Copyright ©The Author(s) 2021. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Diabetes. Apr 15, 2021; 12(4): 383-406
Published online Apr 15, 2021. doi: 10.4239/wjd.v12.i4.383
Diabetic heart disease: A clinical update
Jake Rajbhandari, Cornelius James Fernandez, Mayuri Agarwal, Beverly Xin Yi Yeap, Joseph M Pappachan
Jake Rajbhandari, College of Medical and Dental Sciences, University of Birmingham Medical School, Birmingham B15 2TH, United Kingdom
Cornelius James Fernandez, Mayuri Agarwal, Department of Endocrinology and Metabolism, Pilgrim Hospital, Boston PE21 9QS, United Kingdom
Beverly Xin Yi Yeap, Department of Medicine, The University of Manchester Medical School, Manchester M13 9PL, United Kingdom
Joseph M Pappachan, Department of Endocrinology and Metabolism, Lancashire Teaching Hospitals NHS Trust, Preston PR2 9HT, United Kingdom
Joseph M Pappachan, Faculty of Science, Manchester Metropolitan University, Manchester M15 6BH, United Kingdom
Joseph M Pappachan, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester M13 9PL, United Kingdom
Author contributions: Rajbhandari J and Fernandez CJ performed majority of the initial drafting, prepared the figures and tables, and share the first authorship of the paper; Agarwal M and Yeap BXY did additional literature search and made critical revisions in the write up; Pappachan JM conceived the idea, made critical revisions and provided final approval of the final version of the manuscript to be published.
Conflict-of-interest statement: Authors have no conflicts of interest in relation to this article.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Corresponding author: Joseph M Pappachan, FRCP, MD, Consultant Physician-Scientist, Honorary Research Fellow, Senior Researcher, Department of Endocrinology and Metabolism, Lancashire Teaching Hospitals NHS Trust, Royal Preston Hospital, Sharoe Green Lane, Preston PR2 9HT, United Kingdom.
Received: January 25, 2021
Peer-review started: January 25, 2021
First decision: February 25, 2021
Revised: February 27, 2021
Accepted: March 13, 2021
Article in press: March 13, 2021
Published online: April 15, 2021

Diabetes mellitus (DM) significantly increases the risk of heart disease, and DM-related healthcare expenditure is predominantly for the management of cardiovascular complications. Diabetic heart disease is a conglomeration of coronary artery disease (CAD), cardiac autonomic neuropathy (CAN), and diabetic cardiomyopathy (DCM). The Framingham study clearly showed a 2 to 4-fold excess risk of CAD in patients with DM. Pathogenic mechanisms, clinical presentation, and management options for DM-associated CAD are somewhat different from CAD among nondiabetics. Higher prevalence at a lower age and more aggressive disease in DM-associated CAD make diabetic individuals more vulnerable to premature death. Although common among diabetic individuals, CAN and DCM are often under-recognised and undiagnosed cardiac complications. Structural and functional alterations in the myocardial innervation related to uncontrolled diabetes result in damage to cardiac autonomic nerves, causing CAN. Similarly, damage to the cardiomyocytes from complex pathophysiological processes of uncontrolled DM results in DCM, a form of cardiomyopathy diagnosed in the absence of other causes for structural heart disease. Though optimal management of DM from early stages of the disease can reduce the risk of diabetic heart disease, it is often impractical in the real world due to many reasons. Therefore, it is imperative for every clinician involved in diabetes care to have a good understanding of the pathophysiology, clinical picture, diagnostic methods, and management of diabetes-related cardiac illness, to reduce morbidity and mortality among patients. This clinical review is to empower the global scientific fraternity with up-to-date knowledge on diabetic heart disease.

Keywords: Diabetic heart disease, Type 2 diabetes mellitus, Type 1 diabetes mellitus, Coronary artery disease, Cardiovascular disease, Cardiac autonomic neuropathy, Diabetic cardiomyopathy

Core Tip: Cardiovascular disease is the major cause of morbidity and mortality among patients with diabetes mellitus (DM). Three distinct and common clinical entities viz., coronary artery disease (CAD), cardiac autonomic neuropathy (CAN) and diabetic cardiomyopathy (DCM) collectively form diabetic heart disease. The pathophysiological mechanisms involved in the development of diabetic heart disease are complex and involve multiple metabolic and molecular pathways. Although most clinicians are well-aware that CAD is a cardiac complication of DM, the awareness about CAN and DCM is remarkably low. This clinical update discusses the pathophysiology, diagnostic aspects, and management options for patients with diabetic heart disease, to empower clinicians across the globe to optimally manage the disease scientifically.