Associations Join Efforts to Prevent Cardiovascular Disease

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:

1. Long-term weight loss goal of 5–7% of starting weight;

2. Cholesterol of <200 mg/dl;

3. Fat (mostly mono- and polyunsaturated) intake 25–35% of total energy intake (including <7% saturated and <1% transunsaturated fats); fat intake <30% of total energy intake to achieve weight loss;

4. Fiber intake of ≥14 g/1,000 kcal;

5. Sodium intake of 1,200–2,300 mg (3,000–6,000 mg sodium chloride);

6. Daily alcohol intake of one 12-oz beer, one 4-oz wine, or one 1.5-oz serving of distilled spirits for adult women (two for men) or less;

7. A minimum 150 minutes moderate or 90 minutes vigorous aerobic activity per week distributed over 3 days (at least 2 consecutive days between sessions); 7 hours moderate to vigorous activity per week to maintain major weight loss.

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:

1. Assess tobacco use at each visit; suggest cessation, counseling, referrals, and pharmacotherapy; and continue follow-up.

2. Monitor blood pressure at every visit, aiming for optimal values of <130 mmHg systolic and <80 mmHg diastolic.

3. Recommend 3 months of lifestyle modification for patients with 130–139 mmHg systolic or 80–89 mmHg diastolic blood pressure. Follow with pharmacological treatment if optimal values are not reached.

4. Prescribe angiotensin-converting enzyme (ACE) inhibitors or angiotensin-receptor blockers (ARBs) as tolerated for all hypertensive patients with diabetes. Add beta-blockers, thiazide diuretics, and calcium-channel blockers as needed to obtain optimal values.

5. Monitor renal function/serum potassium levels for stability during the first 3 months of ACE inhibitor, ARB, or diuretic therapy, and every 6 months thereafter.

6. When clinically indicated, take orthostatic measurements, lower the values of hypertensive elderly patients gradually, and refer uncontrolled hypertension patients for specialist care.

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:

1. Encourage all diabetic patients to reduce saturated fat and cholesterol intake, increase dietary fiber and physical activity, and lose weight if needed.

2. Work with diabetic patients to achieve optimal LDL cholesterol of <100 mg/dl.

3. Prescribe statin therapy for diabetic patients >40 years without CVD but with one or more CVD risk factors (cigarette smoking, blood pressure 140/90 mmHg or antihypertensive use, HDL cholesterol <40 mmHg, or a family history of coronary heart disease in first-degree male relatives 55 years or female relatives ≤65 years).

4. Consider LDL cholesterol-lowering medications for those <40 years without overt CVD but judged at increased risk through clinical or risk assessment calculator, and if lifestyle changes do not achieve optimal LDL cholesterol levels.

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:

1. Number of daily steps?

2. Exercise regularly?

3. Use elevators/escalators or stairs?

4. Park near to/far from destination?

5. Daily servings of vegetables, fruits, whole grains?

6. Weekly servings of fish?

7. Favored/amount of desserts, snack foods?

8. Eat due to hunger, stress, habit?

9. Weight change over time?

10. Interest in weight loss?

11. Interest in increasing activity?

12. Interest in formal evaluation?

Source: Adapted from the presidential address by Robert Eckel, MD, at AHA Scientific Sessions 2005