My 35-Year-Old Patient Has Newly Diagnosed Diabetes. What Do We Know About Her Coronary Risk and What Type of Cardiovascular Risk Ascertainment and Treatment, if any, Is Appropriate?

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href="/web/20131110154717/http://www.healio.com/"> Healio</a> <span>›</span> <a href="/web/20131110154717/http://www.healio.com/cardiology"> Cardiology</a> <span>›</span> <a href="/web/20131110154717/http://www.healio.com/cardiology/curbside-consultation"> Curbside Consultation</a> </p>  <div class="content"> <h2> My 35-Year-Old Patient Has Newly Diagnosed Diabetes. What Do We Know About Her Coronary Risk and What Type of Cardiovascular Risk Ascertainment and Treatment, if any, Is Appropriate?</h2> <p class="curbside-author"> Modele O. Ogunniyi, MD, MPH</p> <p class="curbside-author"> Nanette K. Wenger, MD, MACC, MACP, FAHA</p> <p>Cardiovascular disease is the leading cause of morbidity and mortality in patients with diabetes. Individuals with diabetes have 2- to 4-fold increase in cardiovascular events compared with the general population, and two-thirds of them die from cardiovascular-related complications.<sup>1</sup> Whereas both cardiac and coronary heart disease (CHD) mortality in the United States have decreased in recent decades for nondiabetic men, nondiabetic women, and diabetic men, mortality has increased for diabetic women, and in particular for Black diabetic women. Diabetic women, in general, have a more adverse cardiovascular risk profile than diabetic men. Thus, once a woman is diagnosed with diabetes, primary prevention of cardiovascular disease is a priority and must be intensively pursued. Reports in the literature reinforce that diabetic women, compared with their male peers, have less control of hemoglobin A1c, receive less lipid-lowering medication, are less likely to have low-density lipoprotein cholesterol (LDL-C) levels treated to goal, receive less aspirin both with and without coronary heart disease, and are less likely to attain their goal in the control of elevated blood pressure.<sup>2,3</sup> </p> <p>The main goal of cardiovascular risk assessment is to initiate primary prevention. Cardiovascular risk factor management is the mainstay of diabetes care and spans more than glucose control, since glucose control itself does not provide a benefit in reducing the risk of macrovascular events. Secondary prevention of cardiovascular disease in diabetes is not different from that among people without diabetes; we therefore focus this discussion on primary prevention.</p> <p><strong>Cardiovascular Risk Assessment</strong></p> <p> An accurate assessment of cardiovascular risk should be incorporated as part of initial management strategy for the woman with diabetes, keeping in mind that periodic reassessment may be needed due to a change in risk factor profile. We discuss 2 approaches—a coronary heart disease risk equivalent approach that could be applied to all patients with diabetes irrespective of their risk factor profile, and an individualized approach that accounts for the risk factor profile of each patient with diabetes and relies on global cardiovascular risk assessment. </p> <p><em>Diabetes as a Coronary Heart Disease Risk Equivalent</em></p> <p>For many years, it was widely accepted that individuals with diabetes carry a risk of CHD similar to that of people with established CHD; hence the term “CHD risk equivalent” as denoted in the National Cholesterol Education Program, Adult Treatment Panel III (NCEP ATP III) guidelines, which reclassified diabetes from a CHD risk factor to a CHD risk equivalent.<sup>4</sup> As a result, the presence of diabetes assigns an absolute 10-year risk of >20% for experiencing major coronary events, warranting the initiation of antiplatelet and lipid-lowering therapy for primary prevention. This approach, while intuitively attractive, may have limitations. These pertain to the distribution of cardiovascular risk among those with diabetes that has somehow ended the consensus over the CHD risk equivalent notion in diabetes and the lack of unequivocal evidence on the benefit of aspirin for primary prevention among all people with diabetes.<sup>5</sup> Nonetheless, the 2011 American Heart Association guidelines for cardiovascular prevention in women categorizes diabetic women at high risk.<sup>6</sup></p> <p><em>Individualized Cardiovascular Risk Assessment</em></p> <p>Given that the cardiovascular risk among people with diabetes is not uniformly distributed and rather follows a gradient, an individualized cardiovascular risk assessment approach may be essential, especially in those with multiple risk factors. An assessment of individual risk may be necessary for instituting aspirin therapy given the absence of conclusive evidence of benefit from trials of people with diabetes. There is no consensus over the systematic use of aspirin for primary prevention among women with diabetes. An individualized risk assessment requires the use of a risk scoring equation or engine. Commonly used risk scores include the Framingham CHD risk assessment equation, and the more diabetes-specific tool—the United Kingdom Prospective Diabetes Study (UKPDS) Risk Engine.</p> <p><em>Framingham CHD Risk Assessment</em></p> <p>The risk factors included in the Framingham equation are age, systolic blood pressure, treatment for hypertension, total cholesterol, high-density lipoprotein cholesterol (HDL-C), and cigarette smoking. This can be assessed online at <a href="https://web.archive.org/web/20131110154717/http://www.framinghamheartstudy.org/risk/index.html" target="_blank">http://www.framinghamheartstudy.org/risk/index.html</a>. </p> <p><em>United Kingdom Prospective Diabetes Study Risk Engine</em></p> <p>The UKPDS risk engine is a widely used risk calculator, specific for diabetes. It combines risk factors such as age, sex, ethnicity, hemoglobin A1c level, systolic blood pressure, total cholesterol, HDL-C, smoking status, and presence or absence of atrial fibrillation in a model to predict the risk for CHD and stroke. The UKPDS risk engine can be downloaded from <a href="https://web.archive.org/web/20131110154717/http://www.dtu.ox.ac.uk/riskengine/" target="_blank">http://www.dtu.ox.ac.uk/riskengine/</a>.</p> <p> Estimating the CHD risk score for our 35-year-old patient and the decision to start therapy will depend on her overall burden of cardiovascular risk factors.</p> <p><strong>Therapy for Cardiovascular Disease Prevention in Diabetes</strong></p> <p>Once CHD risk has been ascertained, appropriate therapy for primary prevention of CHD should be initiated and surveillance planned. This includes the use of aspirin, if appropriate, and lipid lowering therapy. Blood pressure control and smoking cessation should be initiated as appropriate, as well as systematic lifestyle modifications. </p> <p><em>Aspirin</em><br/> The latest joint guidelines of the American Diabetes Association and the American Heart Association<sup>5</sup> recommend low-dose aspirin (75 to 162 mg/day) for those with calculated CHD risk of >10% and may be considered for primary cardiovascular disease prevention in individuals with intermediate CHD risk.</p> <p><em>Lipid-Lowering Therapy</em> </p> <p>Lipid-lowering therapy has been shown to be beneficial in individuals with diabetes, even those without CHD or abnormal cholesterol levels. Current ATP III guidelines recommend statins in addition to therapeutic lifestyle changes to achieve an LDL-C goal of <100mg/dL, with an optional goal of <70 mg/dL for very high-risk patients.<sup>4</sup> Elevated serum triglyceride levels as a secondary target of lipid-lowering therapy should be considered after the goal for LDL-C has been attained, with a target goal of <150 mg/dL. A non HDL-C target of <130 mg/dL should be achieved, if possible. </p> <p><em>Blood Pressure Control </em></p> <p>Blood pressure control is essential with a target goal of <140/80 mm Hg and <130/80 mm Hg in patients with diabetic nephropathy and proteinuria.<sup>7</sup> Treatment to control blood pressure with an angiotensin-converting enzyme inhibitor or angiotensin II receptor blockers is standard practice. Other blood pressure medications such as β-blockers, thiazide diuretics, and calcium channel blockers may be required to achieve blood pressure goal.</p> <p><em>Therapeutic Lifestyle Changes</em> </p> <p>The role of therapeutic lifestyle changes cannot be overemphasized and should include dietary modifications (reduced intake of sodium, saturated fats, and cholesterol and increased intake of fibers), reduced alcohol consumption, weight loss or maintenance, and regular, moderate intensity physical activity. These have all been shown to be effective when applied systematically.</p> <p><em>Smoking Cessation</em></p> <p>Health care providers must offer smoking cessation counseling and referral to a formal smoking cessation program and/or consideration of pharmacotherapy as needed.</p> <p><strong>Summary</strong></p> <p>Appropriate management of cardiovascular risk among women with diabetes should be individually tailored by health care providers according to the level of CHD risk. Most importantly, clinicians must look beyond solely blood glucose control and engage in continuous multidisciplinary efforts to modify the risk of cardiovascular disease in diabetic women.</p> <p><strong>References</strong></p> <p>1. Centers for Disease Control and Prevention. <em>National Diabetes Fact Sheet: National Estimates and General Information on Diabetes and Prediabetes in the United States, 2011</em>. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention; 2011.</p> <p>2. Hu G, Jousilahti P, Qiao Q, Katoh S, Tuomilehto J. Sex differences in cardiovascular and total mortality among diabetic and non-diabetic individuals with or without history of myocardial infarction. <em>Diabetologia</em>. 2005;48(5):856-861. </p> <p>3. Huxley R, Barzi F, Woodward M. Excess risk of fatal coronary heart disease associated with diabetes in men and women: meta-analysis of 37 prospective cohort studies. <em>BMJ</em>. 2006;332(7533):73-78.</p> <p>4. National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III).Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) final report. <em>Circulation</em>. 2002;106(25):3143-3421.</p> <p>5. Pignone M, Alberts MJ, Colwell JA, et al. Aspirin for primary prevention of cardiovascular events in people with diabetes: a position statement of the American Diabetes Association, a scientific statement of the American Heart Association, and an expert consensus document of the American College of Cardiology Foundation. <em>Diabetes Care</em>. 2010;33(6):1395-1402.</p> <p>6. Mosca L, Benjamin EJ, Berra K, et al. Effectiveness-based guidelines for the prevention of cardiovascular disease in women—2011 update: a guideline from the American Heart Association. <em>Circulation</em>. 2011;123(11):1243-1262.</p> <p>7. American Diabetes Association. Standards of medical care in diabetes—2013. <em>Diabetes Care</em>. 2013;36(suppl 1):S11-S66.</p>   <p> <div class="fb-like" data-href="" data-send="true" data-width="450" data-show-faces="true"></div> </p> <ul class="share"> <li><a href="#" id="twitter">Tweet</a></li> <li><a href="#" id="facebook">Share</a></li> <li><a href="#" id="linkedin">Link</a></li> <li><a href="#" id="digg">Digg</a></li> <li><a href="#" id="email">Email</a></li> <li class="last"><a href="#" onclick="javascript:window.print();" id="print">Print</a></li> </ul> </div>   <div id="respond"> <h4> Comments</h4> <script language="javascript" type="text/javascript"> var idcomments_acct = 'aa6ff53f9870e40f92f83e1b5df3cddf'; var idcomments_post_id = '{0FA8974D-61AB-4EDD-88AC-C8491F7DD766}'; var idcomments_post_url; </script> <span id="IDCommentsPostTitle" style="display: none"></span> <script type="text/javascript" src="https://web.archive.org/web/20131110154717js_/http://www.intensedebate.com/js/genericCommentWrapperV2.js"></script> <p class="comment-notes"> Healio is intended for health care provider use and all comments will be posted at the discretion of the editors. 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My 35-Year-Old Patient Has Newly Diagnosed Diabetes. What Do We Know About Her Coronary Risk and What Type of Cardiovascular Risk Ascertainment and Treatment, if any, Is Appropriate?