Diabetes mellitus and incident cardiovascular disease: does one risk fit all?

major risk factor for cardiovascular disease (CVD) was developed by Haffner et al. in 1998.1 They suggested that a person with diabetes but without previous CVD had an equivalent risk for an event compared to the risk of a recurrent event in a non-diabetic patient with a previous myocardial infarction. This was the position taken by the influential Third Report of the Expert Panel on Detection, Evaluation and Treatment of High Cholesterol in Adults (Adult Treatment Panel III),2 and followed by many later important statements.3 Prior to the data from Haffner et al., data from the Framingham study in the late 1970s suggested that type 2 diabetes mellitus (T2DM) increased the risk of a first CVD event by twoto threefold.4 While more modern data from the Emerging Risk Factors Collaboration (ERFC) suggest that CVD risk may still be around two-fold compared to non-diabetic subjects,5 the ERFC authors acknowledged that duration and age of onset of diabetes were not factored into their analysis, which combined with other recent data has questioned the strength of association.6 These relatively large longitudinal and linkage studies with incident cardiovascular endpoints have focused on specific factors within the general diabetic population. These include the effect of glycaemic control, duration of diabetes, age of onset of diabetes, gender, type of diabetes and ethnicity. Making use of contemporary data and reflecting on these factors, we question whether the increased cardiovascular risk is as significant or as uniform as initially portrayed.