A 65-year-old woman with history of type 2 diabetes mellitus for the last 8 years dies in a hospital She had no other significant medical history. Which of the following is the most likely cause of her death?

Despite all the treatments now available, the outcome for patients with diabetes remains disappointing. Longterm complications of diabetes still cause significant morbidity and moality (Boxes 21.31 and 21.32). Excess moality in diabetes is caused mainly by large blood vessel disease, paicularly myocardial infarction and stroke. Macrovascular disease also causes substantial morbidity from myocardial infarction, stroke, angina, cardiac failure and intermittent claudication. The pathological changes of atherosclerosis in diabetic patients are similar to those in the non-diabetic population but occur earlier in life and are more extensive and severe. Diabetes amplifies the effects of the other major cardiovascular risk factors: smoking, hypeension and dyslipidaemia (Fig. 21.11). Moreover, patients with type 2 diabetes are more likely to have additional cardiovascular risk factors, which co-segregate with insulin resistance in the metabolic syndrome (p. 805). Disease of small blood vessels is a specific complication of diabetes and is termed diabetic microangiopathy. It contributes to moality through renal failure caused by diabetic nephropathy, and is responsible for substantial morbidity and disability: for example, blindness from diabetic retinopathy, difficulty in walking, chronic ulceration of the feet from peripheral neuropathy, and bowel and bladder dysfunction from autonomic neuropathy. The risk of microvascular disease is positively correlated with the duration and degree of sustained hyperglycaemia, however caused and at whatever age it develops. DAVIDSONS PRINCIPLES AND PRACTICE OF MEDICINE 22ND EDITION PAGE NO-826