Macrovascular Complication of Diabetes

This essay discusses the pathophysiology, assessment, and treatment of macrovascular complications of diabetes. It highlights the diagnostic tools and therapeutic strategies for MVD in diabetes. The essay emphasizes the importance of proper patient education, nutritional planning, physical activity, smoking cessation, and psychological care for the treatment and effective management of MVD complications among diabetic patients.

Running head: MACROVASCULAR COMPLICATION OF DIABETES
Macrovascular Complication of Diabetes
Name of the Student
Name of the University
Author Note

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MACROVASCULAR COMPLICATION OF DIABETES
Diabetes Mellitus (DM) is a metabolic disorder. It is characterized by hyperglycemia
that generates due to disequilibrium in insulin secretion and/or insulin action. The
pathological hallmark of DM encompasses vasculature leading to microvascular and
macrovascular complications. The microvascular complications like nephropathy and
retinopathy accelerates the chance of developing macrovascular complications, which
promotes atherosclerosis and eventually leads to the development of cardiovascular disease,
peripheral vascular disease and stroke (Marieb & Hoehn, 2015). The following essay aims to
highlight the pathophysiology associated with macrovascular complications of diabetes
followed by assessment and diagnostic criteria. At the end, the essay will explore common
treatment and management principles underlying macrovascular complications of diabetes.
Macrovascular complications: pathophysiology
According to Chilelli, Burlina and Lapolla (2013), the main pathological mechanism
in macrovascular complications in DM mainly involves atherosclerosis. Atherosclerosis
results from chronic injury or inflammation of the wall of arteries present in the coronary or
peripheral vascular system. Inflammation the walls of the arteries cause oxidation of the
lipids from low-density-lipoprotein particles under the action of angiotensin II. The oxidized
lipid particles accumulate in the endothelial walls leading to narrowing (Bullock & Hales,
2016). The activation of the inflammatory pathway causes stimulation and proliferation of
macrophage and attraction of T-lymphocyte at the site of inflammation. The activated T-
lymphocyte induces proliferation of smooth muscle in the arterial walls and simultaneous
collagen accumulation leading to thickening of arteries. The arterial inflammation leads to
narrowing of the arterial walls throughout the body and thereby increasing the chance of
cardiovascular accident (Chilelli, Burlina & Lapolla, 2013).

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Chawla, Chawla and Jaggi (2016) highlighted the pathophysiology underlying the
inflammation in diabetes and subsequent development of macrovascular complications in
details. According to Chawla, Chawla and Jaggi (2016), hyperglycemia provokes monocyte
adhesion to the arterial cells. These monocyte adhserion triggers type 1 hypersensitivity
reaction, promoting the accumulation of the primary mediators of hypersentivity and thereby
causing thickening of the arteries. Increase blood glucose level activates matrix-degrading
enzyme metalloproteinase, which cause plaque rupture and arterial remodelling leading toe
thickening of the arteries. Diabetes also increases the secretion of the primary inflammatory
mediators like C-reactive protein, plasminogen activator inhibitor and interleukine-6 that
cause activation of macrophage and thereby leading to the development of inflammatory
reaction under the influence of protein kinase C (PKC) pathway.
Another underlying pathophysiology behind the development of the macrovascular
complications include increased rate of platelet adhesion and hypercoagulability (Zhang et
al., 2014). Impaired nitric oxide generation, free radical formation in the platelets and altered
calcium regulation promote platelet aggregation cause hypercoagulability. Increased levels of
plasminogen activator inhibitor type 1 impair fibrinolysis in patients with diabetes. The
combination of these cause increased level of platelet coagulability which in turn cause
vascular occlusion and cardiovascular events in type 2 diabetes (Zhang et al., 2014).
Chawla, Chawla and Jaggi (2016) stated that hyperglycemia and insulin resistance are
main reasons behind the development of macrovascular complications of diabetes.
Development of diabetes is inherently associated with hyperglycemia. However, insulin
resistance develops years before hyperglycemia and during the course of time becomes
clinically significant. Obesity plays an important role in the development of insulin resistance
(common among the people with type 2 diabetes). The release of free-fatty acids,

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inflammatory mediators and reactive oxygen species increases the chance of systemic
inflammation and thereby leading to the development of atherosclerosis.
Assessment and diagnostics
The study conducted by Donaghue et al. (2014) highlighted that assessment of
macrovascular complication of diabetes should start after the age of 10. The main screening
methods that are used to highlight the marcrovascular complications include testing the lipid
profile of the individual after every 5 years along with the annual tabulation of blood
pressure. Truong, Maahs and Daniels (2012) highlighted that for type 1 diabetes (T1D)
individuals, with no significant family history of early cardiovascular disease or individuals
who are over 12 years of age, should undergo proper screening of glycemic level after every
5 years. If T1D have family history of cardio-vascular disease then fasting lipid profile must
be used as screening tool for the detection of macrovascular complications. If lipid screening
is found to be abnormal, annual screening is recommended. For type 2 diabetes (T2D), lipid
profile must be done after every 2 years if lipid content of the blood is found within the
permissible range (Truong, Maahs & Daniels, 2012). Other hallmarks apart from blood lipid
concentration, which can be used to detect the tendency of developing macrovascular
complication, include microalbuminuria. Donaghue et al. (2014) stated that microalbuminuria
is confirmed via analysis of two or three samples for a period of three to six months.
Persistent microalbuminuria is found to predict the end stage of the renal failure, which in
turn increases the chance of developing macrovascular disease. Donaghue et al. (2014)
highlighted that loss of nocturnal dipping on round the clock blood pressure monitoring is
regarded as the early marker for the assessment diabetic renal disease which simultaneously
precedes towards microalbuminuria leading the renal hypertrophy and subsequent
development of macrovascular complications.

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In the domain of selection of the proper assessment and diagnostic tool for the
detection of macrovascular diseases (MVD) in diabetes, Papa et al. (2013) conducted a
population based study. 1199 diabetic cohort from outpatient department were selected on the
basis of their cardiovascular history and other medical and hospital records (cardiac index,
brachial index, duplex ultrasonography of the carotid and lower limbs, computed tomography
angiography and peripheral arteriography). Over the selected group of individuals, Papa et al.
(2013) conducted standardized procedure for the assessment of macrovascular complications.
The analysis of the results indicated that the phenotypic heterogeneity is associated with
different types of macrovascular complications among type 2 diabetes patients. They are also
found to have different metabolic syndrome. Depending on this phenotypic heterogeneity, the
development of the diagnostic tools and therapeutic strategies for MVD must be selected
(Papa et al., 2013).
Park et al. (2015) highlighted that the diagnostic method that can be used for the
detection of MVD include bronchial artery ultrasound for the detection of flow-mediated
dilation. Other diagnostic test for the detection of arthrosclerosis, include cardiac
catheterization, angiogram and echocardiogram. These tests help to analyze the position
where exact thickening of the arteries have occurred (Park et al., 2015). Truong, Maahs and
Daniels (2012) highlighted the importance of cardiovascular imaging in the diagnosis of
MVD, a non-invasive imaging helps to analyze the involvement of heart and vasculature in
diabetes.
Treatment and management
The main foundation of care for the treatment and effective management of MVD
complications among diabetic patient include proper patient education, nutritional planning,
physical activity, smoking cessation and psychological care. Medical nutrition therapy is

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regarded as an effective means for the management and treatment of MVD. The medical
nutrition therapy mainly promotes and support healthy eating patterns, which emphasize on a
variety of nutrient-dense foods in proper size (Brown, Edwards, Seaton & Buckley, 2015).
Consumption of nutritional rich food promotes reduction of the lipid content of the blood,
reduction of glycemic level and blood pressure. Nutritional diet based on height and weight
of the body helps to achieve proper body weight and thereby delaying the MVD
complications in diabetes (Evert et al., 2014). In order to access the nutritional needs,
personal and cultural preferences must be taken in to consideration along with proper health
literacy. Proper health literacy will promote willingness to consume healthy food along with
behavioural change in the diet plan (Gosmanov & Umpierrez, 2013). Khan, Stephens, Franks,
Rook and Salem (2013) highlighted that physical activity is another important aspect for
controlling MVD complications among diabetic patient. This promotion of physical activity
also highlights the importance of reduction in sedentary time. Adults with T2DM should be
encouraged to perform resistance training at least twice a week. Connelly, Kirk, Masthoff and
MacRury (2013) however, highlighted that the older adults with sever MVD complication,
might not be capable for entering into resistance training. In that case, of older adults, mild to
moderate physical exercise like 15 minutes of walk can be proved to be effective. Apart from
proper nutritional diet and physical activity, American Diabetes Association (2015)
highlighted the importance of smoking cessation as important interventions for MVD.
Smoking cessation counselling is regarded to be effective in controlling smoking habits
(Tollefson & Hallman, 2016). In relation to treatment and management of MVD in diabetes,
American Diabetes Association (2015) highlighted that the people with MVD in diabetes
should receive medical care from an integrated and collaborative team who have supreme
expertise in diabetes. The management plan should be written via taking inputs from both the
healthcare professional, patients and their family members (American Diabetes Association,

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2015). In domain of medication management, Bullock & Manias (2016) highlighted the use
of subcutaneous insulin injection in order to manage hyperglycemic shocks and thereby
preventing the chance of developing MVD. The dosage however, needs to be adjusted by the
physicians as per the blood glucose level; age and body mass (Brotto & Rafferty, 2016).
Thus from the above discussion, it can be concluded that pathological hallmark of
DM are microvascular and macrovascular complications. Macorvascular complication of
diabetes mainly arises from inflammation, which leads to the narrowing of the walls of the
arteries. This narrowing of the arterial wall causes atherosclerosis, which increases the chance
of developing several cardiac complications. The main assessment techniques used for the
screening of MVD include detection of the lipid profile, blood glucose level and blood
pressure. The main diagnostic approach that is used for the detection of MVD includes non-
invasive screening techniques. The main treatment and management options for MVD as
highlighted in the essay include observance of proper nutritional diet, daily physical activity,
disease education, awareness, and cessation of smoking and medication management.

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