Complications
Autonomic dysfunction occurs in 40% to 50% of patients with diabetes.[20] This may result in sympathovagal imbalance, which lowers the threshold for life-threatening arrhythmias.[20] Patients who have diabetes and AF have a substantially increased risk of all-cause mortality, cardiovascular mortality, stroke, kidney disease, and heart failure.[7]
Patients with arrhythmias should be monitored and referred for appropriate treatment. Opportunistic screening for AF, by pulse taking or ECG, is recommended in European Society of Cardiology guidelines for all patients with diabetes aged under 65 years, while systematic screening should be considered for those aged 75 years and over or at high stroke risk.[7]
When indicated by risk stratification (e.g., CHA₂DS₂-VASc score), long-term oral anticoagulant therapy is used in patients with AF for reduction of ischaemic stroke and other ischaemic events. A bleeding risk score should also be used to identify and address potential bleeding risk factors, for example, concomitant use of antiplatelet agents.[7]
Joint American Heart Association and American College of Cardiology guidelines recommend that all patients with history or physical examination findings suggestive of peripheral arterial disease (PAD) should have a resting ankle-brachial index (ABI), with or without ankle pulse volume recordings and/or Doppler waveforms.[29] Screening with resting ABI is also considered reasonable in asymptomatic patients with diabetes and any of the following characteristics: aged ≥50 years; aged <50 years with diabetes and one additional risk factor for atherosclerosis; patients with known atherosclerotic disease in another vascular bed (e.g., coronary, carotid, subclavian, renal, mesenteric artery stenosis, or abdominal aortic aneurysm).[29] The American Diabetes Association recommends screening for PAD using ABI in asymptomatic people with diabetes aged ≥65 years, and in people with microvascular disease in any location, or foot complications, or any end-organ damage from diabetes, if a PAD diagnosis would change management.[30] It should also be considered in individuals with diabetes duration ≥10 years and high cardiovascular risk.[30] ABI results: 1.0 to 1.4 is normal; 0.91 to 0.99 is borderline; ≤0.9 is abnormal.
Diabetes is associated with an increased risk of dementia. Aetiological factors include vascular factors (cerebrovascular disease, cardiovascular risk factors, atherosclerosis, and peripheral arterial disease) and non-vascular factors (hyperglycaemia leading to excess formation of advanced glycated end-products, disturbed neuronal signalling leading to cerebral amyloidosis).[411]
The prevalence of depressive disorders is twice as high in patients with diabetes compared with those without diabetes. Depression is also common in patients with coronary disease, particularly after acute myocardial infarction. It is associated with worse health behaviours and possibly worse cardiovascular outcomes.[412]
Evidence on the cardiac effects of depression treatment is limited, but it is reasonable to screen patients and treat as indicated.[312][313][413]
Perioperative mortality rates are typically low, ranging from 0.1% to 0.5%, which is similar to other common abdominal procedures like cholecystectomy and hysterectomy.[30] Major complications occur in 2% to 6% of individuals undergoing metabolic surgery, while minor complications and the need for operative reintervention can occur in up to 15% of cases.[30]
Longer-term risks include nutritional deficiencies, gastrointestinal issues, psychosocial and behavioural changes, and weight regain/insufficient weight loss, as detailed below.[30]
Nutritional deficiencies: risks include vitamin and mineral deficiencies, anaemia, and osteoporosis. These require routine monitoring of micronutrient and nutritional status and lifelong vitamin/nutritional supplementation.[30]
Gastrointestinal issues: dumping syndrome typically occurs shortly (10-30 minutes) after a meal and can present with symptoms like diarrhoea, nausea, vomiting, palpitations, and fatigue. Hypoglycaemia is usually not present at the time of these symptoms but may develop hours later.[30] Post-metabolic surgery hypoglycaemia can occur with procedures like Roux-en-Y gastric bypass and vertical sleeve gastrectomy, typically presenting more than one year after surgery. It is driven by altered gastric emptying, rapid intestinal glucose absorption, and excessive post-prandial secretion of glucagon-like peptide-1 (GLP-1) and other gastrointestinal peptides, leading to overstimulation of insulin release and a sharp drop in plasma glucose, most commonly 1-3 hours after a high-carbohydrate meal. Symptoms range from sweating, tremor, tachycardia, and increased hunger to impaired cognition, loss of consciousness, and seizures.[30] If post-metabolic surgery hypoglycaemia is suspected, clinical evaluation should exclude other potential disorders contributing to hypoglycaemia, and management should include education, medical nutrition therapy with a registered dietitian nutritionist experienced in the condition, and drug treatment, as needed.[30] The American Diabetes Association recommends that continuous glucose monitoring should be used in patients with post-metabolic surgery hypoglycaemia to improve safety.[30]
Psychosocial and behavioural changes: individuals who undergo metabolic surgery may be at increased risk for substance use, worsening or new-onset depression and/or anxiety disorders, and suicidal ideation. Preoperative assessment by a behavioural health professional is recommended.[30]
Weight regain/insufficient weight loss: weight regain is common, with 35% to 50% of individuals experiencing recurrence of type 2 diabetes following a period of remission.[30]
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