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Primary Prevention of Cardiovascular Diseases in People With Diabetes Mellitus: A Scientific Statement From the American Heart Association and the American Diabetes Association
Buse
JB, Ginsberg HN, Bakris GL, et al. Diabetes Care. 2007;30:162-172.
Diabetes causes abnormal glucose levels as well as disorders
that afflict the microvasculature and tissues of the eyes, kidneys, and nerves.
Patients with diabetes also frequently suffer damage to the macrovasculature that
can result in coronary heart disease (CHD), stroke, cardiomyopathy, and peripheral
cardiovascular disease (CVD). Approximately 80% of individuals with diabetes
will develop macrovascular disease. Clinical trials conducted during the past
decade have revealed that patients with diabetes and clinical CVD have
substantially improved event-free survival rates if they receive treatment for
dyslipidemia, hypertension, and hypercoagulability, and receive timely
interventional cardiology or cardiovascular surgery if indicated. Although such
evidence is encouraging for patients diagnosed with clinical CVD, there is far
less comparable information for populations with diabetes but no CVD. Furthermore,
evidence regarding ways to prevent cardiovascular complications in these
populations is lacking. This is of concern because compared to the general
population, patients with diabetes have twice the incidence of morbidity associated
with CVD, such as myocardial infarction (MI) and stroke. A large number of patients
with diabetes do not survive their first CVD event. Those who do survive their
first event subsequently have a substantially higher mortality rate than the
general population. Although the incidence of CVD events among patients with type
2 diabetes mellitus (T2DM) has decreased since the mid-1990s, CVD events still
exact tremendous societal costs, shorten life expectancy, and decrease quality
of life. Implementation of recommended preventive strategies is often
inadequate.
A scientific statement published in January 2007 by the
American Heart Association (AHA) and the American Diabetes Association (ADA) summarizes
guidelines for prevention of CVD among patients with diabetes. The statement was
issued in response to a call for greater cooperation among organizations with a
stake in CVD-prevention efforts in patients with diabetes, which was previously
published in a 1999 joint statement of the ADA, AHA, National Heart, Lung, and
Blood Institute, National Institute of Diabetes and Digestive and Kidney
Diseases, and Juvenile Diabetes Foundation International. The January 2007 joint
statement summarizes current evidence supporting lifestyle and medical
interventions to prevent CVD among patients with diabetes. The AHA-ADA
statement also offers recommendations to reduce or delay the need for medical
intervention, and to enable patients with diabetes to live healthier, longer
lives.
Table. Recommendations for Primary Prevention of CVD in People With Diabetes: Lifestyle Management
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Weight
Structured programs emphasizing lifestyle
changes, such as reduced fat, total energy intake, increased regular physical
activity, and regular participant contact, can produce long-term weight loss
of 5% to 7% and improvements in blood pressure (BP).
For those with elevated plasma triglyceride (TGL) and reduced
high-density lipoprotein cholesterol (HDL-C), improved glycemic control,
moderate weight loss of 5% to 7%, restricted dietary saturated fat intake,
increased physical activity, and modest (5-7%) replacement of dietary
carbohydrate by either mono- or polyunsaturated fats may be beneficial.
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Medical nutrition therapy
To achieve
reductions in low-density lipoprotein cholesterol (LDL-C):
Saturated fats should be <7% of energy intake.
Dietary cholesterol intake should be <200 mg/day.
Intake of trans unsaturated fatty acids should be <1% of energy intake.
Total energy intake should be adjusted to achieve
body-weight goals.
Total fat intake should be moderate (25-35% of total
calories) and mainly mono- or polyunsaturated fat.
Ample intake of dietary fiber (≥ 14 g/1,000
calories consumed) may be of benefit.
Daily alcohol intake should be ≤ 1 drink for
women, ≤ 2 for men. One drink equates to a 12-oz beer, 4-oz glass of
wine, or 1.5-oz glass of distilled spirits. Alcohol increases caloric intake
and should be minimized if weight loss is a goal. Individuals with elevated
TGL should limit alcohol intake, which may exacerbate hypertriglyceridemia.
In both
normo- and hypertensive individuals, a reduction in sodium intake may
lower blood pressure (BP). Goal should be to reduce intake to 1200 to 2300
mg/day, equivalent to 3000 to 6000 mg/day of sodium chloride.
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Physical activity
To improve
glycemic control, assist with weight loss or maintenance, and reduce risk of
CVD, ≥ 150 minutes of moderate-intensity aerobic physical activity or
≥ 90 minutes of vigorous aerobic exercise per week is recommended. The
physical activity should be distributed over ≥ 3 days/week, with
≤ 2 consecutive days without physical activity.
For long-term maintenance of major weight loss, a larger amount of
exercise (7 hours of moderate or vigorous aerobic physical activity per week)
may be helpful.
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Blood pressure
BP should be measured at every routine visit. Patients
with systolic blood pressure (SBP) ≥ 130 mm Hg or diastolic
blood pressure (DBP) ≥ 80 mm Hg should have BP confirmed on a separate day.
Patients with diabetes should be treated to reach SBP <
130 mm Hg and a DBP < 80 mm Hg.
Patients with SBP 130 to 139 mm Hg or DBP 80 to 89 mm Hg
should initiate lifestyle modification alone (weight control, increased
physical activity, alcohol moderation, sodium reduction; emphasis on
increased consumption of fresh fruits, vegetables, and low-fat dairy
products) for ≤ 3 months. If after these efforts targets are not
achieved, then treatment with pharmacological agents should be initiated.
Patients with hypertension (SBP ≥ 140 mm Hg or
DBP ≥ 90 mm Hg) should receive drug treatment in addition to
lifestyle and behavioral therapy.
All patients with diabetes and hypertension should be
treated with a regimen that includes either an ACE inhibitor or ARB. If one
class is not tolerated, initiate the other. Other drug classes demonstrated
to reduce CVD events in patients with diabetes (β-blockers, thiazide
diuretics, and calcium channel blockers) should be added as needed to achieve
BP targets.
If ACE inhibitors, ARBs, or diuretics are used, monitor
renal function and serum potassium in first 3 months.
If stable, follow-up could occur every 6 months thereafter.
Multiple-drug therapy is generally required to achieve
BP targets.
In elderly hypertensive patients, BP should be lowered
gradually to avoid complications.
Orthostatic BP measurement should be performed when
clinically indicated for those with diabetes and hypertension.
Patients not
achieving target BP despite multiple-drug therapy should be referred to a
physician specializing in the care of patients with hypertension.
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Lipids
In adults, test for lipid disorders ≥ 1 time/year,
more if needed to achieve goals. In adults < 40 years with low-risk lipids
(LDL-C < 100 mg/dL, HDL-C > 50 mg/dL, TGL
< 150 mg/dL), assessment may be repeated every 2 years.
Lifestyle modification deserves primary emphasis in all
diabetic individuals. Patients should focus on reduction of saturated fat and
cholesterol, weight loss, and increases in dietary fiber and physical
activity. These lifestyle changes have been shown to improve the lipid
profile in patients with diabetes.
In individuals > 40 years old with diabetes without overt CVD but ≥ 1
major CVD risk factor, the primary goal is LDL-C <
100 mg/dL. If LDL-lowering drugs are used, reduction of ≥ 30% to ≥
40% should be obtained. If baseline LDL-C < 100 mg/dL,
statin therapy should be initiated based on risk-factor assessment and
clinical judgment. Major risk factors in this category include:
Cigarette smoking.
Hypertension (BP > 140/90 mm Hg or use of antihypertensive medication).
Low HDL-C (< 40 mg/dL).
Family history of premature CHD (CHD in first-degree relative male ≤ 55 or female ≤ 65 years old).
In individuals with diabetes < 40 years old without
overt CVD but at increased risk of CVD, the LDL-C goal is <
100 mg/dL, and LDL-lowering drugs should be considered if lifestyle
changes do not achieve the goal.
The ADA
and AHA suggest different approaches to management of HDL- and TGL-associated
CVD risk.
AHA suggests that if TGL 200 to 499 mg/dL, a non–HDL-C goal ≤ 130 mg/dL is a secondary target. If TGL ≥ 500 mg/dL, therapeutic options include fibrate or
niacin before LDL-lowering therapy and treatment of LDL-C to goal after
TGL-lowering therapy. A non–HDL-C level ≤ 130 mg/dL should be
achieved if possible.
ADA suggests HDL-C > 40 mg/dL in men and > 50 mg/dL in women; however, the AHA recommends implementing efforts to
raise HDL-C but does not provide specific goals for such therapy.
Combination
therapy of LDL-lowering drugs (eg, statins) and fibrates or niacin may be
necessary to achieve lipid targets, but this has not been evaluated in
outcome studies for either CVD event reduction or safety.
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Tobacco
All patients with diabetes should be asked about
tobacco use status at every visit.
Every tobacco user should be advised to quit.
The tobacco user“s willingness to quit should be
assessed.
The patient can be assisted by counseling and by
developing a plan to quit.
Follow-up, referral to special programs, or
pharmacotherapy (nicotine replacement, bupropion) as needed.
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Antiplatelet agents
Aspirin
therapy (75-162 mg/day) should be recommended as a primary prevention
strategy in those with diabetes at increased CV risk, including those > 40
years of age or with additional risk factors (family history of CVD, hypertension,
smoking, dyslipidemia, or albuminuria).
Patients with aspirin allergy, bleeding tendency,
existing anticoagulant therapy, recent GI bleeding, and clinically active
hepatic disease are not candidates. Other antiplatelet agents may be
reasonable alternatives.
Aspirin
therapy should not be recommended for people < 21 years old because of
increased risk of Reye“s syndrome in this population. People < 30 years of
age have not been studied.
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Glycemic control
A1C goal for patients is < 7%.
A1C goal for individuals is as close to normal (<
6%) as possible, without causing significant hypoglycemia.
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Type 1 diabetes
Currently all recommendations above for patients with
T2DM also appear appropriate for patients with type 1 diabetes mellitus (T1DM).
No data suggests that interventions that reduce CVD in patients
with T2DM are less effective among patients with T1DM.
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