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Prevalence of and risk factors for coronary heart disease in diabetes mellitus

Richard W Nesto, MD
Section Editors
Bernard J Gersh, MB, ChB, DPhil, FRCP, MACC
David M Nathan, MD
Deputy Editors
Howard Libman, MD
Brian C Downey, MD, FACC


Heart disease, particularly coronary heart disease (CHD) is a major cause of morbidity and mortality among patients with diabetes mellitus [1]. The epidemiology of and risk factors for CHD and the frequency of silent myocardial ischemia in patients with diabetes will be reviewed here. Therapeutic issues are discussed separately. (See "Treatment of acute myocardial infarction in diabetes mellitus" and "Glycemic control for acute myocardial infarction in patients with and without diabetes mellitus" and "Coronary artery revascularization in patients with diabetes mellitus and multivessel coronary artery disease".)


Compared to individuals without diabetes, those with diabetes have a higher prevalence of coronary heart disease (CHD), a greater extent of coronary ischemia, and are more likely to have a myocardial infarction (MI) and silent myocardial ischemia.

Diabetes as a CHD equivalent — The National Cholesterol Education Program report from the United States and guidelines from Europe consider type 2 diabetes to be a CHD equivalent, thereby elevating it to the highest risk category [2,3]. This classification was based in part upon the observation that patients with type 2 diabetes without a prior MI (mean age 58) were at the same risk for MI (20 and 19 percent, respectively) and coronary mortality (15 versus 16 percent) as patients without diabetes who had a prior MI (mean age 56) [4]. Similar findings have been noted in other studies. (See 'Myocardial infarction' below and "Overview of the risk equivalents and established risk factors for cardiovascular disease", section on 'Diabetes mellitus' and "Management of low density lipoprotein cholesterol (LDL-C) in secondary prevention of cardiovascular disease".)

The importance of the association between diabetes and CHD can be illustrated by findings from the Framingham Heart Study and the Multiple Risk Factor Intervention Trial (MRFIT). In the Framingham Heart Study, the presence of diabetes doubled the age-adjusted risk for cardiovascular disease in men and tripled it in women [5]. Diabetes remained a major independent cardiovascular risk factor even when adjusting for advancing age, hypertension, smoking, hypercholesterolemia, and left ventricular hypertrophy.

Similar observations were noted in MRFIT [6]. Among 5163 men who reported taking medications for diabetes (mostly type 2), 9.7 percent died from cardiovascular disease over a 12 year period; the comparable cardiovascular death rate in the 342,815 men not taking medications for diabetes was 2.6 percent. This difference was independent of age, ethnic group, cholesterol level, systolic blood pressure, and tobacco use. However, among diabetic men, the increase in cardiovascular risk rose more steeply than in nondiabetics with the addition of each of these risk factors.


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Literature review current through: Jul 2017. | This topic last updated: Nov 21, 2016.
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  1. Grundy SM, Benjamin IJ, Burke GL, et al. Diabetes and cardiovascular disease: a statement for healthcare professionals from the American Heart Association. Circulation 1999; 100:1134.
  2. National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) final report. Circulation 2002; 106:3143.
  3. De Backer G, Ambrosioni E, Borch-Johnsen K, et al. European guidelines on cardiovascular disease prevention in clinical practice: third joint task force of European and other societies on cardiovascular disease prevention in clinical practice (constituted by representatives of eight societies and by invited experts). Eur J Cardiovasc Prev Rehabil 2003; 10:S1.
  4. Haffner SM, Lehto S, Rönnemaa T, et al. Mortality from coronary heart disease in subjects with type 2 diabetes and in nondiabetic subjects with and without prior myocardial infarction. N Engl J Med 1998; 339:229.
  5. Kannel WB, McGee DL. Diabetes and cardiovascular risk factors: the Framingham study. Circulation 1979; 59:8.
  6. Stamler J, Vaccaro O, Neaton JD, Wentworth D. Diabetes, other risk factors, and 12-yr cardiovascular mortality for men screened in the Multiple Risk Factor Intervention Trial. Diabetes Care 1993; 16:434.
  7. Emerging Risk Factors Collaboration, Sarwar N, Gao P, et al. Diabetes mellitus, fasting blood glucose concentration, and risk of vascular disease: a collaborative meta-analysis of 102 prospective studies. Lancet 2010; 375:2215.
  8. Krolewski AS, Kosinski EJ, Warram JH, et al. Magnitude and determinants of coronary artery disease in juvenile-onset, insulin-dependent diabetes mellitus. Am J Cardiol 1987; 59:750.
  9. Barrett-Connor E, Orchard TJ. Insulin-dependent diabetes mellitus and ischemic heart disease. Diabetes Care 1985; 8 Suppl 1:65.
  10. Booth GL, Kapral MK, Fung K, Tu JV. Relation between age and cardiovascular disease in men and women with diabetes compared with non-diabetic people: a population-based retrospective cohort study. Lancet 2006; 368:29.
  11. Robertson WB, Strong JP. Atherosclerosis in persons with hypertension and diabetes mellitus. Lab Invest 1968; 18:538.
  12. Waller BF, Palumbo PJ, Lie JT, Roberts WC. Status of the coronary arteries at necropsy in diabetes mellitus with onset after age 30 years. Analysis of 229 diabetic patients with and without clinical evidence of coronary heart disease and comparison to 183 control subjects. Am J Med 1980; 69:498.
  13. Pajunen P, Taskinen MR, Nieminen MS, Syvänne M. Angiographic severity and extent of coronary artery disease in patients with type 1 diabetes mellitus. Am J Cardiol 2000; 86:1080.
  14. Stein B, Weintraub WS, Gebhart SP, et al. Influence of diabetes mellitus on early and late outcome after percutaneous transluminal coronary angioplasty. Circulation 1995; 91:979.
  15. Granger CB, Califf RM, Young S, et al. Outcome of patients with diabetes mellitus and acute myocardial infarction treated with thrombolytic agents. The Thrombolysis and Angioplasty in Myocardial Infarction (TAMI) Study Group. J Am Coll Cardiol 1993; 21:920.
  16. Mueller HS, Cohen LS, Braunwald E, et al. Predictors of early morbidity and mortality after thrombolytic therapy of acute myocardial infarction. Analyses of patient subgroups in the Thrombolysis in Myocardial Infarction (TIMI) trial, phase II. Circulation 1992; 85:1254.
  17. Natali A, Vichi S, Landi P, et al. Coronary atherosclerosis in Type II diabetes: angiographic findings and clinical outcome. Diabetologia 2000; 43:632.
  18. Melidonis A, Dimopoulos V, Lempidakis E, et al. Angiographic study of coronary artery disease in diabetic patients in comparison with nondiabetic patients. Angiology 1999; 50:997.
  19. Pajunen P, Nieminen MS, Taskinen MR, Syvänne M. Quantitative comparison of angiographic characteristics of coronary artery disease in patients with noninsulin-dependent diabetes mellitus compared with matched nondiabetic control subjects. Am J Cardiol 1997; 80:550.
  20. Scognamiglio R, Negut C, Ramondo A, et al. Detection of coronary artery disease in asymptomatic patients with type 2 diabetes mellitus. J Am Coll Cardiol 2006; 47:65.
  21. Fox CS, Coady S, Sorlie PD, et al. Trends in cardiovascular complications of diabetes. JAMA 2004; 292:2495.
  22. Gu K, Cowie CC, Harris MI. Diabetes and decline in heart disease mortality in US adults. JAMA 1999; 281:1291.
  23. Yusuf S, Hawken S, Ounpuu S, et al. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study. Lancet 2004; 364:937.
  24. Lee CD, Folsom AR, Pankow JS, et al. Cardiovascular events in diabetic and nondiabetic adults with or without history of myocardial infarction. Circulation 2004; 109:855.
  25. Juutilainen A, Lehto S, Rönnemaa T, et al. Type 2 diabetes as a "coronary heart disease equivalent": an 18-year prospective population-based study in Finnish subjects. Diabetes Care 2005; 28:2901.
  26. Hu G, Jousilahti P, Qiao Q, et al. The gender-specific impact of diabetes and myocardial infarction at baseline and during follow-up on mortality from all causes and coronary heart disease. J Am Coll Cardiol 2005; 45:1413.
  27. Abaci A, Oğuzhan A, Kahraman S, et al. Effect of diabetes mellitus on formation of coronary collateral vessels. Circulation 1999; 99:2239.
  28. Anand DV, Lim E, Lahiri A, Bax JJ. The role of non-invasive imaging in the risk stratification of asymptomatic diabetic subjects. Eur Heart J 2006; 27:905.
  29. Yokoyama I, Momomura S, Ohtake T, et al. Reduced myocardial flow reserve in non-insulin-dependent diabetes mellitus. J Am Coll Cardiol 1997; 30:1472.
  30. Di Carli MF, Bianco-Batlles D, Landa ME, et al. Effects of autonomic neuropathy on coronary blood flow in patients with diabetes mellitus. Circulation 1999; 100:813.
  31. Niakan E, Harati Y, Rolak LA, et al. Silent myocardial infarction and diabetic cardiovascular autonomic neuropathy. Arch Intern Med 1986; 146:2229.
  32. Faerman I, Faccio E, Milei J, et al. Autonomic neuropathy and painless myocardial infarction in diabetic patients. Histologic evidence of their relationship. Diabetes 1977; 26:1147.
  33. Langer A, Freeman MR, Josse RG, Armstrong PW. Metaiodobenzylguanidine imaging in diabetes mellitus: assessment of cardiac sympathetic denervation and its relation to autonomic dysfunction and silent myocardial ischemia. J Am Coll Cardiol 1995; 25:610.
  34. Watkins PJ, Mackay JD. Cardiac denervation in diabetic neuropathy. Ann Intern Med 1980; 92:304.
  35. Stevens MJ, Raffel DM, Allman KC, et al. Cardiac sympathetic dysinnervation in diabetes: implications for enhanced cardiovascular risk. Circulation 1998; 98:961.
  36. Ranjadayalan K, Umachandran V, Ambepityia G, et al. Prolonged anginal perceptual threshold in diabetes: effects on exercise capacity and myocardial ischemia. J Am Coll Cardiol 1990; 16:1120.
  37. Kannel WB. Lipids, diabetes, and coronary heart disease: insights from the Framingham Study. Am Heart J 1985; 110:1100.
  38. Margolis JR, Kannel WS, Feinleib M, et al. Clinical features of unrecognized myocardial infarction--silent and symptomatic. Eighteen year follow-up: the Framingham study. Am J Cardiol 1973; 32:1.
  39. Shlipak MG, Elmouchi DA, Herrington DM, et al. The incidence of unrecognized myocardial infarction in women with coronary heart disease. Ann Intern Med 2001; 134:1043.
  40. Norhammar A, Tenerz A, Nilsson G, et al. Glucose metabolism in patients with acute myocardial infarction and no previous diagnosis of diabetes mellitus: a prospective study. Lancet 2002; 359:2140.
  41. Hu FB, Stampfer MJ, Haffner SM, et al. Elevated risk of cardiovascular disease prior to clinical diagnosis of type 2 diabetes. Diabetes Care 2002; 25:1129.
  42. Coutinho M, Gerstein HC, Wang Y, Yusuf S. The relationship between glucose and incident cardiovascular events. A metaregression analysis of published data from 20 studies of 95,783 individuals followed for 12.4 years. Diabetes Care 1999; 22:233.
  43. Qiao Q, Pyörälä K, Pyörälä M, et al. Two-hour glucose is a better risk predictor for incident coronary heart disease and cardiovascular mortality than fasting glucose. Eur Heart J 2002; 23:1267.
  44. Singer DE, Nathan DM, Anderson KM, et al. Association of HbA1c with prevalent cardiovascular disease in the original cohort of the Framingham Heart Study. Diabetes 1992; 41:202.
  45. DECODE Study Group, the European Diabetes Epidemiology Group.. Glucose tolerance and cardiovascular mortality: comparison of fasting and 2-hour diagnostic criteria. Arch Intern Med 2001; 161:397.
  46. Levitan EB, Song Y, Ford ES, Liu S. Is nondiabetic hyperglycemia a risk factor for cardiovascular disease? A meta-analysis of prospective studies. Arch Intern Med 2004; 164:2147.
  47. Khaw KT, Wareham N, Bingham S, et al. Association of hemoglobin A1c with cardiovascular disease and mortality in adults: the European prospective investigation into cancer in Norfolk. Ann Intern Med 2004; 141:413.
  48. Sui X, Lavie CJ, Hooker SP, et al. A prospective study of fasting plasma glucose and risk of stroke in asymptomatic men. Mayo Clin Proc 2011; 86:1042.
  49. Selvin E, Coresh J, Golden SH, et al. Glycemic control and coronary heart disease risk in persons with and without diabetes: the atherosclerosis risk in communities study. Arch Intern Med 2005; 165:1910.
  50. Meigs JB, Nathan DM, D'Agostino RB Sr, et al. Fasting and postchallenge glycemia and cardiovascular disease risk: the Framingham Offspring Study. Diabetes Care 2002; 25:1845.
  51. Blake DR, Meigs JB, Muller DC, et al. Impaired glucose tolerance, but not impaired fasting glucose, is associated with increased levels of coronary heart disease risk factors: results from the Baltimore Longitudinal Study on Aging. Diabetes 2004; 53:2095.
  52. Hammoud T, Tanguay JF, Bourassa MG. Management of coronary artery disease: therapeutic options in patients with diabetes. J Am Coll Cardiol 2000; 36:355.
  53. Taegtmeyer H, McNulty P, Young ME. Adaptation and maladaptation of the heart in diabetes: Part I: general concepts. Circulation 2002; 105:1727.
  54. Haffner SM, Mykkänen L, Festa A, et al. Insulin-resistant prediabetic subjects have more atherogenic risk factors than insulin-sensitive prediabetic subjects: implications for preventing coronary heart disease during the prediabetic state. Circulation 2000; 101:975.
  55. Mogensen CE, Hansen KW, Pedersen MM, Christensen CK. Renal factors influencing blood pressure threshold and choice of treatment for hypertension in IDDM. Diabetes Care 1991; 14 Suppl 4:13.
  56. Adler AI, Stratton IM, Neil HA, et al. Association of systolic blood pressure with macrovascular and microvascular complications of type 2 diabetes (UKPDS 36): prospective observational study. BMJ 2000; 321:412.
  57. Chobanian AV, Bakris GL, Black HR, et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA 2003; 289:2560.
  58. Garg A, Grundy SM. Management of dyslipidemia in NIDDM. Diabetes Care 1990; 13:153.
  59. O'Brien T, Nguyen TT, Zimmerman BR. Hyperlipidemia and diabetes mellitus. Mayo Clin Proc 1998; 73:969.
  60. Lipid and lipoprotein levels in patients with IDDM diabetes control and complication. Trial experience. The DCCT Research Group. Diabetes Care 1992; 15:886.
  61. Pérez A, Wägner AM, Carreras G, et al. Prevalence and phenotypic distribution of dyslipidemia in type 1 diabetes mellitus: effect of glycemic control. Arch Intern Med 2000; 160:2756.
  62. Haffner SM, Stern MP, Hazuda HP, et al. Cardiovascular risk factors in confirmed prediabetic individuals. Does the clock for coronary heart disease start ticking before the onset of clinical diabetes? JAMA 1990; 263:2893.
  63. Sacks FM, Tonkin AM, Craven T, et al. Coronary heart disease in patients with low LDL-cholesterol: benefit of pravastatin in diabetics and enhanced role for HDL-cholesterol and triglycerides as risk factors. Circulation 2002; 105:1424.
  64. Heart Protection Study Collaborative Group. MRC/BHF Heart Protection Study of cholesterol lowering with simvastatin in 20,536 high-risk individuals: a randomised placebo-controlled trial. Lancet 2002; 360:7.
  65. Lu W, Resnick HE, Jablonski KA, et al. Non-HDL cholesterol as a predictor of cardiovascular disease in type 2 diabetes: the strong heart study. Diabetes Care 2003; 26:16.
  66. Qin R, Chen T, Lou Q, Yu D. Excess risk of mortality and cardiovascular events associated with smoking among patients with diabetes: meta-analysis of observational prospective studies. Int J Cardiol 2013; 167:342.
  67. Selvin E, Marinopoulos S, Berkenblit G, et al. Meta-analysis: glycosylated hemoglobin and cardiovascular disease in diabetes mellitus. Ann Intern Med 2004; 141:421.
  68. Ravipati G, Aronow WS, Ahn C, et al. Association of hemoglobin A(1c) level with the severity of coronary artery disease in patients with diabetes mellitus. Am J Cardiol 2006; 97:968.
  69. Huxley R, Barzi F, Woodward M. Excess risk of fatal coronary heart disease associated with diabetes in men and women: meta-analysis of 37 prospective cohort studies. BMJ 2006; 332:73.
  70. Gerstein HC, Mann JF, Yi Q, et al. Albuminuria and risk of cardiovascular events, death, and heart failure in diabetic and nondiabetic individuals. JAMA 2001; 286:421.
  71. Wachtell K, Ibsen H, Olsen MH, et al. Albuminuria and cardiovascular risk in hypertensive patients with left ventricular hypertrophy: the LIFE study. Ann Intern Med 2003; 139:901.
  72. Adler AI, Stevens RJ, Manley SE, et al. Development and progression of nephropathy in type 2 diabetes: the United Kingdom Prospective Diabetes Study (UKPDS 64). Kidney Int 2003; 63:225.
  73. Ninomiya T, Perkovic V, de Galan BE, et al. Albuminuria and kidney function independently predict cardiovascular and renal outcomes in diabetes. J Am Soc Nephrol 2009; 20:1813.
  74. Gregg EW, Gerzoff RB, Caspersen CJ, et al. Relationship of walking to mortality among US adults with diabetes. Arch Intern Med 2003; 163:1440.
  75. Hu G, Eriksson J, Barengo NC, et al. Occupational, commuting, and leisure-time physical activity in relation to total and cardiovascular mortality among Finnish subjects with type 2 diabetes. Circulation 2004; 110:666.
  76. Ajani UA, Gaziano JM, Lotufo PA, et al. Alcohol consumption and risk of coronary heart disease by diabetes status. Circulation 2000; 102:500.
  77. Solomon CG, Hu FB, Stampfer MJ, et al. Moderate alcohol consumption and risk of coronary heart disease among women with type 2 diabetes mellitus. Circulation 2000; 102:494.
  78. Hoogeveen EK, Kostense PJ, Jakobs C, et al. Hyperhomocysteinemia increases risk of death, especially in type 2 diabetes : 5-year follow-up of the Hoorn Study. Circulation 2000; 101:1506.
  79. Eckel RH, Wassef M, Chait A, et al. Prevention Conference VI: Diabetes and Cardiovascular Disease: Writing Group II: pathogenesis of atherosclerosis in diabetes. Circulation 2002; 105:e138.
  80. Clarkson P, Celermajer DS, Donald AE, et al. Impaired vascular reactivity in insulin-dependent diabetes mellitus is related to disease duration and low density lipoprotein cholesterol levels. J Am Coll Cardiol 1996; 28:573.
  81. Mäkimattila S, Virkamäki A, Groop PH, et al. Chronic hyperglycemia impairs endothelial function and insulin sensitivity via different mechanisms in insulin-dependent diabetes mellitus. Circulation 1996; 94:1276.
  82. Di Carli MF, Janisse J, Grunberger G, Ager J. Role of chronic hyperglycemia in the pathogenesis of coronary microvascular dysfunction in diabetes. J Am Coll Cardiol 2003; 41:1387.
  83. Miura H, Wachtel RE, Loberiza FR Jr, et al. Diabetes mellitus impairs vasodilation to hypoxia in human coronary arterioles: reduced activity of ATP-sensitive potassium channels. Circ Res 2003; 92:151.
  84. Nitenberg A, Paycha F, Ledoux S, et al. Coronary artery responses to physiological stimuli are improved by deferoxamine but not by L-arginine in non-insulin-dependent diabetic patients with angiographically normal coronary arteries and no other risk factors. Circulation 1998; 97:736.
  85. Kawano H, Motoyama T, Hirashima O, et al. Hyperglycemia rapidly suppresses flow-mediated endothelium-dependent vasodilation of brachial artery. J Am Coll Cardiol 1999; 34:146.
  86. Quiñones MJ, Hernandez-Pampaloni M, Schelbert H, et al. Coronary vasomotor abnormalities in insulin-resistant individuals. Ann Intern Med 2004; 140:700.
  87. Hsueh WA, Lyon CJ, Quiñones MJ. Insulin resistance and the endothelium. Am J Med 2004; 117:109.
  88. Mather KJ, Verma S, Anderson TJ. Improved endothelial function with metformin in type 2 diabetes mellitus. J Am Coll Cardiol 2001; 37:1344.
  89. Mullen MJ, Wright D, Donald AE, et al. Atorvastatin but not L-arginine improves endothelial function in type I diabetes mellitus: a double-blind study. J Am Coll Cardiol 2000; 36:410.
  90. Skyrme-Jones RA, O'Brien RC, Berry KL, Meredith IT. Vitamin E supplementation improves endothelial function in type I diabetes mellitus: a randomized, placebo-controlled study. J Am Coll Cardiol 2000; 36:94.
  91. Winocour PD. Platelet abnormalities in diabetes mellitus. Diabetes 1992; 41 Suppl 2:26.
  92. Davì G, Catalano I, Averna M, et al. Thromboxane biosynthesis and platelet function in type II diabetes mellitus. N Engl J Med 1990; 322:1769.
  93. Calverley DC, Hacker MR, Loda KA, et al. Increased platelet Fc receptor expression as a potential contributing cause of platelet hypersensitivity to collagen in diabetes mellitus. Br J Haematol 2003; 121:139.
  94. Davì G, Ciabattoni G, Consoli A, et al. In vivo formation of 8-iso-prostaglandin f2alpha and platelet activation in diabetes mellitus: effects of improved metabolic control and vitamin E supplementation. Circulation 1999; 99:224.
  95. Rosove MH, Frank HJ, Harwig SS. Plasma beta-thromboglobulin, platelet factor 4, fibrinopeptide A, and other hemostatic functions during improved, short-term glycemic control in diabetes mellitus. Diabetes Care 1984; 7:174.
  96. Shechter M, Merz CN, Paul-Labrador MJ, Kaul S. Blood glucose and platelet-dependent thrombosis in patients with coronary artery disease. J Am Coll Cardiol 2000; 35:300.
  97. Kwaan HC. Changes in blood coagulation, platelet function, and plasminogen-plasmin system in diabetes. Diabetes 1992; 41 Suppl 2:32.
  98. Ostermann H, van de Loo J. Factors of the hemostatic system in diabetic patients. A survey of controlled studies. Haemostasis 1986; 16:386.
  99. Saito I, Folsom AR, Brancati FL, et al. Nontraditional risk factors for coronary heart disease incidence among persons with diabetes: the Atherosclerosis Risk in Communities (ARIC) Study. Ann Intern Med 2000; 133:81.
  100. Stec JJ, Silbershatz H, Tofler GH, et al. Association of fibrinogen with cardiovascular risk factors and cardiovascular disease in the Framingham Offspring Population. Circulation 2000; 102:1634.
  101. Badawi H, el-Sawy M, Mikhail M, et al. Platelets, coagulation and fibrinolysis in diabetic and non-diabetic patients with quiescent coronary heart disease. Angiology 1970; 21:511.
  102. Small M, Lowe GD, MacCuish AC, Forbes CD. Thrombin and plasmin activity in diabetes mellitus and their association with glycaemic control. Q J Med 1987; 65:1025.
  103. Gray RP, Patterson DL, Yudkin JS. Plasminogen activator inhibitor activity in diabetic and nondiabetic survivors of myocardial infarction. Arterioscler Thromb 1993; 13:415.
  104. McGill JB, Schneider DJ, Arfken CL, et al. Factors responsible for impaired fibrinolysis in obese subjects and NIDDM patients. Diabetes 1994; 43:104.
  105. Sobel BE, Woodcock-Mitchell J, Schneider DJ, et al. Increased plasminogen activator inhibitor type 1 in coronary artery atherectomy specimens from type 2 diabetic compared with nondiabetic patients: a potential factor predisposing to thrombosis and its persistence. Circulation 1998; 97:2213.
  106. Zhang J, Ren S, Sun D, Shen GX. Influence of glycation on LDL-induced generation of fibrinolytic regulators in vascular endothelial cells. Arterioscler Thromb Vasc Biol 1998; 18:1140.
  107. Nordt TK, Schneider DJ, Sobel BE. Augmentation of the synthesis of plasminogen activator inhibitor type-1 by precursors of insulin. A potential risk factor for vascular disease. Circulation 1994; 89:321.
  108. Sambola A, Osende J, Hathcock J, et al. Role of risk factors in the modulation of tissue factor activity and blood thrombogenicity. Circulation 2003; 107:973.
  109. Moreno PR, Murcia AM, Palacios IF, et al. Coronary composition and macrophage infiltration in atherectomy specimens from patients with diabetes mellitus. Circulation 2000; 102:2180.
  110. Mautner SL, Lin F, Roberts WC. Composition of atherosclerotic plaques in the epicardial coronary arteries in juvenile (type I) diabetes mellitus. Am J Cardiol 1992; 70:1264.