Diabetes, Plasma Insulin, and Cardiovascular Disease

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Abstract
SUBJECTS WITH diabetes mellitus, an impaired fasting glucose level, or insulin resistance are at high risk of cardiovascular morbidity and mortality. Persons with diabetes have a 2 to 4-fold higher risk of myocardial infarction, stroke, and death from cardiovascular disease than individuals without diabetes.1 Even people with mild impairment of fasting plasma glucose (FPG) level may have excess risk.2 Insulin resistance, often approximated by high fasting plasma insulin (FPI) level in large epidemiologic studies, is also associated with cardiovascular risk, although it is not clear how much of this association can be explained by other coexisting metabolic abnormalities, such as high triglyceride level, low high-density lipoprotein cholesterol (HDL-C) level, central obesity, and hypertension (a constellation of abnormalities often referred to as the insulin resistance or metabolic syndrome).3 With the dramatic recent rise in prevalence of diabetes and obesity,4,5 strategies to reduce cardiovascular morbidity and mortality in these high-risk groups are urgently needed. The recent National Cholesterol Education Program (NCEP) III treatment report placed particular emphasis on the need for aggressive risk factor reduction for persons with diabetes or with the metabolic syndrome.6