The British Journal of Diabetes & Vascular Disease

http://dvd.sagepub.com Early-onset type 2 diabetes: not a benign condition

Soon H Song British Journal of Diabetes & Vascular Disease 2009; 9; 137 DOI: 10.1177/1474651409103561 The online version of this article can be found at: http://dvd.sagepub.com

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CASE REPORT

Early-onset type 2 diabetes: not a benign condition

SooN H SoNg
Introduction
The age of onset for type 2 diabetes has decreased, driven by increasing obesity. Despite the young age, these subjects possess adverse cardiovascular risk profiles and therefore are at risk of macrovascular complications. This case illustrates this point.
Figure 1. Coronary angiogram showing a tight stenosis in the left anterior descending artery

Case history
J.T. is a 39-year-old non-smoking female with type 2 diabetes. She was referred to a diabetes clinic because of poor glycaemic control, despite being on maximal doses of metformin and gliclazide. She was diagnosed with type 2 diabetes at 35 years of age and has a medical history of hypertension and a family history of ischaemic heart disease. Her parents suffered myocardial infarctions in their 60s. Her medications included metformin 1 g twice daily, gliclazide 160 mg twice daily, bendrofluazide 2.5 mg daily and felodipine MR 5 mg daily. When seen at the diabetes clinic, J.T. was obese (body mass index 35.8 kg/m2) with a HbA1c of 9% and total cholesterol level of 6.2 mmol/L. She was also hypertensive, with a blood pressure reading of 159/103 mmHg, but showed no signs of overt diabetic microvascular or macrovascular complications. J.T. was started on insulin treatment and her glycaemic control improved to a HbA1c level of 7.8%. Within 15 months of her first attendance at the diabetes clinic, she was admitted with chest pains. Her electrocardiogram showed abnormal ST segment changes in the anterior leads. The troponin I level was significantly raised at 6.8 ng/ml and she was diagnosed with non-ST elevation myocardial infarction. Coronary angiography showed occlusive atherosclerotic disease in the left anterior descending artery (figure 1). She underwent coronary angioplasty and stenting. Echocardiogram showed impaired left ventricular systolic function. Following this episode, J.T. made a satisfactory recovery and atorvastatin treatment was commenced to reduce her cholesterol level.

Acronyms and abbreviations HbA1c NICE glycated haemoglobin A1c National Institute for Health and Clinical Excellence

Discussion
This case is a good illustration of the increasing evidence in published literature that early-onset type 2 diabetes (diagnosed below age of 40 years) is a high-risk condition for development

Correspondence to: Dr Soon H Song Diabetes Centre, Northern general Hospital, Sheffield, S5 7AU, UK. Tel: +44 (0)114 2714976; Fax: +44 (0)114 2266726 E-mail: soon_song@hotmail.com Br J Diabetes Vasc Dis 2009;9:137138

of premature diabetes-related complications including cardiovascular disease.1,2 Although this patient was only in her 30s, she possessed multiple cardiovascular risk factors, namely, obesity, hypertension, hypercholesterolaemia and family history of ischaemic heart disease. Despite this, her blood pressure was not well controlled and she was not treated with a statin for hypercholesterolaemia. The issue of starting lipid-lowering therapy can present a clinical challenge because there is lack of clinical trial evidence to support statin treatment in this age group. As recommended by the NICE guideline, the overall cardiovascular risk profile should be assessed by taking into consideration the presence of adverse risk factors to guide the decision to initiate statin treatment.3 As illustrated in this case, age is not a good barometer of cardiovascular risk in young
10.1177/1474651409103561 137

The Author(s), 2009. Reprints and permissions: http://www.sagepub.co.uk/journalsPermissions.nav THE BRITISH JOURNAL OF DIABETES AND VASCULAR DISEASE

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CASE REPORT

Key messages

Diary dates
24 26 June 2009 obesity and Its Management. 11th Annual Training Meeting. Liverpool, www.aso.org.uk The Physiological Society, Main Meeting 2009 Dublin, Ireland. E-mail: meetings@physoc.org Web: http://www.physiology2009.org/ BPS Summer Meeting Edinburgh, Scotland E-mail: meetings@bps.ac.uk Web: http:// www.bps.ac.uk Congress of the European Association for Clinical Pharmacology and Therapeutics Edinburgh, Scotland E-mail: meetings@bps. ac.uk Web: http://www.bps.ac.uk International Association for the Study of obesity, SCoPE Summer School Cambridge, UK E-mail: lrichards@iaso.org Web: http:// www.scope-online.org/documents/ SCoPESummerSchoolProgramme.pdf The Physiological Basis for obesity Therapeutics Colorado, USA E-mail: Colorado@faseb.org Web: https://secure.faseb.org/faseb/meetings/ Summrconf/Programs/11710.pdf glucose Transporter Biology and Diabetes Lucca, Italy E-mail: italy@faseb.org Web: https://secure.faseb.org/faseb/meetings/ Summrconf/Programs/11806.pdf obesity Management Symposium. Cambridge. http://www.endocrinology.org/meetings/2009/ oms2009/registration.html 1st Basic Postgraduate Course of the European Society of Endocrinology - Endocrinology meets Science Torino, Italy E-mail: martina.dipaolo@ fobiotech.org Web: http://www.fobiotech.org/ attivita_2009/endocrinology_2009.html 45th Annual meeting of the European Association for the Study of Diabetes Vienna, Austria E-mail: secretariat@easd.org Web: http://www.easd.org/ 2nd Central European Congress on obesity Budapest, Hungary Contact: Congress Secretariat E-mail: cecon@asszisztencia.hu Web: http://www.asszisztencia.hu/cecon/ 19th International Congress of Nutrition 2009: Nutrition Security for All BITEC, Bangkok Thailand. http://www.icn2009.com/ 7 10 July

Young people with type 2 diabetes are at risk of mac-

rovascular complication
Age is not a good indicator of overall cardiovascular

risk
Prevention through aggressive risk management is

crucial to improve long-term prognosis.

8 10 July

type 2 diabetic subjects. The principal aim of diabetes management is to prevent complications and this is even more pertinent in early-onset subjects given the potential for longer disease duration and exposure to adverse risk factors. once cardiovascular disease ensues, the mortality rate increases significantly.4 As multiple atherosclerotic risk factors often co-exist in young type 2 diabetic subjects,2 multifactorial intervention is crucial to reduce the burden of diabetes-related complications and mortality.5 To conclude, this case emphasises the salient message that early-onset type 2 diabetes is not a benign condition and should be aggressively managed.

12 15 July

2 5 August

16 21 August

References
1. Hillier TA, Pedula KL. Complications in young adults with early-onset type 2 diabetes: losing the relative protection of youth. Diabetes Care 2003;26:2999-3005. Song SH, Hardisty CA. Cardiovascular risk profile of early and later onset type 2 diabetes. Practical Diabetes Int 2007;24:20-4. National Institute for Health and Clinical Excellence. Type 2 diabetes. The management of type 2 diabetes. NICE clinical guideline. London: NICE, 2008. Sprafka JM, Burke gL, Folsom AR et al. Trends in prevalence of diabetes mellitus in patients with myocardial infarction and effect of diabetes on survival. Diabetes Care 1991;14:537-43. gaede P, Lund-Andersen H, Parving HH et al. Effect of a multifactorial intervention on mortality in type 2 diabetes. N Engl J Med 2008;358:580-91.

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24 26 September

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29 September 2 October

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VOLUME 9 ISSUE 3 . MAy/JUNE 2009

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