All patients with evidence of diffuse inflammatory vascular disease should get a 2-hour glucose tolerance test, regardless of normal fasting blood sugar or normal hemoglobin A1C16. I have coined the term EUGLYCEMIC DIABETES MELLITUS to describe those patients that have a normal fasting blood sugar or hemoglobin A1C but have an abnormal 2-hour glucose tolerance test. The increased cardiometabolic risk demonstrated did not correlate with the degree of glucose abnormality, whether it was present on not. It’s like being a little pregnant, you are or you are not. This is frequently seen in those patients who have early onset or diffuse atherosclerosis as this is a leading cause of atherogenic dyslipidemia and subsequent cardiovascular disease. Patients that scare me the most are those with diffuse cardiovascular disease. I label these the inflammatory vasculopathy as opposed to the discrete lesion. Diabetic heart disease is frequently seen as Diffuse Luminal irregularities or diffuse areas of atherosclerosis rather than the discrete lesion. Cardiac surgeons are seeing much more complex disease with the obesity epidemic seen today. Many have strong family histories of cardiovascular disease and many have normal or near normal LDL levels. I have seen these patients put on low-dose statins because “the cholesterol is normal”. However metabolic issues in these patients related to insulin resistance and genetic variability play an even greater role. We need to recognize this vulnerable patient prompting a full cardiometabolic workup. Furthermore, new noninvasive imaging techniques are being used to identify these high-risk patients. These include computed tomography (CT) coronary calcium score, computed tomography angiogram (CTA) coronary arteries, and the fractional flow reserve (FFR) which helps predict the degree of stenosis and which patients would benefit from subsequent coronary angiography. The CTA coronary arteries with FFR not only show structure but demonstrate function as well. I predict that with the higher accuracy and a much lower radiation dosage, this test may ultimately surpass the nuclear stress imaging in cardiac risk stratification.
When it comes to exercise, I say, “less is more, and failure is success”. High intensity interval training is superior to moderate intensity continuous training at improving cardiometabolic risk17. A program of less time but higher intensity leading to muscle failure is easy to achieve and leads to successful improvement in cardiovascular risk. Walking should be the baseline, exercise the goal.