Cardiovascular risk factors in diabetic patients with hypertension

Individuals with diabetes mellitus have cardiovascular disease (CVD) mortality comparable to nondiabetics who have suffered a myocardial infarction or stroke. Aggressive management of risk factors such as hypertension, dyslipidemia, and platelet dysfunction in persons with diabetes has been shown to reduce morbidity and mortality in prospective randomized controlled clinical trials. Accordingly, there are national mandates to lower blood pressure to less than 130/85 mm Hg, reduce low-density lipoprotein cholesterol to less than 100 mg/dL, and institute aspirin therapy in adult patients with diabetes. Although not definitively shown to reduce CVD, there are also recommendations to control the level of glycemia, as well. This article discusses CVD risk factors in the diabetic patient with hypertension.     

Cardiovascular disease in type 2 diabetes: challenge for treatment and prevention

Type 2 diabetes increases the risk of cardiovascular disease (CVD) two- to fourfold compared with the risk in non-diabetic subjects. Although type 2 diabetes is associated with a clustering of risk factors (small, dense low-density lipoprotein [LDL] particles, low high-density lipoprotein [HDL] cholesterol, high triglycerides, elevated blood pressure, obesity, central obesity, hyperinsulinaemia, hyperglycaemia, etc.), the cause for an excess risk of CVD remains unknown. Recent drug treatment trials have indicated that the lowering of total and LDL cholesterol and blood pressure is similarly beneficial in diabetic and non-diabetic subjects. The treatment of hyperglycaemia reduces micro- and macrovascular complications in type 2 diabetic patients. Beta-blocking agents, angiotensin-converting enzyme inhibitors, aspirin, and thrombolytic therapy are also effective in the treatment of CVD amongst diabetic patients.     

Treatment of hypertension in patients with diabetes

At least 17 million people in the United States have diabetes mellitus, and another 50 million have hypertension. These chronic diseases increasingly coexist in our aging population. Both diseases are important predisposing factors for the development of cardiovascular disease (CVD) and renal disease, and the coexistence of these risk factors is a very powerful promoter of CVD and renal disease. There is accumulating evidence that the rigorous treatment of hypertension and other risk factors such as dyslipidemia and hyperglycemia considerably lessens the burden of CVD and renal disease in patients with diabetes mellitus. There is considerable evidence that strategies addressing diet and exercise reduce the development of diabetes and are an important component of treatment in persons who have established diabetes. There are also considerable data suggesting that the treatment strategies that interrupt the renin-angiotensin system have special benefits in patients with diabetes and may prevent the development of clinical diabetes in hypertensive patients with impaired glucose tolerance. Data from a recent study indicate that the control of systolic blood pressure, using a diuretic agent as part of antihypertensive therapy, reduces the risk of stroke and other CVD end points. Recent reports indicate that angiotensin receptor-blocking agents decrease the rate of development of proteinuria and diabetic renal disease. These observations will likely have a significant impact on treatment of hypertension in patients with type 2 diabetes mellitus.     

Cardiovascular risk assessment scores for people with diabetes: a systematic review

People with type 2 diabetes have an increased risk of cardiovascular disease (CVD). Multivariate cardiovascular risk scores have been used in many countries to identify individuals who are at high risk of CVD. These risk scores include those originally developed in individuals with diabetes and those developed in a general population. This article reviews the published evidence for the performance of CVD risk scores in diabetic patients by: (1) examining the overall rationale for using risk scores; (2) systematically reviewing the literature on available scores; and (3) exploring methodological issues surrounding the development, validation and comparison of risk scores. The predictive performance of cardiovascular risk scores varies substantially between different populations. There is little evidence to suggest that risk scores developed in individuals with diabetes estimate cardiovascular risk more accurately than those developed in the general population. The inconsistency in the methods used in evaluation studies makes it difficult to compare and summarise the predictive ability of risk scores. Overall, CVD risk scores rank individuals reasonably accurately and are therefore useful in the management of diabetes with regard to targeting therapy to patients at highest risk. However, due to the uncertainty in estimation of true risk, care is needed when using scores to communicate absolute CVD risk to individuals.     

Cardiovascular risk in diabetes: a brief review

Cardiovascular disease (CVD) is the major cause of the morbidity and mortality associated with diabetes in the US. A 2- to 3-fold incidence of CVD occurs in both type 1 and type 2 diabetic individuals over that in age- and gender-matched non-diabetic persons. Recent encouraging data demonstrating a decline in CVD mortality in the general US population do not reflect such a decline in the diabetic population, particularly in women.Increased risk for CVD is related to duration of diabetes and hyperglycemia, as well as hypertension, dyslipidemia, insulin resistance, gender, coagulation abnormalities, and other factors. Health care providers need to advocate for an uncompromising, multi-component attack on all modifiable risk factors for CVD, including glucose control, in the person with diabetes mellitus. This review focuses on known modifiable risk factors for CVD associated with diabetes, potential targets for primary and secondary prevention.     

Primary prevention of cardiovascular disease and type 2 diabetes in patients at metabolic risk: an endocrine society clinical practice guideline

OBJECTIVE: The objective was to develop clinical practice guidelines for the primary prevention of cardiovascular disease (CVD) and type 2 diabetes mellitus (T2DM) in patients at metabolic risk. CONCLUSIONS: Healthcare providers should incorporate into their practice concrete measures to reduce the risk of developing CVD and T2DM. These include the regular screening and identification of patients at metabolic risk (at higher risk for both CVD and T2DM) with measurement of blood pressure, waist circumference, fasting lipid profile, and fasting glucose. All patients identified as having metabolic risk should undergo 10-yr global risk assessment for either CVD or coronary heart disease. This scoring will determine the targets of therapy for reduction of apolipoprotein B-containing lipoproteins. Careful attention should be given to the treatment of elevated blood pressure to the targets outlined in this guideline. The prothrombotic state associated with metabolic risk should be treated with lifestyle modification measures and in appropriate individuals with low-dose aspirin prophylaxis. Patients with prediabetes (impaired glucose tolerance or impaired fasting glucose) should be screened at 1- to 2-yr intervals for the development of diabetes with either measurement of fasting plasma glucose or a 2-h oral glucose tolerance test. For the prevention of CVD and T2DM, we recommend that priority be given to lifestyle management. This includes antiatherogenic dietary modification, a program of increased physical activity, and weight reduction. Efforts to promote lifestyle modification should be considered an important component of the medical management of patients to reduce the risk of both CVD and T2DM.     

老年人群心血管疾病的健康管理及预防

我国心血管疾病(CVD)患病人数持续上升,国民CVD危险因素个体暴露显著增加。老年人群作为特殊群体,其CVD患病率及死亡率均高,并带来了沉重的社会及经济负担。通过有效的CVD健康管理及预防能够有效降低老年人CVD患病率及死亡率,不仅可以延长老年人寿命,而且可以改善老年人生活质量。合理的方式包括:生活方式的干预;血压、血脂、血糖的控制及监测;小剂量阿司匹林的应用。老年人群CVD的健康管理模式需个体化,同时要注意评估衰弱、老年共病、多重用药及个人意愿。     

New concepts in dyslipidemia in the metabolic syndrome and diabetes

Trials have revealed that cardiovascular risk is not uniform in the population, but is distributed in a "risk pyramid." Diabetic patients with prior cardiovascular disease (CVD) are at greatest risk. Nondiabetic patients with CVD, diabetic patients without CVD, and subjects with the metabolic syndrome form the next three risk categories. The presence of insulin resistance-related metabolic abnormalities is a common denominator in this risk pyramid. Insulin resistance is a core defect in type 2 diabetes and the metabolic syndrome. Because insulin resistance may cause the atherogenic dyslipidemia that is commonly associated with these conditions, therapeutic strategies that combat insulin resistance could substantially reduce cardiovascular risk. Evidence suggests that defects in mitochondrial oxidative phosphorylation (which may be inherited, age related, or lifestyle acquired) may play a critical role in the pathogenesis of insulin resistance. Reduced mitochondrial oxidative phosphorylation can be partially reversed by improved diet, increased exercise, and administration of peroxisome proliferator-activated receptor-alpha agonists (omega-3 fatty acids and fibrates). Statin therapy has demonstrated clinical benefits in insulin-resistant patients but residual cardiovascular risk remains elevated. Fibrates also improve the lipid profile and reduce cardiovascular risk in a variety of insulin-resistant populations. Affected individuals should be targeted for therapeutic lifestyle intervention. Patients with atherogenic dyslipidemia who have developed insulin resistance, the metabolic syndrome, or type 2 diabetes should receive more intensive interventions including, where appropriate, statin-fibrate combination therapy, to comprehensively modify the lipid profile together with aggressive control of blood pressure and glucose to minimize risk in this very high-risk population.     

Aspirin and Other Antiplatelet Agents and Their Effects on Cardiovascular Disease in Type 2 Diabetes

Reduction of cardiovascular disease (CVD) events in patients with type 2 diabetes remains an area of intense interest and research. Recent trials of lower systolic blood pressure goals and combination lipid therapy have failed to show a significant reduction in CVD events in patients with diabetes. Antiplatelet agents are an additional option for CVD risk reduction in patients both with and without diabetes. However, two recent trials have questioned the role of aspirin in the primary prevention of CVD events in patients with diabetes. Although sub-analyses of larger trials have suggested a potential benefit of thienopyridine therapy in patients with diabetes, direct comparative trials are lacking and aspirin remains the appropriate first-line agent. Recent guidelines issued by the American Diabetes Association, American Heart Association, and American College of Cardiology Foundation on the use of aspirin for primary prevention in patients with diabetes remain the standard of practice. Two ongoing trials will help to address the question of the relative benefit of aspirin in patients with diabetes. The Aspirin and Simvastatin Combination for Cardiovascular Events Prevention Trial in Diabetes (ACCEPT-D) and A Study of Cardiovascular Events in Diabetes (ASCEND) are both randomized trials of 100 mg of aspirin compared to placebo and will enroll a combined 15,000 patients with diabetes between the two trials. Results may become available as soon as 2012.     

Statins and kidney disease

The prevalence of chronic kidney disease (CKD) is increasing worldwide. This clinical and social problem is mainly related to the ongoing epidemic of obesity and metabolic syndrome resulting in hypertension and diabetes mellitus. CKD is a well-recognized risk multiplier for the development of cardiovascular disease (CVD), and it is widely known that CVD is the leading cause of morbidity and mortality in patients with CKD. Lipid metabolism abnormalities are commonly associated with CKD. These consist of increased levels of low-density lipoproteins (LDL), triglycerides, very-low-density lipoproteins (VLDL) and lipoprotein(a), and reduced levels of HDL cholesterol. Lipid abnormalities contribute to cardiovascular morbidity and mortality in CKD patients. Some evidence also suggests that dyslipidemia may contribute to the progression of renal disease associated with type 1 and type 2 diabetic as well as non-diabetic renal disease. In the general population, HMG-CoA reductase inhibitors (statins) reduce the cardiovascular risk and prevent CVD. Similar data from secondary analyses of CKD subgroups of larger prospective trials using statins suggest a beneficial effect on cardiovascular outcomes and - albeit with more conflicting evidence - the progression of renal disease. Statins reduce blood levels of LDL cholesterol but also have multiple effects above and beyond cholesterol lowering, including direct effects on vascular tissue, kidney, bone, and glucose metabolism. The evidence linking dyslipidemia management with statins to cardiovascular disease and the decline in renal function in CKD patients will be presented in this review.     

Multifactorial Intervention to Reduce Cardiovascular Events in Type 2 Diabetes

Type 2 diabetes is associated with a significantly increased risk of cardiovascular disease (CVD) morbidity and mortality. Although several clinical trials have evaluated the effects of interventions to reduce CVD risk in people with diabetes, such studies are primarily conducted to target individual risk factors such as hypertension, hyperglycemia, and dyslipidemia rather than using a multifactorial interventional approach. Existing clinical trial data suggest that intensive multifactorial interventions that target several important risk factors simultaneously result in a significantly greater risk reduction in CVD risk compared with single risk factor interventions. However, few studies have evaluated the efficacy and effectiveness of such interventions on CVD hard end points. A multidisciplinary team management of diabetes should focus on weight control, diet, physical activity, diabetes education, and adherence to pharmacotherapy. An individually tailored aggressive management program to reduce multiple CVD risk factors simultaneously has great potential to prevent CVD morbidity and mortality among patients with type 2 diabetes.     

Diabetes and impaired glucose tolerance: a review of the epidemiological and trial evidence for their role in cardiovascular risk

People with diabetes mellitus are at increased risk of cardiovascular disease (CVD). There is a higher prevalence of recognized risk factors, such as hypertension and abnormal blood lipids, in the diabetic population and this may account for some of the increase in risk. However, the epidemiological evidence suggests that hyperglycemia per se is itself a risk factor for CVD, with no evidence of a lower threshold below which risk does not continue to fall. In the past, the cut-offs for considering an individual to have diabetes or not have been determined according to the risk of microvascular complications. If the relationship between glycemia and macrovascular complications is continuous throughout the range it may be arbitrary what level is used for diagnosis. Trials of lipid-lowering, and blood pressure reduction in diabetes have shown significant benefits for CVD prevention. This applies both to the reduction of elevated levels of blood pressure and cholesterol and, more recently, to lowering of these risk factors within the "normal" range. Randomized evidence for glucose lowering is not as conclusive, but it seems likely that glucose control should be treated in a similar manner.     

Diabetes mellitus and diabetes-associated vascular disease.

Diabetes-related cardiovascular disease remains the leading cause of death in patients with type 2 diabetes. Hypertension is common among diabetics and has the same pathogenetic mechanisms as insulin resistance, in which the activated renin-angiotensin system contributes to the emerging high blood pressure and hyperglycemia. Hyperglycemia is one of the triggering factors for vascular dysfunction and clotting abnormalities and, therefore, for accelerated atherosclerosis in diabetes. Glycated hemoglobin levels, as a reflection of the degree of glycemia, are strongly associated with the risk of cardiovascular disease in diabetics and in the general population. Tight glycemic control, the treatment of dyslipidemia and raised blood pressure, in addition to the use of antiplatelet therapy, all powerfully reduce the risks associated with diabetes. Furthermore, angiotensin-converting enzyme inhibitors might offer additional cardioprotection to diabetics above that provided by blood pressure reduction.     

Long-term risk reduction: who needs treatment?

Patients with type 2 diabetes or the metabolic syndrome have an elevated risk of developing cardiovascular disease (CVD). Until recently, strategies to reduce cardiovascular risk in these patients focused mainly on controlling glycemia and blood pressure as a means of preventing disease progression. However, the metabolic abnormalities that cluster both in patients with type 2 diabetes and the metabolic syndrome are all independent risk factors for atherogenesis. There is now substantial evidence that dyslipidemia is an important, modifiable risk factor for CVD in patients with type 2 diabetes or the metabolic syndrome. Recent sub-group analyses of landmark statin trials, such as the Heart Protection Study (HPS), confirm that the benefits of intensive statin therapy on CVD risk extend to patients with type 2 diabetes, irrespective of baseline lipid levels. In addition, the Collaborative AtoRvastatin Diabetes Study (CARDS), the first statin study to focus solely on patients with type 2 diabetes, was stopped early due to the overwhelming benefits of statin therapy on cardiovascular risk in a study population who previously would not have been considered dyslipidemic (mean baseline low-density lipoprotein cholesterol [LDL-C], 3.0 mmol/l [116 mg/dl]). As a result, treatment guidelines are setting increasingly stringent goals for LDL-C levels in an attempt to reduce cardiovascular risk. However, with physicians estimating that approximately 50% of patients with type 2 diabetes do not achieve these goals, initiation of appropriate, effective and rapid-acting statin therapy is paramount in these high-risk patients.     

The effect of sodium‐glucose cotransporter 2 inhibitors and glucagon‐like peptide 1 agonists on cardiovascular disease in patients with type 2 diabetes

Patients with type 2 diabetes have a significantly increased risk of cardiovascular disease (CVD) compared to the general population—with CVD accounting for two out of every three deaths in patients with diabetes. In 2008, the FDA suggested that CVD risk should be evaluated for any new antidiabetic therapy, leading to a multitude of large CVD outcome trials to assess CVD risk from these medications. Interestingly, several of these outcome trials with new novel antidiabetic therapies have demonstrated a clear and definite CVD advantage at mid‐term follow up in high‐risk patients with T2DM. In this review, we discuss two relatively new classes of diabetic drugs, sodium‐glucose cotransporter 2 inhibitors and glucagon‐like peptide 1 agonists, and their efficacy in improving cardiovascular outcomes.     

Poor control and management of cardiovascular risk factors among Albanian diabetic adult patients

BACKGROUND: Cardiovascular and metabolic risk factors represent potential targets for intervention. A good metabolic control, associated with control of blood pressure and cholesterol levels is proven to reduce the risk of cardiovascular disease among individuals with diabetes mellitus. OBJECTIVES: To examine 2004-2005 medical records of adults with previously diagnosed diabetes and to evaluate the fulfillment of diabetes guidelines treatment, for the metabolic control and management of cardiovascular risk factors. RESEARCH, DESIGN AND METHODS: We reviewed the data from the National Register of Diabetes (Tirana district), updated during this period. As guidelines we used the ADA 2006 Recommendations for metabolic control, HTA, lipid profile and aspirin therapy. RESULTS: We examined 7259 medical records. Only 14.58% of the patients had an HbA1c <7%. Central obesity was present in 39% of our patients. Overall, only 31.9% of our patients achieved the target for blood pressure (SBP<130 mmHg and DBP<80 mmHg). Two-third of our patients had total cholesterol >200 mg/dl. In total, only 5.5% of our patients attained recommended goals of cardiovascular risk factors for HbA1c, blood pressure and lipid profile. CONCLUSIONS: The follow-up of diabetic patients during the transient period in Albania is marked by a deterioration of diabetes metabolic control and poor management of cardiovascular risk factors. Further public health efforts are needed for better control of these risk factors among adults with diagnosed diabetes.     

Cardiovascular disease in diabetes mellitus: classical and non-classical risk factors

Cardiovascular disease, which includes coronary heart disease (CHD), cerebrovascular disease (CVD), and peripheral vascular disease (PVD), is the leading cause of mortality in populations, particularly in the diabetic one. Individuals with diabetes have at least a two-fold to four-fold increased risk of having cardiovascular events and a double risk of death compared with age-matched subjects without diabetes. A decline in mortality from CVD has been shown, but decline due to CHD is consistently lower in individuals with diabetes when compared with non-diabetics. The presence of several factors in diabetes leads to high occurrence of CVD such as hyperglycemia, insulin resistance, and classical and non-classical risk factors (systemic hypertension, dyslipidemia, obesity, proinflammatory condition and others). It is possible that the atherogenic role of obesity may be at least in part due to increased adipocyte production of cytokines. Considering the marked association of diabetes and CVD and unfavorable prognosis following an event, it is important to identify who is at high risk and how to screen. The American Heart Association and American Diabetes Association recommend risk stratification using diagnostic tests. However, the challenge is to accurately identify patients without a prior history of an event and those without symptoms strongly suggesting CVD, in whom additional testing would be indicated in order to achieve the most effective prevention. The benefits of glycemic control and the other risk factors have already been shown and justify optimization of the management of this high-risk population, aiming to reduce cardiovascular mortality disease and improve quality of life.     

Cardiovascular disease risk in subjects with type 2 diabetes mellitus in a population in southern Spain

To calculate overall 10-year cardiovascular disease (CVD) risk for patients with type 2 diabetes we applied the UKPDS and SCORE prediction models to data derived from clinical notes of 1846 patients (mean age 65.5 years; 55.8% women) with type 2 diabetes attending eight Primary-Care Centres serving a catchment population of 200,000 citizens in Andalusia. The results showed obesity and high blood pressure present in >50%, established CVD in 24%, retinopathy in 30%, and nephropathy in 17%. Mean HbAlc level was 7.3%. Compliance with therapeutic goals was 54% for systolic blood pressure <130 mmHg, 39% for HbA1c <7% and 9% for LDL cholesterol <2.58 mmol/L. Approximately 33% were receiving treatment with metformin, statins, renin-angiotensin system inhibitors and anti-aggregation agents. UKPDS risk for coronary heart disease (CHD) was 23% and 16% for stroke. The SCORE 10-year mortality risk was 5%. Correlation coefficient between the two models predicting CVD risk was 0.68 (p<0.001). We conclude that, despite the European consensus that CVD is low in Mediterranean countries, the CVD risk factors in the type 2 diabetes sub-population in southern Spain is relatively high. Specific measures of health-care intervention are needed if CVD-associated morbido-mortality rates in these diabetic patients are to be reduced.     

The role of antiplatelets in hypertension and diabetes mellitus

Cardiovascular disease (CVD) remains the main cause of mortality and morbidity in patients with diabetes. Prevention of CVD in diabetes involves a multifactorial approach that aims to treat the cluster of risk factors including hyperglycemia, dyslipidemia, obesity, hypertension, and hypercoagulation associated with this condition. Antiplatelets reduce the prothrombotic environment in diabetes, but complications of this therapeutic approach include a general risk of bleeding, specifically intracranial hemorrhage, the risk of which increases in the presence of hypertension. Current guidelines recommend the use of antiplatelet agents after tight control of blood pressure, which, in clinical practice, is not always possible. In this review, the evidence for antiplatelet use in diabetes with particular emphasis on patients with associated hypertension is examined. Safe levels of blood pressure with antiplatelet therapy, various studies, and general recommendations for diabetes patients, in light of current evidence, are explored.     

Serum glucose control in diabetic patients with cardiovascular disease: Should we be less aggressive?

Although aggressive control of hyperglycemia significantly reduces microvascular complications in patients with diabetes, there is no clear evidence that it improves macrovascular cardiovascular disease (CVD) outcomes. Data from recent studies suggest that intensive treatment of blood glucose has no significant effect on CVD outcomes and may even paradoxically increase cardiovascular and all-cause mortality, especially in older patients with longstanding type 2 diabetes and preexisting CVD. At present, it is prudent to aim for a glycated hemoglobin (HbA_1c) target of 7%, provided this can be achieved without hypoglycemia and other adverse effects of antidiabetic treatment. Treatment of patients with diabetes should begin early and include intensive efforts to promote a healthy lifestyle. Less stringent HbA_1c goals may be appropriate in older patients with advanced microvascular and macrovascular disease, other comorbid conditions, and a history of severe hypoglycemia. At all times, cholesterol, blood pressure, and other CVD risk factors should be aggressively managed.