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Prevention of cardiovascular disease (CVD) is an important goal for anyone, but it carries increased significance for people with diabetes.
"Two-thirds or more of the mortality associated with diabetes is a result of cardiovascular disease," notes John B. Buse, MD, PhD, of University of North Carolina at Chapel Hill. More important, one-third of first cardiovascular events in people with diabetes are fatal, he adds.
Lifestyle modifications, regular clinical assessments, and medication monitoring reduce CVD risk. Unfortunately, Buse says, "general cardiovascular risk reduction is not uniformly practiced."
That's why the American Diabetes Association (ADA) and the American Heart Association (AHA) have joined forces to help improve primary prevention practices. In the joint scientific statement "Primary Prevention of Cardiovascular Diseases in People With Diabetes Mellitus," the groups summarize recommendations for smoking cessation, diet, physical activity, and weight control, as well as regular assessments of blood pressure, weight, blood lipids, and blood glucose.1
"The ADA and the AHA are in complete agreement" that all these interventions are important for general CVD risk reduction and for risk reduction among individuals with type 1 and type 2 diabetes, says Buse, ADA's president-elect for medicine and science and co-author of the statement.
Survey data suggest that 91% of physicians view their patients with diabetes at very high or extremely high risk for CVD; yet more than half of patients with diabetes do not think of themselves as at risk for cardiac problems or stroke, and 60% do not feel they are at risk for hypertension or hypercholesterolemia.2
Therefore, physicians must do more to stress the risk for CVD in their patients with diabetes. The ADA and AHA have condensed accepted and essential intervention, assessment, and monitoring practices into this one document to facilitate the increased use of these practices in the clinical setting.
BEGIN WITH LIFESTYLE MANAGEMENT
"Reeducation of the patient about food selection and the importance of regular physical activity, combined with regular reevaluation and behavioral interventions to maintain adherence," statement authors write, "may be the most successful approach to improve long-term outcomes."1
Additionally, "The aggressive use of lifestyle modifications can reduce or delay the need for medical interventions."1 Physicians should guide their patients to make healthful lifestyle modifications based on the following goals and guidelines:
14 g/1,000 kcal; Physicians should be prepared to refer patients to structured programs that monitor energy and fat intake and physical activity.
REGULAR CLINICAL ASSESSMENTS, THERAPEUTIC MANAGEMENT ENCOURAGED
Primary CVD prevention also involves the following clinical assessment and management strategies:
All adults should have lipid levels assessed annually. Those <40 years with LDL cholesterol <100 mg/dl, HDL cholesterol >50 mg/dl, and triglycerides <150 mg/dl may be rechecked every 2 years. Additionally, physicians should take the following steps in treating patients with diabetes:
65 years).
Beyond this, the ADA and AHA recommendations differ. The ADA suggests
lowering triglycerides to <150 mg/dl and raising HDL cholesterol to >40
mg/dl (>50 mg/dl in women), while the AHA considers LDL cholesterol as a
secondary target goal of 130 mg/dl if triglycerides are 200–499
mg/dl, and fibrate or niacin use prior to LDL cholesterol-lowering therapy for
triglyceride levels 500 mg/dl.
Glycated hemoglobin (A1C) should be maintained as close to <6% as possible without causing significant hypoglycemia.
Antiplatelet aspirin therapy (75–162 mg) should be considered for all diabetic patients at increased cardiovascular risk except patients with aspirin allergy or taking anticoagulant therapy, those with bleeding tendency or recent gastrointestinal bleeding, patients with clinically active hepatic disease, and patients <21 years. Such patients may use other antiplatelet agents.
THE TIME FACTOR
"In the context of a health maintenance visit, we encourage patients to lose weight and eat a healthy diet, and when we have a patient with a new diagnosis of diabetes we work with them for tight control of the variables that will help prevent heart attacks, strokes, kidney disease, and foot and other complications," says Michael Kalinowski, MD, with Higganum Family Medical Group in Higganum, Conn.
Kalinowski sees prevention as a moving target, "dependent upon whether one is trying to prevent initial disease or subsequent complications once disease has developed." Time constraints make steadying this target more difficult.
Using disease-specific check boxes or flow chart assessments is one strategy to ensure that clinicians address all recommended preventative measures, says Buse. Another strategy is to comanage the disease with another organization, such as a diabetes education program, community health center, or weight maintenance program that will address patient lifestyle management issues, he adds.
Robert H. Eckel, MD, professor of medicine at University of Colorado at Denver suggests that 3 minutes of questions can give physicians adequate information about a patient's physical activity level and nutritional habits (see sidebar).3 With another 30 seconds using a PDA-loaded risk assessment tool to determine a patient's 10-year risk for coronary heart disease events, "I can inform him or her about their risk and how that relates or translates into therapeutic recommendations," Eckel says.
"The truth is that any solution that might work for Dr. X may not
work for Dr. Y," Buse notes. Likewise, different solutions work for
different patients. Practices that engage in quality improvement efforts seem
to perform better in preventive care areas, he adds. Ultimately, patients must
understand the overall beneficial effects of lifestyle modifications and that
appropriate modifications coupled with medical interventions will reduce their
risk of CVD and permit them healthier and longer lives. 
Lifestyle Checkup
Clinicians should ask patients with diabetes these lifestyle questions during each office visit:
Source: Adapted from the presidential address by Robert Eckel, MD, at AHA Scientific Sessions 2005
References
2. Merz CN, Buse JB, Tuncer D, et al.: Physician attitudes and
practices and patient awareness of the cardiovascular complications of
diabetes. J Am Coll Cardio/40:1877–1881, 2002.
3. Eckel RH: Preventive cardiology by lifestyle intervention: Opportunity and/or challenge? Presidential address at the 2005 American Heart Association Scientific Sessions. Circulation 113: 2657–2661, 2006.
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