The term cardiometabolic risk refers to having a high 10-year and/or lifetime risk for cardiovascular disease (CVD). Specific causes that can increase cardiometabolic risk include hyperglycemia, hypertension, dyslipidemia, obesity, and insulin resistance. When patients have one or more of these risk factors and are physically inactive or smoke, cardiometabolic risk is further increased. “Patients with type 2 diabetes often have many risk factors associated with cardiometabolic risk,” explains Cecilia C. Low Wang, MD, FACP (Figure). “It’s important to consider cardiometabolic risk as part of a comprehensive approach to patient care.” This allows clinicians to consider multiple disease pathways and risk factors to facilitate earlier intervention.
The State of Risk
According to current estimates, two of every three Americans are overweight or obese, and about 86 million have prediabetes. Nearly half of all adults in the United States have high cholesterol, and about one-third have high blood pressure (BP). “While it’s important to track A1C among patients with type 2 diabetes, it’s also critical to manage BP and cholesterol because these are two of the most important cardio-metabolic risk factors,” Dr. Low Wang says. Research has shown that good BP control can reduce diabetes-related deaths by 32% and lower the risk of stroke by 44% and micro-vascular complications by 37%.
Addressing Risk Factors
There are non-modifiable and modifiable cardio-metabolic risk factors to consider when managing patients with type 2 diabetes. Non-modifiable risk factors include age, race and ethnicity, gender, and family history. Modifiable factors include obesity, dyslipidemia, inflammation, hypertension, smoking, physical inactivity, unhealthy diet, and insulin resistance. “Patients should understand that having diabetes means being at higher risk for CVD,” says Dr. Low Wang. “It’s important to address cardiometabolic risk as early as possible.”
Making efforts to manage modifiable risk factors is of the utmost importance, according to Dr. Low Wang. “It’s critical to address risk factors early, especially if patients are overweight or obese and have other risk factors that can be modified with lifestyle modifications and therapies,” she says. “Patients need to understand that while their CVD risk factors may not currently be causing them harm, it’s likely that they will cause problems later in life.”
Preventive Therapeutic Approaches
Lifestyle modifications are paramount to the care of patients with diabetes in order to reduce their overall cardiometabolic risk. Losing weight, increasing physical activity, quitting smoking, and using statins and other medications are important approaches. Glycemic targets should be individualized, with more stringent A1C goals for recently diagnosed patients who have long life expectancies. Less stringent A1C goals should be set for patients with frequent or severe hypoglycemia, those with advanced complications, and those who respond poorly to therapy.
Aspirin therapy is a primary prevention strategy for patients with increased cardiovascular risk, which includes most men aged 50 and older, most women aged 60 and older, and anyone with at least one additional major risk factor. Aspirin can be used as a secondary prevention strategy in those with diabetes who have a history of CVD. In addition to lifestyle modifications, either moderate- or high-dose cholesterol-lowering therapy should be considered for patients with type 2 diabetes, regardless of baseline lipid levels since diabetes itself is a risk factor for heart disease. All patients with diabetes who have overt CVD should be on high-intensity cholesterol-lowering doses.
“Clinicians should ensure that patients recognize the importance of healthy lifestyle behaviors like eating right and exercising regularly, even after they’ve been given medications to address their cardiometabolic risk,” Dr. Low Wang says. “Patients should know why they’re taking the medications they’ve been prescribed and be educated about what they will do to lower their CVD risk. If side effects from these medications are encountered, it’s important to address them quickly to ensure adherence to treatment regimens.”
Routine Assessments Required
Dr. Low Wang says that healthcare teams managing patients with diabetes should routinely assess cardiometabolic risk and treat risk factors as early as possible. “There are many prevention and management strategies that can be implemented to achieve goals,” she says. “In the future, it’s hoped that more research will further assist clinicians as they evaluate and treat patients for cardiometabolic risk factors throughout care. In the meantime, having discussions about risks for CVD and stroke with patients with diabetes can go a long way toward optimizing outcomes.”
Readings & Resources (click to view)
American Diabetes Association. Cardiometabolic risk, type 2 diabetes, and cardiovascular disease. Available at http://professional.diabetes.org/SlideLibraryDetail.aspx?ssPath=Cardiometabolic_Risk_0f775d32-0576-4a32-90e3-198bd4eb469b&ssName=Cardiometabolic_Risk.ppt&ssId=22&ssTitle=Cardiometabolic Risk, Type 2 Diabetes and Cardiovascular Disease.
Brunzell JD, Davidson M, Furberg CD, et al.; American Diabetes Association; American College of Cardiology Foundation. Lipoprotein management in patients with cardiometabolic risk: consensus statement from the American Diabetes Association and the American College of Cardiology Foundation. Diabetes Care. 2008;31:811–822.
Engelsen Cd, Koekkoek PS, Godefrooij MB, Spigt MG, Rutten GE. Screening for increased cardiometabolic risk in primary care: a systematic review. Br J Gen Pract. 2014;64:e616-e626.
Poon VT, Kuk JL, Ardern CI. Trajectories of metabolic syndrome development in young adults. PLoS One. 2014;9:e111647.
Franch-Nadal J, Mata-Cases M, Vinagre I, et al. Differences in the cardiometabolic control in type 2 diabetes according to gender and the presence of cardiovascular disease: results from the eControl Study. Int J Endocrinol. 2014;2014:131709.