Primary Prevention of Cardiovascular Diseases in People with Diabetes

Below is a summary of a joint statement of the American Heart Association andthe American Diabetes Association with recommendations for the primary prevention of cardiovascular diseases in people with diabetes mellitus. The statement contains recommendations for cardiovascular assessment, lifestyle and pharmacological management of patients with diabetes.

Title:

Primary Prevention of Cardiovascular Diseases in People with DiabetesMellitus: A Scientific Statement from the American Heart Association and theAmerican Diabetes Association

Authors:

JB Buse, HN Ginsberg, et al.Reference: Circulation 2007: 115: 114-26,
http://circ.ahajournals.org/cgi/content/abstract/115/1/114

Reviewer:

Carlos Mendoza Montano, PhD, ProCOR contributing editor, APRECOR,Guatemala, e-mail: projhouse@intelnet.net.gt

INTRODUCTION

Diabetes mellitus is a disease defined by abnormalities of fasting or postprandial glucose and frequently is associated with coronary heart disease(CHD), stroke, peripheral arterial disease, cardiomyopathy, and congestive heart failure.
Diabetes generally results in early death from cardiovascular diseases(CVDs).
This review presents a summary of a joint statement of the American Heart Association (AHA) and the American Diabetes Association (AHA) with recommendations for the Primary Prevention of Cardiovascular Diseases in People with Diabetes Mellitus.
The statement contains recommendations for cardiovascular assessment, lifestyle and pharmacological management of patients with diabetes.

COMPREHENSIVE RISK ASSESSMENT

When diabetes exists in patients with established CVD, absolute risk for future events is very high.
Nonetheless, the absolute risk for macrovascular CVD varies among individuals with diabetes, and an accurate assessment of risk clearly depends on the individuals' characteristics.
Some patients, such as children and young adults with recent-onset diabetes, are at relatively low risk of CVD over an intermediate time frame.
For this reason, it is recommended individualizing risk assessment on the basis of risk-prediction algorithms to provide more appropriate risk factor interventions than those recommended by general guidelines that are geared toward middle-aged and older individuals with type 2 diabetes mellitus.

RECOMMENDATIONS FOR LIFESTYLE INTERVENTION FOR PRIMARY PREVENTION OF CVD

Weight Management

The joint statement emphasizes lifestyle changes such as reduced fat (<30%>
For individuals with elevated plasma triglycerides and reduced high-density lipoprotein cholesterol (HDL-C), moderate weight loss (5% to 7% of startingweight), dietary saturated fat restriction, increased physical activity, and modest replacement of dietary carbohydrate (5% to 7%) by either monounsaturated or polyunsaturated fats may be beneficial.

Medical Nutrition Therapy

To achieve reductions in LDL-C, saturated fats should be <7%>
Total energy intake should be adjusted to achieve body-weight goals.
Total dietary fat intake should be moderated (25% to 35% of total calories) and should consist mainly of monounsaturated or polyunsaturated fat.
Ample intake of dietary fiber ( 14 g per1000 calories consumed) may be of benefit. If individuals choose to drink alcohol, daily intake should be limited to 1 drink for adult women and 2 drinksf or adult men.

Physical Activity

To improve glycemic control, assist with weight loss or maintenance, and reduce risk of CVD, at least 150 minutes of moderate-intensity aerobic physical activity or at least 90 minutes of vigorous aerobic exercise per week is recommended.
The physical activity should be distributed over at least 3 days per week, with no more than 2 consecutive days without physical activity.
For long-term maintenance of major weight loss, a larger amount of exercise (7 hoursof moderate or vigorous aerobic physical activity per week) may be helpful.

RECOMMENDATIONS FOR BLOOD PRESSURE CONTROL

Epidemiological analyses and randomized clinical trials have demonstrated the impact of elevated blood pressure as a risk factor for both microvascular and macrovascular disease in diabetes. As a result, blood pressure management is one of the most critical aspects of the care of the patient with diabetes.
Blood pressure should be measured at every routine diabetes visit.
Patients with diabetes should be treated to a systolic blood pressure <130>
If, after these efforts, targets are not achieved, treatment with pharmacological agents should be initiated. Patients with hypertension (systolic blood pressure >=140 mm Hg or diastolic blood pressure>=90 mm Hg) should receive drug therapy in addition to lifestyle and behavioral therapy.
Multiple-drug therapy generally is required to achieve blood pressure targets.

RECOMMENDATIONS FOR LIPID MANAGEMENT

In patients with type 2 diabetes mellitus, triglycerides are often elevated, HDL-C is generally decreased, and LDL-C may be elevated, borderline, or normal.
Elevated LDL-C is identified as the primary target of lipid-lowering therapy by both the ADA and the AHA. In adult patients, lipid levels should be measured atleast annually and more often if needed to achieve goals.
Lifestyle modification deserves primary emphasis in all diabetic individuals.
Patients should focus onthe reduction of saturated fat and cholesterol intake, weight loss (ifindicated), and increases in dietary fiber and physical activity.
In individuals with diabetes who are over the age of 40 years, without overt CVD, but with 1 or more major CVD risk factors, the primary goal is an LDL-C level <100>40 mg/dl; in women, an HDL-C goal 10 mg/dl higher should be considered.

RECOMMENDATIONS FOR TOBACCO USE CESSATION

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'swillingness to quit should be assessed. The patient can be assisted by counseling and by developing a cessation plan.
Follow-up, referral to special programs, or pharmacotherapy should be incorporated as needed.

ANTIPLATELET AGENTS

Aspirin is widely regarded as the most cost-effective intervention to reduce CVDin the general population and in patients with diabetes.
Aspirin therapy (75 to162 mg/d) should be recommended as a primary prevention strategy in those with diabetes at increased cardiovascular risk, including those who are >40 years ofage or who have additional risk factors (family history of CVD, hypertension, smoking, dyslipidemia, or albuminuria).
People with aspirin allergy, bleeding tendency, existing anticoagulant therapy, recent gastrointestinal bleeding, and clinically active hepatic disease are not candidates for aspirin therapy.
Other antiplatelet agents may be a reasonable alternative for patients at high risk.

GLUCOSE MANAGEMENT

Glycemic control clearly reduces microvascular complications in patients with diabetes; however, one of the most hotly debated clinical questions in diabetes is whether better glycemic control is associated with a reduction in CVD outcomes and how low we should go in pursuing glycemic targets.
The glycosylated hemoglobin (A1c) goal for patients in general is <7%. color="#990000">COMMENTS

The benefits of cardiovascular risk factor reduction in patients with diabetes have been clearly demonstrated. Appropriate lifestyle and medical interventionswill reduce the occurrence of CVD and allow people with diabetes to live healthier and longer lives.
But these benefits must be more convincingly communicated to health care professionals and individuals with diabetes, particularly in developing countries which are experiencing a significant increase in the incidence of both diabetes and CVD.