Diabetes mellitus is a major cardiovascular risk factor and its prevalence has been increasing globally. This review examines the contributions of the MESA (Multi-Ethnic Study of Atherosclerosis), a diverse American cohort (6,814 adults ages 45 to 84, recruited from 2000 to 2002, 50% female, 62% nonwhite) toward understanding the relationship between diabetes and clinical and subclinical cardiovascular disease. People with diabetes have a high burden of subclinical vascular disease as measured by coronary artery calcification (CAC), carotid artery intima-media thickness, valvular calcification, and alterations in left ventricular structure. CAC substantially improves cardiovascular risk prediction. Among adults with diabetes, 63% had CAC >0; above CAC >400 Agatston units the event rate was 4% annually, whereas an absence of CAC was a marker of a very low cardiovascular disease rate (0.4% to 0.1% annually). These stark differences in rates may have implications for screening and/or targeted prevention efforts based on CAC burden. MESA has also provided insight on diabetes epidemiology.

Highlights

• Diabetes is strongly associated with incident coronary artery calcium and with progression in the amount of coronary artery calcium.
• Coronary artery calcium can be used to improve the prediction of incident cardiovascular disease among adults with diabetes.
• Diabetes remains an independent risk factor for incident cardiovascular disease, even after accounting for the increased burden of subclinical atherosclerosis.
• Inflammatory markers, ethnic-specific waist circumference thresholds, depression, and neighborhood characteristics are associated with incident diabetes.