Management of Diabetes & Heart Disease

Overview

• Evidence is beginning to emerge that diabetes and cardiovascular disease –two of the leading causes of global morbidities and mortalities – are linked. This is a brief clinical summary of current knowledge, with an emphasis on evidence-based management approaches

Contents

• Screening for Diabetes

• Tailor Glycemic Control

• Why CVD Management Matters

• Link between Diabetes & Heart Disease– Key Mechanisms

– Clinical Manifestations of Atherosclerosis (A)

– Risk Factors

• Diabetic ABCS

• Therapeutic Lifestyle Changes

• Monitoring

• Glucose Control & Heart Disease: Evidence

Screening for

Diabetes

Assess risk in symptomatic adults who are overweight or obese (BMI ≥25 kg/m2) and who have ≥1 of the following additional risk factors for diabetes: physical inactivity; first-degree relative with diabetes; high-risk ancestry (e.g., African American, Latino, Native American, Asian American, Pacific Islander).

Women diagnosed with gestational diabetes; hypertension (BP ≥140/90 mmHg or taking therapy for hypertension); women with polycystic ovary syndrome.

HDL cholesterol level <35 mg/dL (0.90 mmol/L) and/or a triglyceride level >250 mg/dL (2.82 mmol/L); HbA1c ≥5.7%; impaired glucose tolerance, or impaired fasting glucose on previous testing; other clinical conditions associated with insulin resistance (e.g., severe obesity, acanthosis nigricans); or a history of CVD.

If no risk factors, then screening is

recommended beginning at age 40.

Abbreviations: BMI, body mass index; BP, blood pressure; CVD, cardiovascular disease; HDL, high-density lipoprotein; HbA1c, glycated hemoglobin

Reference: Epocrates (An AthenaHealth Company): https://online.epocrates.com/diseases/53337/Diabetic-cardiovascular-disease/Screening.

Tailor Glycemic Control

A1c >6.5% for patients with comorbid conditions and high risk for hypoglycemia

A1c ≤6.5% for patients without comorbid conditions and at risk for hypoglycemia

Abbreviations: A1c, glycated hemoglobin test

Reference: Epocrates (An AthenaHealth Company):2017; https://online.epocrates.com/diseases/53337/Diabetic-cardiovascular-

disease/Screening.

Why CVD Management Matters

Reference: Epocrates (An AthenaHealth Company): 2017; https://online.epocrates.com/diseases/53337/Diabetic-cardiovascular-disease/Treatment-Approach.

CAD is the most common form

of CVD in patients with

diabetes

Risk of stroke up to 4-fold in

patients with diabetes

Up to 20% of patients with

PAD are known to have diabetes

Aortic atherosclerosis may be present in patients with

diabetes

Link between Diabetes & Heart Disease: Key Mechanisms

Abbreviation: CVD, cardiovascular disease

Reference: Epocrates (An AthenaHealth Company): https://online.epocrates.com/diseases/53337/Diabetic-cardiovascular-disease/Etiology.

This Photo by Unknown Author is licensed under CC BY-SA

Key mechanism underlying CVD in diabetes is accelerated atherosclerosis.

Clinical Manifestations

of Atherosclerosis

(A)

ACoronary Arteries

Angina Pectoris and

Acute Coronary

Syndromes

Reference:

Epocrates (An AthenaHealth Company): Diabetic cardiovascular disease. Etiology. 2017; https://online.epocrates.com/diseases/53337/Diabetic-cardiovascular-disease/Etiology.

ACerebral or Cerebellar

Arteries

Transient Ischemic Attacks/

Strokes

APeripheral Circulation

Intermittent Claudication/Gangrene

Link between Diabetes & Heart Disease: Risk Factors

• Heart disease risk the longer you have diabetes

• Patients with diabetes are nearly 2x as likely to die of heart disease/stroke versus people without the disease

• Patients with diabetes die at a younger age than patients without diabetes

• Blood vessels and nerves of the heart are damaged

• Risk factors must be managed to prevent a stroke or heart disease

• Smoking

• High blood pressure

• Abnormal cholesterol levels

• Obesity and belly fat

• Genetic predisposition

• Control diabetic ABCSAcronym

ABCS: A =A1c or glycated hemoglobin test; B=blood pressure; C=cholesterol; S=smoking

Reference:

US National Institutes of Health. National Institutes of Diabetes and Digestive and Kidney Diseases. Diabetes, Heart Disease, and Stroke. 2017; https://www.niddk.nih.gov/health-information/diabetes/overview/preventing-problems/heart-disease-stroke.

Diabetic ABCS

A. The average hemoglobin A1c, HbA1c, or glycohemoglobintest measures average blood glucose levels over the past 3 months

B. High blood pressure (BP) can precipitate a heart attack

– Goal for most people with diabetes is below 140/90 mm Hg, but should be tailored based on patient needs

C. Patients over 40 years may need to take a statin

– Lowers cholesterol and may protect the heart

– Younger patients with too much “bad” cholesterol/LDL may also be candidates for statins

S. Both smoking and diabetes narrow the blood vessels i.e., the heart works harder

Abbreviation: A1c, glycated hemoglobin

Reference:

Epocrates (An AthenaHealth Company) 2017; https://online.epocrates.com/diseases/53337/Diabeti c-cardiovascula r-disea se/Scre ening.

Acronym

ABCS: A = A1c or glycated hemoglobin test; B=blood pressure; C=cholesterol; S=smoking

Reference: US National Institutes of Health. National Institutes of Diabetes and Digestive and Kidney Diseases. Diabetes, Heart Disease, and

Stroke. 2017; https://www.niddk.nih.gov/health-information/diabetes/overview/preventing-problems/heart-disease-stroke.

Therapeutic Lifestyle Changes

• Lifestyle changes may lower the risk of CVD in high-risk patients, including individuals with diabetes

Reference: Hennekens CH, Lopez-Sendon J. UpToDate. 2017; https://www.uptodate.com/contents/prevention-of-cardiovascular-disease-events-in-those-with-established-disease-or-at-high-risk.

Weight Reduction

Yoga

Physical Activity

Diet/Alcohol

Smoking Cessation

Text Messaging

Cardiac Rehabilitation

Programs

Adjunctive Therapies

Monitoring

Overall

•Diabetes should be monitored every 6 to 12 months in patients with controlled disease

•Healthy lifestyle modifications should be encouraged

•BP

•Weight

•Activity level

PAD

•An ankle brachial index (ABI) to test for PAD could benefit patients with diabetes to test

•Exertional leg symptoms; nonhealing wounds; age 65 years or older; or age 50 years or older with diabetes or smoking history are further considerations for ABI test

CVD

•Patients with known CVD should consider ACE inhibitors, statins, and aspirin

•-blockers should be considered for at least 2 years after MI

•Patients with CHF/risk for heart failure should avoid thiazolidinediones

•Patients with stable CHF and normal renal function can consider metformin

Abbreviations:

ACE, angiotensin-converting enzyme inhibitors; BP, blood pressure; CVD, cardiovascular disease; CHF, chronic heart failure; MI, myocardial infarction; PAD, peripheral artery disease

Reference:

Epocrates (An AthenaHealth Company): 2017; https://online.epocrates.com/diseases/53351/Diabetic-cardiovascular-disease/Prognosis

Glucose Control & Heart Disease: Evidence

Type 1 diabetes

• Intensive glycemic control has long-term beneficial CVD effects, as determined in the Diabetes Control and Complications Trial (DCCT)a

1

Type 2 diabetes

• Very intensive glucose control (goal HbA1c <6% to 6.5% over 3-5 years) studied in patients with type 2 diabetes in ACCORD, ADVANCE, and VADT trialsb

• Differences among ACCORD, VADT, and ADVANCE trials may be due to study design and patient characteristics

• MI, revascularization, and unstable angina less frequent in intensive glycemic control arm versus standard group (<6.0% versus 7.0%-7.9%) of ACCORD study (follow-up analysis)b

2

Abbreviations:

ACCORD = Action to Control Cardiovascular Risk in Diabetes trial; ADVANCE = Action in Diabetes and Vascular Disease trial; CVD, cardiovascular disease; HbA1c, glycated hemoglobin; MI, myocardial infarction; VADT = Veterans Administration Diabetes Trial

Reference: a. Nathan DM, Cleary PA, Backlund JY, et al. N Engl J Med. 2005;353(25):2643-2653; b. Epocrates (An AthenaHealth Company): 2017; https://online.epocrates.com/diseases/53337/Diabetic-cardiovascular-disease/Prognosis.