Coronary Artery Disease and Diabetes.

Diabetes is considered a significant risk factor, unsurprisingly, for coronary artery disease. And if you look at the European guidance for treatment of cholesterol, the cholesterol targets are a lot lower once you have diabetes. So in patients, in young patients who have either type 1 diabetes or type 2 diabetes under the age of 50 who've had it for a short period of time, that alone increases their risk from low risk to moderate risk of having coronary disease. Once you've had diabetes and still don't have target end organ damage, once you've had diabetes for over 10 years, you're then considered at high risk for coronary artery disease. if you have diabetes with evidence of end organ damage, that's albuminuria or nephropathy or peripheral neuropathy, you're considered at very high risk for coronary artery disease. So the treatment targets for cholesterol vary depending on whether you're low risk, moderate risk, high risk, or very high risk. And so, for example, if you're at low risk, the goal for LDL cholesterol alone is under three millimoles per liter. If you're at moderate risk, the goal for LDL cholesterol is under 2.6. If you're at high risk, it's under 1.8. Whereas if you're very high risk, so anyone who's had diabetes for over 10 years, or you have evidence of end organ damage, the target for cholesterol level, LDL cholesterol level is under 1.4 millimoles per liter. So you think if you're low risk, your target is less than three. And if you're very high risk, then your target is under half that value. So diabetes with end organ damage, or sorry, diabetes for longer duration than 20 years, and the treatment target is less than 1.4. So really, when you have diabetes, the onus is on the physician looking after the patient as well as the patient to try and really drive down the cholesterol aggressively, really try and drive it down as hard as you can. And that's, of course, again, with statin therapy. And it's worth, you know, there's no point in starting on a low-dose statin and then just assuming you're on a statin and you're sorted. it's really important to try and make sure you keep to those targets by getting it checked at six months, increasing the dose of statins. Because once you've, let's say you're on a high dose of torvastatin and your cholesterol is still above the target, you can help affect your chances of having coronary disease by driving it down further. Things like adding in ezetimibe will also help lower your cholesterol further. So, and one of the studies that I was talking about earlier was a meta-analysis of almost 19,000 patients. And it showed that in patients with diabetes, statins were able to reduce the LDL cholesterol enough to cause a 9% reduction in all-cause mortality. So not just heart attacks, but all-cause mortality reduction by 9%, and a 21% reduction in incidence of major heart disease per every one millimole per liter that you lower your LDL cholesterol by. So, you know, if you wanted a 9%, almost 10% chance lower of dying, then, you know, take the SAT in it. It's basically as simple as that.