Coronary Artery Disease (CAD) remains a leading cause of cardiovascular morbidity and mortality worldwide, with a disproportionately high burden observed in patients with diabetes mellitus [1][2]. Diabetes, characterized by chronic hyperglycemia, accelerates the development of atherosclerosis through complex synergistic mechanisms, including endothelial dysfunction, chronic inflammation, oxidative stress, and lipid metabolism abnormalities [3][4]. Numerous studies have demonstrated that diabetes increases the risk of CAD by two to fourfold compared to the general population [5].

In diabetic patients, CAD presents with well-documented clinical and anatomical specificities, notably more diffuse involvement, a predominance of multivessel disease, and a higher frequency of left main coronary artery lesions [6][7]. Furthermore, the increased prevalence of silent myocardial ischemia in this population often leads to delayed diagnosis and more severe clinical presentations at the time of management.

Despite therapeutic advances—including Percutaneous Coronary Intervention (PCI), Coronary Artery Bypass Grafting (CABG), and optimized medical therapy—the cardiovascular prognosis for diabetic patients remains unfavorable [8]. International guidelines emphasize the critical importance of an individualized and multidisciplinary approach for the management of these high-risk individuals [9].

In sub-Saharan Africa, and specifically in Cameroon, data regarding the specific characteristics of CAD in diabetic patients remain scarce [10]. To address this gap, the present study aimed to describe and compare the sociodemographic, clinical, biological, echocardiographic, angiographic, and therapeutic profiles of coronary artery disease between diabetic and non-diabetic patients in a contemporary Cameroonian cohort.

This study highlights the distinct clinical, angiographic, and therapeutic features of Coronary Artery Disease (CAD) among diabetic patients in Cameroon. Our results show that, compared to non-diabetics, diabetic patients present with significantly more extensive coronary involvement, characterized by a predominance of multivessel disease and more frequent Left Main Coronary Artery (LMCA) involvement. These observations confirm the heightened severity profile of diabetic CAD widely described in the international literature [5][11].

Diabetes mellitus is a major and independent cardiovascular risk factor. It increases the risk of CAD by twofold to fourfold, independent of other traditional risk factors. This association is driven by complex pathophysiological mechanisms involving chronic hyperglycemia, insulin resistance, endothelial dysfunction, systemic inflammation, and accelerated atherosclerosis [4]. These mechanisms not only promote the progression of atheromatous plaques but also enhance their anatomical diffusion and complexity.

In our cohort, the significantly higher frequency of three-vessel disease in diabetic patients is consistent with prior research showing that diabetic CAD is often diffuse, multi-segmental, and preferentially affects distal segments [7]. This specific anatomical distribution largely explains the poorer prognosis observed in diabetic coronary patients, with an increased incidence of Major Adverse Cardiovascular Events (MACE) and higher long-term mortality [12].

A pivotal finding of our study is the striking association between diabetes and LMCA involvement. Diabetic patients in our Cameroonian cohort faced a more than sevenfold increased risk of LMCA lesions compared to non-diabetics (OR = 7.57; 95% CI [1.41 - 40.55]; p = 0.014). Several studies have previously reported this preferential involvement of critical proximal segments in diabetics, exposing these patients to a high risk of left ventricular dysfunction and severe acute complications [7]. This lesion localization increases management complexity and justifies the frequent need for surgical revascularization or multidisciplinary consultation.

Clinically, we observed no significant difference in consultation delays or indications for coronary angiography between diabetic and non-diabetic patients. However, the literature emphasizes that silent myocardial ischemia is more prevalent in diabetics, contributing to diagnostic delays and more advanced clinical presentations [13]. This clinical peculiarity could partially explain the increased anatomical severity observed in our diabetic population.

Regarding associated risk factors, dyslipidemia was significantly more frequent among diabetic patients, confirming its central role in the pathophysiology of diabetic atherosclerosis [3]. Conversely, other cardiovascular comorbidities, such as hypertension and smoking, did not differ significantly between groups, suggesting that diabetes exerts its own independent aggravating effect on CAD beyond the accumulation of traditional risk factors.

Therapeutically, revascularization strategies—specifically PCI versus optimal medical therapy—did not differ significantly. However, the more frequent requirement for Heart Team discussions in diabetic patients (29.6% vs 9.1%) reflects the increased decision-making complexity arising from lesion diffusion and anatomical severity. Current international guidelines underscore the importance of a multidisciplinary approach for high-risk patients with multivessel or LMCA involvement [14].

Major clinical trials, notably the FREEDOM trial, have demonstrated the superiority of Coronary Artery Bypass Grafting (CABG) over Percutaneous Coronary Intervention (PCI) in diabetic patients with multivessel disease regarding long-term mortality and MACE [8]. Similarly, the SYNTAX trial highlighted higher rates of repeat revascularization in diabetic patients treated with PCI, particularly for complex lesions. Beyond revascularization, the emergence of new therapeutic classes, such as SGLT2 inhibitors and GLP-1 receptor agonists, has transformed management by demonstrating cardiovascular benefits independent of glucose-lowering effects [15].

Strengths and limits

Our study has several strengths, notably the detailed analysis of clinical and angiographic characteristics in a sub-Saharan African context where data remain limited [10].

However, the modest sample size and the observational nature of the study limit the generalizability of the results. In addition, detailed data regarding diabetes characteristics, such as disease duration, treatment modality, and glycemic control (HbA1c), were not systematically available in the registry. These factors may influence the severity and extent of coronary artery disease in diabetic patients. Also, due to the relatively small sample size, particularly the limited number of diabetic patients, multivariable regression analysis was not performed. Consequently, the associations observed should be interpreted cautiously, as potential confounding factors could not be fully adjusted for. Finally, because of the cross-sectional design and the angiography-based sampling strategy, the present study identifies associations rather than causal relationships, and the findings may reflect a population with relatively high cardiovascular risk.

Despite these limitations, our findings provide original and pertinent data on CAD specificities in Cameroon, underscoring the urgent need for early detection and a multidisciplinary management approach tailored to this high-risk population.

In conclusion, this pioneer study in Cameroon demonstrates that diabetic patients present with a significantly higher burden of coronary artery disease compared to their non-diabetic counterparts. Our findings reveal a distinct angiographic phenotype characterized by a high prevalence of multivessel disease and left main coronary artery involvement. These anatomical complexities, often compounded by poorly controlled dyslipidemia, necessitate a systematic multidisciplinary approach through “Heart Team” discussions to optimize revascularization strategies. As the first report from the DéRICA registry, this work underscores the urgent need for intensified cardiovascular screening and aggressive risk factor management among the growing diabetic population in Sub-Saharan Africa.

Gemini AI was used for sound translation and reference verification.

The study was conducted with approval from the Institutional Ethics Committee of Yaoundé General Hospital. Although a formal approval number was not assigned, the study was authorized by the hospital authorities. The study reporting followed the STROBE guidelines for observational studies.