Clinicians should take an active role in helping their patients with type 2 diabetes protect themselves from developing cardiovascular disease, or CVD, in the future.
Cardiovascular disease (CVD) has been well documented as a major cause of morbidity and mortality for individuals with diabetes. Adults with diabetes have a two- to four-fold higher risk of CVD when compared with those without diabetes. “The common conditions coexisting with type 2 diabetes—especially hypertension and dyslipidemia— are clear risk factors for CVD,” says Craig D. Williams, PharmD. “Diabetes itself also confers independent risk of CVD.”
The association among diabetes, hypertension, and dyslipidemia has been known for many decades, and researchers are continuing to collect more data about the interconnectedness of diabetes and heart disease. There has also been an increased appreciation of the impact of obesity on CVD. The concept that these metabolic abnormalities can cluster in many individuals has led to greater efforts to prevent and treat these conditions, especially in patients with diabetes.
Assessing Risk of CVD in Diabetes
There are many approaches for estimating the risk of diabetes and CVD. One such tool—Diabetes PHD (Personal Health Decisions), which is available online at www.diabetes.org—is of particular value for this task for both clinicians and patients. Diabetes PHD is an easy-to-use internet program made available by the American Diabetes Association. It can be used to explore the effects of a wide variety of interventions, including weight loss, smoking cessation, and the addition of medications. It has been studied and validated extensively across many types of clinical trials, and it incorporates most known CVD risk factors. Research suggests that such risk assessment tools are rarely used in clinical practice. More frequent utilization of such tools may enhance patient–provider communication about risks and risk reduction.
“Data highlight the urgent need to improve practices in assessing global risk for CVD
Simply ascertaining blood glucose, blood pressure, and LDL cholesterol levels in addition to assessing tobacco use and noting the presence of obesity may be enough to warrant a more in-depth risk assessment. “By collecting information on these risk factors, clinicians should be triggered to either monitor patients more closely or initiate appropriate interventions to prevent or identify diabetes and emerging CVD,” says Dr. Williams. “If patients have several borderline abnormalities in other cardiovascular health parameters, these too should be addressed.”
Manage the Risk Factors of CVD
Numerous studies have shown that modifying lifestyle and keeping A1C, blood pressure, and cholesterol levels in the goal range can help control individual cardiovascular risk factors and may help prevent or slow CVD in people with diabetes. The American Diabetes Association recommends weight loss and sustained physical activity to improve cardiometabolic risk factors. Large benefits are seen when multiple risk factors are addressed globally. Pharmacologic therapy is often indicated when overt disease is detected, typically in the early stages.
“Clinicians should remember that obesity is a growing epidemic, but it can be prevented with help from healthcare providers,” Dr. Williams says. Obesity is often a visible marker of other underlying risk factors that can be addressed. Greater clinical attention on obesity is necessary because it threatens to undermine all gains that have been made to prevent and control chronic diseases like CVD and diabetes.
In addition to obesity, blood pressure control and keeping lipids in check are especially important to preventing CVD in diabetes (Table 1 and Table 2). “Controlling blood pressure reduces the risk of CVD in people with diabetes by about one-third,” says Dr. Williams. “It also reduces the risk of diabetic complications by 33%. For every 10 mm Hg reduction in systolic blood pressure, the risk for any complication related to diabetes is cut significantly. Improved control of cholesterol can reduce the risk of CVD complications by 20% to 50%.”
Gaps Persist in Diabetes Care
Unfortunately, research shows that there is still a wide gap between current and desired diabetes care with regards to CVD risk factors. “Only about 7% to 8% of people meet the goals for A1C, blood pressure, and cholesterol,” Dr. Williams says. “Two in five people with diabetes have poorly controlled LDL cholesterol, and one in three has poorly controlled blood pressure. These data highlight the urgent need to improve practices in assessing global risk for CVD and diabetes. In order to make CVD a greater priority when treating diabetes, clinicians need to be proactive. More communication between patients and physicians about the CVD risks associated with diabetes is essential. Only then can we develop effective individualized treatment plans that are most appropriate for patients.”
Readings & Resources (click to view)
American Diabetes Association. Standards of Medical Care in Diabetes—2011. Diabetes Care. 2011;34:S11-S61. Available at: http://care.diabetesjournals.org/content/34/Supplement_1/S11.full.
Eckel RH, Kahn R, Robertson RM, Rizza RA. Preventing cardiovascular disease and diabetes: a call to action from the American Diabetes Association and the American Heart Association. Circulation. 2006;113:2943-2946. Available at: http://circ.ahajournals.org/content/113/25/2943.full.
Grantham NM, Magliano DJ, Tai G, Cohen N, Shaw JE. Antiplatelets in diabetes management. Intern Med J. 2010;40:458-462.
Park L, Wexler D. Update in diabetes and cardiovascular disease: synthesizing the evidence from recent trials of glycemic control to prevent cardiovascular disease. Curr Opin Lipidol. 2010;21:8-14.