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Women and heart disease: The role of diabetes and hyperglycemia

The JAMA Network Journals

In a special article in the May 10 issue of The Archives of Internal Medicine, Elizabeth Barrett-Connor, M.D., of the University of California, San Diego, and colleagues explore the role of diabetes among women with cardiovascular disease (CVD).

According to the article, CVD is the primary cause of death in women, and women with type 2 diabetes mellitus are at a greater risk of CVD compared to nondiabetic women. "In the United States, 498,863 women died from CVD in 2001, compared with 266,693 deaths from cancer," the authors write. However, in a large survey of women conducted in 2003, fewer than half of the women surveyed perceived heart disease as their greatest health threat.

In addition to high blood glucose levels (the hallmark of diabetes), there are other risk factors that contribute to a higher risk for CVD among diabetic women, including hypertension, dyslipidemia (an imbalanced lipid and cholesterol profile) and cigarette smoking.

"With the diagnosis of diabetes, the relative risk of CVD increases more in women than in men," write the authors. "For instance, the risk of acute myocardial infarction (MI, or heart attack) is 150 percent greater in diabetic than in nondiabetic women but only 50 percent greater in diabetic than in nondiabetic men, according to the Framingham [a large study] data."

The authors outline several strategies for treating women with diabetes and CVD, including controlling blood glucose levels in order to get the diabetes under control. "The Diabetes Control and Complications Trial, a study conducted in patients with type 1 diabetes, demonstrated a 41 percent reduction (albeit nonsignificant ... ) in cardiovascular events in those undergoing intensive therapy and better blood glucose control."

Preventing diabetes is another strategy the researchers discuss. "Type 2 diabetes mellitus is preventable, and hyperglycemia [high blood glucose], the universal feature of diabetes, is treatable," they write. "Preventive measures include weight loss and increased physical activity. Now that prevention has been shown to be feasible, it is important to identify those at high risk of developing diabetes, as well as those with undiagnosed diabetes."

Cholesterol can also be managed to help reduce CVD among women with type 2 diabetes. "Cholesterol is the most important risk factor for CVD in men and women, with and without diabetes," the authors write. "In light of [studies] highlighting the benefits of lipid-lowering medications, as well as data that show underutilization in individuals with diabetes and particularly women, clinicians should make special efforts not to neglect treatment of dyslipidemia in these populations."

The researchers conclude that "Most women with diabetes will develop CVD years earlier than their nondiabetic counterparts. Future challenges, therefore, include preventing diabetes; managing diabetes well if it cannot be prevented, including treatment that would be appropriate for persons with known heart disease; diagnosing the complications early; and treating the complications properly if they cannot be avoided."


(Arch Intern Med. 2004;164:934-942. Available post-embargo at

Editor's Note: The roundtable discussion on which this commentary was based was organized and supported by an unrestricted educational grant from the Lilly Centre for Women's Health, Indianapolis.

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