To the Editor We read with interest the article by Scirica et al¹ on the prognostic implications of biomarker assessment in patients with type 2 diabetes. Although their findings are extremely interesting, other factors involved in cardiovascular outcome have not been completely evaluated.

Patients with diabetes are considered at high risk for developing both microvascular and macrovascular disease. Despite recent evidence suggesting an association of diabetic microvascular disease with plaque vulnerability,² the link between microvascular and macrovascular disease remains elusive. Microvascular disease is ongoing despite adequate glycemic control, and the development of diabetic retinopathy, diabetic foot, or diabetic nephropathy may indeed flag a subgroup of patients with diabetes with a poorer outcome. The pathogenic mechanisms involved in the progress of atherosclerosis in these patients are indeed multifactorial; insulin resistance and adipose tissue dysfunction, dysglycemia and advanced glycation end product formation, dyslipidemia, oxidative stress, endothelial dysfunction, and arterial stiffening are all partly responsible for activation of proatherogenic pathways.³