The deadly quartet revisited

  • Prakash C. Deedwania
    Requests for reprints should be addressed to Prakash C. Deedwania, MD, University of California, San Francisco School of Medicine, 2615 East Clinton Avenue, Fresno, California 93703
    Cardiology Division, Department of Medicine, University of California/San Francisco School of Medicine, San Francisco, California, USA

    Stanford University Medical Center, Palo Alto, California, USA
    Search for articles by this author
      Coronary artery disease (CAD) is the leading cause of death and disability in the United States. Each year, >1 million US citizens suffer from myocardial infarction.

      1998 Heart and Stroke Statistical Update. Dallas, TX: American Heart Association; 1998.

      In addition, nearly 14 million people have stable CAD. It is accepted that the risk of CAD is increased in individuals with major coronary risk factors. Hypertension is a well-established risk factor for CAD. Hyperlipidemia, particularly the presence of high levels of low-density lipoprotein (LDL) cholesterol, has also gained attention as a major risk factor for CAD. Most recently, it has been found that hyperglycemia and hyperinsulinemia in people suffering from diabetes are both major risk factors for CAD.
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      1. 1998 Heart and Stroke Statistical Update. Dallas, TX: American Heart Association; 1998.

        • Zimmet P.Z.
        • Alberti K.G.M.M.
        The changing face of macrovascular disease in non-insulin-dependent diabetes mellitus.
        Lancet. 1997; 350: 1-4
        • Eastman R.C.
        • Keen H.
        The impact of cardiovascular disease on people with diabetes.
        Lancet. 1997; 350: 29-32
        • Klein R.
        Hyperglycemia and microvascular and macrovascular disease in diabetes.
        Diabetes Care. 1995; 18: 258-268
        • Nathan D.M.
        • Meigs J.
        • Singer D.E.
        The epidemiology of cardiovascular disease in type 2 diabetes mellitus: how sweet it is... or is it?.
        Lancet. 1997; 350: 4-9
        • Savage P.J.
        • Saad M.F.
        Insulin and atherosclerosis.
        Br Heart J. 1993; 69 (Editorial): 473-475
        • DeFronzo R.A.
        Insulin resistance, hyperinsulinemia, and coronary artery disease.
        J Cardiovasc Pharmacol. 1992; 20: S1-S16
        • DesPres J.-P.
        • Lamarche B.
        • Mauriege P.
        • et al.
        Hyperinsulinemia as an independent risk factor for ischemic heart disease.
        N Engl J Med. 1996; 334: 952-957
        • Bonoro E.
        • Kiechl S.
        • Willeit J.
        • et al.
        Prevalence of insulin resistance in metabolic diseases from a population-based study.
        Diabetes. 1997; 46 (Abstr.): 136A
        • Grossman E.
        • Messerli F.H.
        Diabetic and hypertensive heart disease.
        Ann Intern Med. 1996; 125: 304-310
        • Solymoss B.C.
        • Marcil M.
        • Chaour M.
        • et al.
        Fasting hyperinsulinism, insulin resistance syndrome, and coronary artery disease in men and women.
        Am J Cardiol. 1995; 76: 1152-1156
        • Agewall S.
        • Wikstrand J.
        • Ljungman S.
        • et al.
        Usefulness of microalbuminuria in predicting cardiovascular mortality in treated hypertensive men with and without diabetes mellitus.
        Am J Cardiol. 1997; 80: 164-169
        • Milan Study on Atherosclerosis and Diabetes (MiSAD) Group
        Prevalence of unrecognized silent myocardial ischemia and its association with atherosclerotic risk factors in noninsulin-dependent diabetes mellitus.
        Am J Cardiol. 1997; 79: 134-139
        • The Diabetes Control and Complications Research Group
        Effect of intensive diabetes management on macrovascular events and risk factors in the Diabetes Control and Complications Trial.
        Am J Cardiol. 1995; 75: 894-903
        • Curb J.D.
        • Pressel S.L.
        • Cutler J.A.
        • et al.
        Effect of diuretic-based antihypertensive treatment on cardiovascular disease risk in older diabetic patients with isolated systolic hypertension.
        JAMA. 1996; 276: 1886-1892
        • Pyorala K.
        • Pedersen T.R.
        • Kjekshus J.
        The effect of cholesterol lowering with simvastatin on coronary events in diabetic patients with coronary artery disease.
        Diabetes. 1995; 44 (Abstr.): 35A
        • Sacks F.M.
        • Pfeffer M.A.
        • Moye L.A.
        • et al.
        The effect of pravastatin on coronary events after myocardial infarction in patients with average cholesterol levels.
        N Engl J Med. 1996; 335: 1001-1009
        • Berger M.
        • Sawicki P.T.
        The clinical significance of insulin resistance in the treatment of hypertension.
        European Heart J. 1994; 15: 74-77
        • Estacio R.O.
        • Jeffers B.W.
        • Hiatt W.R.
        • et al.
        The effect of nisoldipine as compared to enalapril on cardiovascular outcomes in patients with non-insulin-dependent diabetes and hypertension.
        N Engl J Med. 1998; 338: 846-852
        • Syvanne M.
        • Taskinen M.R.
        Lipids and lipoproteins as coronary risk factors in non-insulin-dependent diabetes mellitus.
        Lancet. 1997; 350: 20-23
        • Steiner G.
        The dyslipoproteinemias of diabetes.
        Atherosclerosis. 1994; 110: S27-S33
        • American Diabetes Association
        Management of dyslipidemia in adults with diabetes. Position Statement.
        Diabetes Care. 1998; 21: 160-178