Therapy insight: heart disease and the insulin-resistant patient

Insulin-resistance syndromes are of pandemic proportions; 150 million people worldwide and an estimated 43 million people in the US are currently affected by type 2 diabetes mellitus or metabolic syndrome respectively. Treatment of heart disease in the context of type 2 diabetes requires multifactorial risk-factor management, including lifestyle modification and drug treatment for comorbidities. Management of coronary risk extends beyond simple cholesterol lowering. Early use of cardiac imaging and, where appropriate, revascularization should be considered in high-risk or symptomatic patients. Traditionally, patients with type 2 diabetes and coronary arterial disease have been treated surgically, but percutaneous revascularization of these patients is increasingly common. Indeed, revascularization by use of drug-eluting coronary stents combined with administration of novel antiplatelet agents has revolutionized percutaneous coronary intervention in patients with type 2 diabetes. Despite these advances, there is no consensus of opinion regarding revascularization strategies or risk-factor management in insulin-resistant patients with symptomatic or prognostically important coronary arterial disease. Furthermore, specific therapies and preventative strategies for diabetic cardiomyopathy and heart failure in patients with type 2 diabetes remain elusive. The identification of optimized approaches for the prevention and treatment of the metabolic syndrome and heart disease in insulin-resistant, nondiabetic patients remains a major global challenge.