CVD and Risk Management Standards in Diabetes Care

Chamberlain JJ, Johnson EL, Leal S, Rhinehart AS, Shubrook JH, Peterson L.
Cardiovascular Disease and Risk Management: Review of the American Diabetes Association Standards of Medical Care in Diabetes 2018. Ann Intern Med 2018;168:640-650.

The following are key points to remember from this synopsis on guidance relating to cardiovascular disease (CVD) and risk management in adults with diabetes:

  1. The American Diabetes Association (ADA) annually updates its Standards of Medical Care in Diabetes to provide evidence-based recommendations for the diagnosis and management of patients with diabetes.
  2. Atherosclerotic cardiovascular disease (ASCVD), defined as coronary heart disease (CHD), cerebrovascular disease, or peripheral artery disease, is the leading cause of morbidity and mortality in persons with diabetes, and is the largest contributor to the direct and indirect costs of diabetes. ADA Standards of Medical Care recommend that CV risk factors be assessed at least annually in all patients with diabetes.
  3. Blood pressure (BP) should be measured using American Heart Association guidelines at every routine clinical visit. Patients with elevated BP (≥140/90 mm Hg) should have BP confirmed using multiple readings, including measurements on a separate day, to diagnose hypertension. All hypertensive patients with diabetes should monitor their BP at home. Most patients with diabetes and hypertension should be treated to a systolic BP goal of <140 mm Hg and a diastolic BP goal of <90 mm Hg. Lower targets, such as 130/80 mm Hg, may be appropriate for individuals at high risk of CVD using a shared decision-making process.
  4. Lifestyle intervention along with pharmacologic therapy should be initiated for patients with BP >120/80 mm Hg. Lifestyle intervention consists of weight loss if overweight or obese, a Dietary Approaches to Stop Hypertension–(DASH) style dietary pattern including reducing sodium (<2300 mg/d) and increasing potassium intake, moderation of alcohol intake, and increased physical activity.
  5. Patients with confirmed office-based BP ≥160/100 mm Hg should, in addition to lifestyle therapy, have prompt initiation and timely titration of two drugs or a single-pill combination of drugs demonstrated to reduce CV events (CVEs) in diabetes. Treatment should include drug classes demonstrated to reduce CVEs in diabetics including angiotensin-converting enzyme inhibitors (ACEi), angiotensin-receptor blockers (ARBs), thiazide-like diuretics, or dihydropyridine calcium channel blockers. ACEi and ARBs should not be used together or either with direct renin inhibitors.
  6. Multiple-drug therapy is generally required to achieve BP targets. An ACEi or ARB at the maximally tolerated dose indicated for BP treatment is the recommended first-line treatment for hypertension in patients with diabetes and urinary albumin-to-creatinine ratio ≥300 mg/g creatinine or 30–299 mg/g creatinine. For patients treated with an ACEi, ARB, or diuretic, serum creatinine/estimated glomerular filtration rate and serum potassium levels should be monitored at least annually. Patients with hypertension who are not meeting BP targets on three classes of antihypertensive medications (including a diuretic) should be considered for mineralocorticoid receptor antagonist therapy.
  7. Lifestyle modification should focus on weight loss (if indicated); the reduction of saturated fat, trans fat, and cholesterol intake; increase of dietary n-3 fatty acids, viscous fiber, and plant stanols/sterols intake; and increased physical activity should be recommended to improve the lipid profile in patients with diabetes. Intensify lifestyle therapy and optimize glycemic control for patients with elevated triglyceride levels (≥150 mg/dl) and/or low high-density lipoprotein cholesterol <40 mg/dl for men and <50 mg/dl for women. Randomized trials do not support use of omega-3 polyunsaturated fatty acids for primary or secondary prevention. But randomized trials show that a Mediterranean-style diet rich in polyunsaturated and monounsaturated fats can improve glycemic control and lipid levels.
  8. The American College of Cardiology/American Heart Association ASCVD risk calculator has limited use for assessing CV risk in persons with diabetes because it does not account for the duration of diabetes or the presence of other complications, such as albuminuria. Lipid assessment should be performed in all diabetics. For patients of all ages with diabetes and ASCVD, high-intensity statin therapy should be added to lifestyle therapy. For patients with diabetes aged <40 years with additional ASCVD risk factors, consider using a moderate-intensity statin in addition to lifestyle therapy. For patients with diabetes aged 40–75 years and >75 years without ASCVD, use moderate-intensity statin in addition to lifestyle therapy. In clinical practice, providers may need to adjust the intensity of statin therapy based on individual low-density lipoprotein cholesterol (LDL-C) response and side effects. Patients not tolerating the recommended dose should be placed on the highest tolerated dose. For patients with diabetes and ASCVD, if LDL-C is ≥70 mg/dl on maximally tolerated statin dose, consider adding additional LDL-lowering therapy such as ezetimibe or PCSK9 (proprotein convertase subtilisin/kexin type 9) inhibitor after considering the potential for further ASCVD risk reduction, drug-specific adverse effects, and patient preferences. Ezetimibe may be preferred due to lower cost.
  9. Several studies have shown that statin use is associated with a modestly increased risk for incident diabetes; the increased risk may be limited to persons with diabetes risk factors. In one study, the absolute risk increase was small; 1.2% of participants receiving placebo and 1.5% receiving rosuvastatin developed diabetes over 5 years of follow-up, and the CVE reduction with statins outweighed the risk for diabetes, even for patients at the highest risk for diabetes. For patients with fasting triglyceride levels ≥500 mg/dl, evaluate for secondary causes of hypertriglyceridemia and consider medical therapy to reduce the risk of pancreatitis. Hypertriglyceridemia should be addressed with dietary and lifestyle changes, including abstinence from alcohol. Severe hypertriglyceridemia [>1000 mg/dl]) may warrant pharmacologic therapy (fibric acid derivatives, fish oil, or both) to reduce risk for acute pancreatitis. Combination therapy (statin/fibrate) has not been shown to improve ASCVD outcomes and is generally not recommended. Statin plus niacin has not been shown to provide additional CV benefit above statin therapy alone, and may increase the risk of stroke with additional side effects, and is generally not recommended. Combination therapy with a statin and a fibrate is associated with increased risk for abnormal aminotransferase levels, myositis, and rhabdomyolysis.
  10. Aspirin use in diabetes is a bit controversial. There is evidence that aspirin therapy (75-162 mg/day) is effective for secondary prevention in those with diabetes and a history of ASCVD. For patients with ASCVD and documented aspirin allergy, clopidogrel 75 mg/day should be used. Dual antiplatelet therapy (with low-dose aspirin and a P2Y12 inhibitor) is reasonable for a year after an acute coronary syndrome, and may have benefits beyond this period. Aspirin therapy (75-162 mg/day) may be considered as a primary prevention strategy in those with type 1 or type 2 diabetes who are at increased CV risk. This includes most men and women with diabetes aged ≥50 years who have at least one additional major risk factor (family history of premature ASCVD, hypertension, dyslipidemia, smoking, or albuminuria) and are not at increased risk of bleeding. Clinical judgment should be used for patients at intermediate risk (younger patients with ≥1 risk factor or older patients with no risk factors).
  11. Screening for ASCVD in asymptomatic patients with high risk is not recommended, in part because high-risk patients should already be receiving intensive medical therapy—an approach that provides benefit similar to that of invasive revascularization. Screening with noninvasive testing to identify persons for different treatment strategies remains unproven.
  12. General treatment recommendations include that in patients with known ASCVD, consider ACEi or ARB to reduce CVEs. In patients with prior myocardial infarction, beta-blockers should be continued for ≥2 years after the event. In patients with type 2 diabetes with stable congestive heart failure (CHF), metformin may be used if estimated glomerular filtration rate remains >30 ml/min, but should be avoided in unstable or hospitalized patients with CHF. In patients with type 2 diabetes and established ASCVD, anti-hyperglycemic therapy should begin with lifestyle management and metformin and subsequently incorporate an agent proven to reduce major adverse CVEs and CV mortality (currently empagliflozin and liraglutide), after considering drug-specific and patient factors. Patients at increased ASCVD risk should receive aspirin, a statin, and an ACEi or ARB if they have hypertension unless a particular drug class is contraindicated. Although clear benefit exists for ACEi and ARBs in patients with diabetic kidney disease or hypertension, the benefits in patients with ASCVD in the absence of these conditions are less clear, especially when LDL-C is concomitantly controlled. In patients with prior myocardial infarction, active angina, or HF, beta-blockers should be used.

Clinical Topics: Acute Coronary Syndromes, Diabetes and Cardiometabolic Disease, Dyslipidemia, Heart Failure and Cardiomyopathies, Prevention, Vascular Medicine, Atherosclerotic Disease (CAD/PAD), Hypertriglyceridemia, Lipid Metabolism, Nonstatins, Novel Agents, Statins, Acute Heart Failure, Exercise, Hypertension, Smoking

Keywords: Acute Coronary Syndrome, Albuminuria, Angiotensin-Converting Enzyme Inhibitors, Antihypertensive Agents, Aspirin, Atherosclerosis, Blood Pressure, Cerebrovascular Disorders, Cholesterol, LDL, Cholesterol, HDL, Coronary Disease, Diabetes Mellitus, Type 2, Dyslipidemias, Exercise, Fatty Acids, Omega-3, Fatty Acids, Unsaturated, Fibric Acids, Fish Oils, Glucosides, Heart Failure, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Hypertension, Hypertriglyceridemia, Hypoglycemic Agents, Metabolic Syndrome X, Myocardial Infarction, Niacin, Obesity, Overweight, Peripheral Arterial Disease, Potassium, Primary Prevention, Rhabdomyolysis, Risk Factors, Secondary Prevention, Smoking, Sodium, Stroke, Triglycerides, Weight Loss

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