Cvd and risk management standards in diabetes care – american college of cardiology gas or electricity more expensive


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.

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 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 (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.

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.

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).

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.

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

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), 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