Targets of CV Risk – Beyond Glycemia

Supported by an unrestricted educational grant from Pfizer, Inc.
Wed June 16, 2004
6:30 – 8:30 AM

Program Director:
Robert Ratner, MD

Faculty:
Lawrence Blonde, MD
William Cushman, MD
Robert Kreisberg, MD

Reviewed by Joelle Escoffery, PhD

The goal of this symposium was to evaluate the available treatment guidelines and clinical evidence for the treatment of dyslipidemia and hypertension among people with diabetes. The National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III) recommends that diabetes be treated as a cardiovascular equivalent.  Low density lipoprotein (LDL) cholesterol is the highest therapeutic priority, with a recommended goal of 100 mg/dL.  Secondary goals include treatment of atherogenic dyslipidemia (eg, non-high density lipoprotein (non-HDL) cholesterol, which is computed by subtracting HDL cholesterol from total cholesterol) and metabolic syndrome.  Emerging risk factors such as particle size, homocysteine, and prothrombic factors may also be considered, although no treatments currently exist to address these risk factors.  Instead, the presence of these risk factors serves as a guide to intensify existing treatment. However, the NCEP ATP III guidelines were published in 2001, and currently available evidence suggests a more rigorous approach to the management of dyslipidemia.  People with type 2 diabetes and/or the metabolic syndrome may have a unique lipid profile. LDL levels may be normal, but small, dense LDL and HDL particles may be present and may not be easily detectable through the routine lipid profile.  Rather than performing more sophisticated tests, it was recommended that treatment with statin therapy should be routine, as it has been shown to be effective for both primary and secondary prevention of cardiovascular events. Further, there is evidence suggesting an additional benefit of lowering LDL below 100 mg/dL. Fibrate therapy can also be considered for the treatment of atherogenic dyslipidemia. In terms of blood pressure guidelines, most of the currently available evidence supports lowering blood pressure to 140/90 mm/Hg. However, a more stringent goal of 130/80 mm/Hg is recommended by the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7).  This goal does appear to be achievable, although frequently 2 to 3 medications are required to meet this goal.