Update on Prevention of Cardiovascular Disease in Diabetics
- Fox CS, Golden SH, Anderson C, et al.
- Update on Prevention of Cardiovascular Disease in Adults With Type 2 Diabetes Mellitus in Light of Recent Evidence: A Scientific Statement From the American Heart Association and the American Diabetes Association. Circulation 2015;Aug 5:[Epub ahead of print].
The following are 10 points to remember about prevention of cardiovascular disease (CVD) in adults with type 2 diabetes mellitus (DM):
- CVD is the most common cause of death for adults with diabetes. Since the last published statement, glycated hemoglobin (HgA1c) (≥6.5%) is now recommended for screening and diagnosis of DM. Improving the diagnosis and care of adults with DM is the focus of this statement.
- Clinical practice recommendations now include the diagnosis of an HgA1c ≥6.5% for diabetes in addition to a 2-hour glucose of ≥200 mg/dl or a fasting glucose of ≥125 mg/dl. Prediabetes criteria include an HgA1c ≥5.7-6.4%, a 2-hour glucose of ≥149–199 mg/dl, or a fasting glucose of ≥100-125 mg/dl.
- Lifestyle modification is a central component of prediabetes and diabetes care. Regular physical activity has been associated with improvements in lipids and blood pressure and should be thought of in conjunction with cardioprotective medications such as statins. Strength training in combination with aerobic exercise may improve glucose control, although definitive large trials are not available.
- Dietary patterns can impact overall diabetes control. A dietary pattern that emphasizes fruits and vegetables with reduced saturated fat and low-fat dairy products is recommended. Diabetes can be associated with low high-density lipoprotein cholesterol and elevated triglycerides. Dietary modification with emphasis on fruits and vegetables, reduction of refined sugars, in addition to weight loss and regular exercise can improve lipid profiles significantly.
- Weight management is often a key concern among diabetics, and with weight loss, improvements in glucose can be seen. Changes in dietary patterns and physical activity can result in weight loss. Bariatric surgery or pharmacotherapy can be useful for weight loss. Reducing drugs that promote weight gain is often helpful as well. Current American Heart Association/American College of Cardiology/Obesity Society guidelines recommend consideration of bariatric surgery for adults with a body mass index ≥35 kg/m2 and obesity-related comorbidities such as DM.
- Low-dose aspirin (75-162 mg/day) is reasonable for adult diabetics with a 10-year CVD risk of ≥10%. Aspirin is also reasonable for adults with diabetes at intermediate risk, defined as a 10-year CVD risk between 5% and 10%.
- Many studies have examined targets for glucose control. Based on this evidence, the current guidelines recommend an HgA1c ≤7.0% (fasting glucose <130 mg/dl) for reducing risk of microvascular disease. Lower targets (HgA1c ≤6.5%) can be considered for select patients with a long life expectancy and no significant CVD. However, in all patients, significant hypoglycemia is to be avoided. Among those with a history of severe hypoglycemia, an HgA1c <8.0% may be considered.
- Blood pressure control has been debated in recent years. These guidelines recommend patients with DM aim for a goal of <140/90 mm Hg. Lower targets may be preferable for younger patients. When possible, an angiotension-converting enzme inhibitor or angiotensin-receptor blocker is recommended for blood pressure control.
- Lipid management is important for CVD risk reduction among diabetics. Current guidelines recommend those with DM between the ages of 40 and 75 years and a low-density lipoprotein of 70-89 mg/dl be prescribed a moderate-intensity statin. Among those <40 or >75 years of age, clinicians should evaluate the benefits and risks related to statins with each patient. Fasting triglycerides >500 mg/dl should be treated.
- Kidney disease is not uncommon among diabetics. Elevated urine albumin and impaired glomerular filtration rate are recommended methods to monitor renal function. Adults with DM and renal impairment are at increased risk for CVD. Renin-angiotensin system inhibitors may slow progression of renal disease.
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