Risk of hypoglycemia in cardiovascular disease

Risk of hypoglycemia in cardiovascular disease

Risk of hypoglycemia in cardiovascular disease can be at various levels. Though good long term control of diabetes mellitus is beneficial in those with cardiovascular disease, episodes of hypoglycemia has been shown to be deleterious. It has been associated with elevated cardiac troponins, though it has been questioned whether it is due to hypoglycemia per se or the more severe diabetes mellitus in these patients [1].

Severe hypoglycemia leads to sympathetic overactivity resulting in tachycardia, increased peripheral resistance, increased systemic blood pressure and enhanced myocardial contractility. All these can worsen myocardial ischemia and injury (as documented by elevated troponin), more so in those with pre-existing coronary artery disease [2].

Acute hypoglycemia may lead to release of vasoactive substances leading to vascular injury [3]. This may be mediated by the release of catecholamines and other neurohormonal peptides in severe hypoglycemia. Increased levels of biomarkers, cell adhesion molecules, enhanced blood viscosity and platelet aggregation may promote a thrombogenic milieu leading to myocardial infarction [2].

Severe hypoglycemia may be associated with severe hypertension, hypokalemia and prolongation of QT interval [4]. This could lead on to life threatening ventricular arrhythmias.

References

1. 1. Rezende PC, Everett BM, Brooks MM, Vlachos H, Orchard TJ, Frye RL, Bhatt DL, Hlatky MA. Hypoglycemia and Elevated Troponin in Patients With Diabetes and Coronary Artery Disease. J Am Coll Cardiol. 2018 Oct 9;72(15):1778-1786.
   2. Deedwania P. Dangers of Hypoglycemia in Cardiac Patients With Diabetes: Time to Switch to Safer, Newer Drugs. J Am Coll Cardiol. 2018 Oct 9;72(15):1787-1789.
   3. Wright RJ, Newby DE, Stirling D, Ludlam CA, Macdonald IA, Frier BM. Effects of acute insulin-induced hypoglycemia on indices of inflammation: putative mechanism for aggravating vascular disease in diabetes. Diabetes Care. 2010 Jul;33(7):1591-7.
   4. Tsujimoto T, Yamamoto-Honda R, Kajio H, Kishimoto M, Noto H, Hachiya R, Kimura A, Kakei M, Noda M. Vital signs, QT prolongation, and newly diagnosed cardiovascular disease during severe hypoglycemia in type 1 and type 2 diabetic patients. Diabetes Care. 2014;37(1):217-25.