ADA Guidance for the Screening and Management of CVD in Diabetes

Atherosclerotic cardiovascular disease (ASCVD) is the leading cause of morbidity and mortality in patients with diabetes, and the American Diabetes Association (ADA) recommendations for managing these patients involve early assessment followed by targeted intervention, according to research presented at the American Academy of Physician Assistants (AAPA) Annual Meeting, held May 18 to 22, 2019, in Denver, Colorado.

Stephen Brunton, MD, executive director of the Primary Care Metabolic Group, reviewed the ADA Standards of Medical Care in Diabetes — Cardiovascular Disease and Risk Management guidelines created to inform clinicians on screening practices for all aspects of cardiovascular care in diabetes, including hypertension, lipid management, antiplatelet agents, and cardiovascular disease.

Hypertension is a common comorbidity among patients with both type 1 and type 2 diabetes, and antihypertensive therapies reduce ASCVD events, heart failure, and microvascular complications. Recommendations for the management blood pressure and hypertension for patients with diabetes are as follows:

• Blood pressure should be measured at every routine clinical visit.
• All hypertensive patients with diabetes should monitor their blood pressure at home.
• Blood pressure targets should be individualized through a shared decision-making process that addresses cardiovascular risk, potential adverse effects, effects of antihypertensive medications, and patient preferences.
• Individuals with diabetes and hypertension at higher cardiovascular risk should have a blood pressure target of <130/80 mm Hg.
• Individuals with diabetes and hypertension at lower cardiovascular risk should have a blood pressure target of <140/90 mm Hg.
• In pregnant patients with diabetes and preexisting hypertension who are being treated with antihypertensive therapy, blood pressure targets of 120-160/80-105 mm Hg are ideal.

Treatment strategies for managing the risk of cardiovascular disease goes beyond simply implementing a statin. Patients with blood pressure values >120/80 mm Hg should implement the DASH diet, which includes reduced sodium and increased potassium intake, moderation of alcohol consumption, and increased physical activity.  In addition, the following pharmacologic interventions should be implemented:

• Patients with blood pressure ≥140/90 mm Hg should have prompt initiation and timely titration of pharmacologic therapy to achieve blood pressure goals.
• Patients with blood pressure ≥160/90 mm Hg should have pharmacologic intervention of 2 drugs or a combination drug to reduce cardiovascular events.
• Treatment should include drug classes such as angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) to reduce cardiovascular events.
• Multiple-drug therapy should be implemented to achieve blood pressure targets except for combination ACE inhibitors and ARBs, or combination ACE inhibitors or angiotensin receptor blockers with direct renin inhibitors.
• An ACE inhibitor or ARB is first-line therapy for hypertension in patients with diabetes and urinary albumin-to-creatinine ratio ≥300 mg/g creatinine or 30 to 299 mg/g creatinine.
• Patients receiving treatment with an ACE inhibitor, ARB, or a diuretic should undergo annual screening of serum potassium levels, as well as serum creatinine/estimated glomerular filtration rate.
• Mineralocorticoid receptor antagonist therapy should be considered for patients with resistant hypertension.

Adaptation of the Mediterranean or DASH diets decreases both saturated and trans fat, and increases dietary fatty acids, viscous fiber, and plant sterol intake. Combined with increased physical activity and lipid management, these interventions can reduce the risk of patients with diabetes developing ASCVD. For patients with elevated triglyceride levels, clinicians should suggest an intensified lifestyle adjustment and optimization of glycemic control. 

In adults not taking statins or other lipid-lowering therapy, lipid profiles should be obtained at the time of diabetes diagnosis, at the time of the initial evaluation, and every 5 years thereafter. Clinicians should obtain a lipid profile at initiation of statin or other lipid-lowering therapy, at 4 to 12 weeks after treatment initiation or when there is a change in dose, and annually thereafter.

High-intensity statin treatment in addition to lifestyle intervention is recommend for patients of all ages with diabetes and ASCVD or those with a 10-year ASCVD risk >20%. For patients aged <40 years with diabetes and additional ASCVD risk factors, moderate-intensity statin combined with lifestyle therapy is advised. High-intensity statin therapy should be considered for patients with diabetes and multiple ASCVD risk factors. Statin therapy is contraindicated in pregnancy.

Aspirin 75 to 162 mg/d as a secondary prevention strategy is advised for patients with diabetes and a history of ASCVD. For patients with ASCVD who may be allergic to aspirin, clopidogrel 75 mg/d is advised. Following a discussion on the benefits vs increased risk of bleeding, aspirin may be used as a primary prevention strategy for patients with diabetes who are at increased cardiovascular risk.

Among patients with confirmed ASCVD and type 2 diabetes, sodium-glucose cotransporter-2 (SGLT2) inhibitors or glucagon-like peptide-1 (GLP-1) receptor agonists with cardiovascular disease benefit are recommended. For these patients with a high risk of heart failure, SGLT2 inhibitors are preferred.

Screening for ASCVD is not recommended for asymptomatic patients. Screening for coronary artery disease should be considered in the presence of atypical cardiac symptoms, signs or symptoms of associated vascular disease, or abnormalities identified on electrocardiogram.

References

1. Brunton S. American Diabetes Association: cardiovascular risk and treatment options. Presented at: The American Academy of Physician Assistants (AAPA) Annual Meeting; May 18-22, 2019; Denver, CO. Presentation DV9009.

2. American Diabetes Association. 10. Cardiovascular Disease and Risk Management: Standards of Medical Care in Diabetes—2019. Diabetes Care. 2019;42(Supplement 1):S103-S123.