk of a heart attack and stroke. Taking a daily aspirin tablet can reduce the risk. The American Diabetes Association recommends preventive treatment with aspirin for people with type 1 and type 2 diabetes who have a high risk of cardiovascular disease or who have had a heart attack, stroke, or bypass surgery. The recommended dosage is 75–162 mg a day.
Always talk to your doctor before starting treatment with aspirin. You should not take aspirin if you are allergic to it, are taking anticoagulant drugs like warfarin (Coumadin), or have a bleeding disorder.