Cardiometabolic Risk 2015

7/25/2019 Cardiometabolic Risk 2015

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Cardiometabolic Risk,Type 2 Diabetes and

Cardiovascular Disease


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Learning Objectives

Identify !y discussing cardiometabolicrisk "C#R$ factors it! patients it! orat risk for prediabetes and type 2diabetes can positively impact t!eir

!ealt! Implement screening strategies to

promote early detection and prevention

Discuss it! patients !o preventing

risk factors can positively impact !ealt! List risk factor treatment options and

define goals of treatment


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T!e %tate of Risk

2 out of & 'mericans are overeig!t orobese

T!ere are an estimated () million

'mericans it! prediabetes

*early + in 2 -%- adults !as !ig!c!olesterol

+ in & 'merican adults !as !ig! bloodpressure


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*umber and .ercentage of -%- .opulationit! Diagnosed Diabetes +/0(12+

CDC3s Division of Diabetes Translation- *ational Diabetes %urveillance %ystem-


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4eart Disease 5acts

+ in ) deat!s eac! year in t!e -%- is from!eart disease-

4eart disease is t!e leading cause of deat! for

men and omen-

6+0, 'mericans !ave a !eart attack eac!year-

020, are a first !eart attack- +/, !appen in people !o !ave already

!ad a !eart attack-

CDC3s Division of 4eart Disease and %troke .revention-


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Cardiometabolic Risk


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Cardiometabolic Risk 5actors

*on7#odifiable

'ge

Race8et!nicity

9ender

5amily !istory

#odifiable

Overeig!t

'bnormal lipid

metabolism Inflammation

4ypertension

%moking

.!ysical inactivity n!ealt!y diet

Insulin resistance


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3.5

18.8 20.2

45.0

P


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?!at 're ?e to Do@

Current approac!es for C


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%creening 5or Diabetes

Testing at least every & yrs starting at age ;0

'merican Diabetes 'ssociation- Diabetes Care. 2+0=&("%uppl- +$> %&+7%&2-

Test .rediabetes Diabetes

5.9 +7+20 mg8dL A+2) mg8dL

O9TT +;7+// mg8dL A2 mg8dL

'+C 0-67)-;B A)-0B


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ounger8#ore 5reuent Testing

If patient is overeig!t or obese and !as + or more oft!e folloing risk factors "or 2 if not overeig!t$>

+stdegree relative it! diabetes

.!ysically inactive

Certain race8et!nicity

Elevated blood glucose 4ypertension

Lo 4DL c!olesterol and8or !ig! triglyceride level

4istory of 9D#

Delivering baby eig!ing F/ lbs .olycystic ovary syndrome ".CO%$



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'+C A )-BI59 and I9TG Ot!er5eatures

Lifestyle intervention

and8or metformin,follo7up H) mo

Intervention and 5ollo7p

%creen for Diabetes>'+C 7 or 75.9 1 or 7

27!our, 607g O9TT

*ormal

Re7evaluate in &years if risk

factors remain

METFORMIN IS NOT F! !""RO#E FOR "RE#ENTION

Lifestyle

intervention,follo7up H+ year

'+C A 0-6BI59 or I9T DI'ETE%

Lifestyle intervention

plus metformin,follo7upH& mo



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.rediabetes

.rediabetes is an important risk factorfor future diabetes and cardiovasculardisease

%tudies !ave s!on t!at lifestylemodification can reduce t!e rate ofprogression from prediabetes to diabetes



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$%&%'a(i)eInc

idence

ofia*e(e+

,-.

Year+

40

30

20

10

0

0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0

"'ace*o

Me(for&in

/ife+('e

Jnoler ?C, et al- NEJM- 22=&;)>&/&7;&-

Diabetes .revention .rogram


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Lifestyle #odification

Lose 6B of body eig!t

Reduce calories and dietary fat

'c!ieve %D' recommendations fordietary fiber and !ole grains

Limit intake of sugar7seetenedbeverages



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enefits of .!ysical 'ctivity

Increased insulin sensitivity

Improved lipid levels

Loer blood pressure

?eig!t control

Improved blood glucose control

Reduced risk of C


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;% Trial

27

45

231

0

10

20

30

40

50

"'ace*o Si&)a+(a(in "'ace*o Si&)a+(a(in

n:22

&2BRisk Reduction

.atients?it! #ajor

CoronaryEvent "B$

00BRisk Reduction

.yrMlM et al- Diabetes Care- +//6=2>)+;-

n:;2;2NC4D deat! or nonfatal #I

Nondiabetic.atientsDiabetic.atients

%tatins reduce coronary events


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Lipid #anagement

%creening for 'dultsTime of first diagnosis=

't initial medical evaluation= and8or

't age ; years and every +72 yearst!ereafter

'merican Diabetes 'ssociation- Diabetes Care. 2+0>&("%uppl- +$> %;/7%06-


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Lipid #anagement

Intensify lifestyle t!erapy and optimieglycemic control in patients it!>

Triglycerides A+0 mg8dL= and8or

Lo 4DL c!olesterol

P; mg8dL for men

P0 mg8dL for omen



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%tatin T!erapy


'ge Risk factors Recommendedstatin doseN #onitoringit! lipidpanel

P;years

*one *one 'nnually

or asneeded tomonitorad!erence

C


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%tatin T!erapy



;760years

*one #oderate

's neededto monitorad!erence

C


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%tatin T!erapy



F60years

*one #oderate

's neededto monitorad!erence

C


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J.D% lood .ressure %tudy

Tig!t blood pressure control "+;;8(2 mm4g$lead to>

&2B reduction in diabetes deat!s

;;B reduction in stroke

&6B reduction in microvascularcomplications

#Q- +//( %ep +2=&+6"6+)$>6&7+&-


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4ypertension

9oals for people it! diabetes and!ypertension

Loer targets "P+& mm4g, P( mm49$may be appropriate for certain individuals"younger patients$ if it can be ac!ievedit!out undue treatment burden-

lood .ressure 9oal

%ystolic P+; mm4gDiastolic P/ mm4g



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Treatment . A+;8/ mm4g

Lifestyle t!erapy G prompt initiation8timelytitration of drugs to ac!ieve goals-

Include 'CE in!ibitor or an angiotensinreceptor blocker "'R$-

#ultiple7drug t!erapy "2 or more agentsat maKimal doses$ is generally reuired-

'dminister + or more anti!ypertensivemedications at bedtime-



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J.D%> Legacy EffectS

After median 8.8 years post-trial follow-up

!rea(e Endoin( 17 2007

!n dia*e(e+ re'a(ed endoin( RRR: 12

P: 0.02 0.040

Micro)a+c%'ar di+ea+e RRR: 25 24

P: 0.00 0.001

Mocardia' infarc(ion RRR: 1 15

P: 0.052 0.014

!''-ca%+e &or(a'i( RRR: 13

P: 0.44 0.007RRR Re'a(i)e Ri+6 Red%c(ion " /o Ran6

4olman RR, et al- New England Journal of Medicine2(= &0/>+0667+0(/-

'CCORD>


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'CCORD>EKploring loer targets

N Engl J Med. &)&"&$>2&&72;;, 2+- T!e Lancet, &6) "/6&/$>;+/&, 2+- N Engl JMed.&0(>20;070/, 2(- N Engl J Med. &)2"+6$>+0607(0, 2+- N Engl J Med.&)2"+6$>+0)&76;, 2+-

T!ree randomiations T!ree results

'+C target P)B vs 67(B #ore intensive glycemic controlmicrovascular benefitno C


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Individualied 9lycemic Targets

#ore or less stringent goals may be

appropriate for individual patients-

'+C P6-B

.reprandial plasma

glucose

(7 +& mg 8dL

.eak postprandialplasma glucose

P +( mg 8dL

'merican Diabetes 'ssociation- Diabetes Care. 2+0>&("%uppl- +$> %&&7%;-

'ntiplatelet Trialists3


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'ntiplatelet Trialists3Collaboration

n:;02 P


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'spirin T!erapy

.rimary prevention strategy in t!ose it!increased cardiovascular risk !o !ave at leastone additional major risk factor

most men aged F0 years

most omen aged F) years %econdaryprevention strategy in t!ose it! diabetes it!a !istory of C&("%uppl- +$> %;/7%06-


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%moking

Is t!e smoker illing to uit@


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%ummary

Routinely assess patients3 C#R

Recommend multiple prevention andmanagement strategies to ac!ieve goals

Lifestyle Ot!er appropriate treatments

Evaluate patients it! C#R for ot!er riskfactors

Discuss risk for diabetes, !eart diseaseand stroke 1 and 1 benefits ofprevention


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%tandards of #edical Care

'n update of %tandards of #edicalCare in Diabetes appearsannually in t!e Qanuary

supplement of t!e journalDiabetes Care

Care-DiabetesQournals-org


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Continuing Education

Online self assessments,ebcasts and in7person

education opportunities>

.rofessional-Diabetes-org8ce


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.atient Education #aterials

+$ 5ree, reproducible patient !andouts in Englis!and %panis!

diabetes-org8toolkit

2$ Diabetes Risk Test

diabetes-org8risktest

&$ #y 4ealt! 'dvisor 1 ( and + year C#R

calculator

diabetes-org8#4'

Documents

Cardiometabolic Risk 2015