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Vascular Protection in People with Diabetes
Can J Diabetes 37 (2013) S322
Contents lists available at SciVerse ScienceDirect
Canadian Journal of Diabetes journal homepage: www.canadianjournalofdiabetes.com
Executive Summary
Vascular Protection in People with Diabetes KEY MESSAGES Diabetes promotes both the development and adverse impact of cardiovascular disease (CVD) risk factors (e.g. hypertension, dyslipidemia, renal dysfunction) and, as a consequence, accelerates cardiovascular age. Persons with diabetes generally have a cardiovascular age 10 to 15 years in advance of their chronological age (1). Advanced cardiovascular age substantially increases both the proximate and lifetime risk for CVD events, resulting in a reduced life expectancy of approximately 12 years (2). Although young patients with diabetes rarely will have a high proximate risk for CVD events, they have a relative proximate risk many fold greater than that of individuals without diabetes (1). All adults with diabetes require chronic disease care strategies that include health behaviour education and, for many individuals, pharmacological vascular protection, in order to promote CVD event risk reduction. The requirement for pharmacological vascular protection therapies (statins, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers and acetylsalicylic acid) should be determined by both an individual’s proximate and lifetime CVD event risk.
Highlights of Revisions Two chapters from the 2008 guidelinesd“Identification of Individuals at High Risk of Coronary Events” and “Vascular Protection in People with Diabetes”dhave been combined into one chapter. A new recommendation eliminates the need to determine the risk status for patients before deciding on vascular protective medication use. The chapter now provides a more precise definition of the people who should receive vascular protective medications (angiotensin converting enzyme [ACE] inhibitor, angiotensin II receptor blocker [ARB], statin, or acetylsalicylic acid [ASA]). It is now recommended that ASA not be routinely used for primary prevention in diabetes.
RECOMMENDATIONS 1. All individuals with diabetes (type 1 or type 2) should follow a comprehensive, multifaceted approach to reduce cardiovascular risk, including: Achievement and maintenance of healthy body weight Healthy diet Regular physical activity Smoking cessation Optimal glycemic control (usually A1C 7%) Optimal blood pressure control (<130/80 mm Hg) Additional vascular protective medications in the majority of adult patients (see Recommendations 2 to 6 below) [Grade D, Consensus, for type 1 diabetes, children/adolescents; Grade A, Level 1 (1,2), for type 2 diabetes] 2. Statin therapy should be used to reduce cardiovascular risk in adults with type 1 or type 2 diabetes) with any of the following features: i. Clinical macrovascular disease [Grade A, Level 1 (3)] ii. Age 40 years [Grade A, Level 1 (3,4), for type 2 diabetes; Grade D, Consensus, for type 1 diabetes] 1499-2671/$ e see front matter Ó 2013 Canadian Diabetes Association http://dx.doi.org/10.1016/j.jcjd.2013.02.022
iii.
Age <40 years and 1 of the following: Diabetes duration >15 years and age >30 years [Grade D, Consensus] Microvascular complications [Grade D, Consensus] Warrants therapy based on the presence of other risk factors according to the 2012 Canadian Cardiovascular Society Guidelines for the Diagnosis and Treatment of Dyslipidemia (5) [Grade D, Consensus]
3. ACE inhibitor or ARB, at doses that have demonstrated vascular protection, should be used to reduce cardiovascular risk in adults with type 1 or type 2 diabetes with any of the following: i. Clinical macrovascular disease [Grade A, Level 1 (6,7)] ii. Age 55 years [Grade A, Level 1 (6,7), for those with an additional risk factor or end organ damage; Grade D, Consensus, for all others] iii. Age <55 years and microvascular complications [Grade D, Consensus] Note: Among women with childbearing potential, ACE inhibitors, ARBs or statins should only be used if there is reliable contraception. 4. ASA should not be routinely used for the primary prevention of cardiovascular disease in people with diabetes [Grade A, Level 2 (8)]. ASA may be used in the presence of additional cardiovascular risk factors [Grade D, Consensus]. 5. Low-dose ASA therapy (81e325 mg) may be used for secondary prevention in people with established cardiovascular disease [Grade D, Consensus]. 6. Clopidogrel 75 mg may be used in people unable to tolerate ASA [Grade D, Consensus]. Abbreviations: A1C, glycated hemoglobin; ACE, angiotensin-converting enzyme; ARB, angiotensin receptor blocker; ASA, acetylsalicylic acid.
References 1. Gaede P, Vedel P, Larsen N, et al. Multifactorial intervention and CAD in patients with type 2 diabetes. N Engl J Med 2003;348:383e93. 2. Gaede P, Lund-Andersen H, Parving HH, Pedersen O. Effect of a multifactorial intervention on mortality in type 2 diabetes. N Engl J Med 2008;358:580e91. 3. Collins R, Armitage J, Parish S, et al. MRC/BHF Heart Protection Study of cholesterol-lowering with simvastatin in 5963 people with diabetes: a randomised placebo controlled trial: Heart Protection Study Collaborative Group. Lancet 2003;361:2005e16. 4. Colhoun HM, Betteridge DJ, Durrington PN, et al. Primary prevention of cardiovascular disease with atorvastatin in type 2 diabetes in the Collaborative Atorvastatin Diabetes Study (CARDS): multicentre randomised placebocontrolled trial. Lancet 2004;364:685e96. 5. Anderson TJ, Grégoire J, Hegele RA, et al. 2012 Update of the Canadian Cardiovascular Society Guidelines for the Diagnosis and Treatment of Dyslipidemia for the Prevention of Cardiovascular Disease in the Adult. Can J Cardiol 2013;29:151e67. 6. Gerstein HC, Yusuf S, Mann JFE, et al, The Heart Outcomes Prevention Evaluation (HOPE) Study Investigators. Effects of ramipril on CAD and microvascular outcomes in people with diabetes mellitus: results of the HOPE study and MICRO-HOPE substudy. Lancet 2000;355:253e9. 7. Yusuf S, Teo K, Pogue J, et al. Telmisartan, ramipril, or both in patients at high risk for vascular events. N Engl J Med 2008;358:1547e59. 8. de Berardis G, Sacco M, Strippoli GF, et al. Aspirin for primary prevention of cardiovascular events in people with diabetes: meta-analysis of randomised controlled trials. BMJ 2009;339:b4531.
Contents lists available at SciVerse ScienceDirect
Canadian Journal of Diabetes journal homepage: www.canadianjournalofdiabetes.com
Executive Summary
Vascular Protection in People with Diabetes KEY MESSAGES Diabetes promotes both the development and adverse impact of cardiovascular disease (CVD) risk factors (e.g. hypertension, dyslipidemia, renal dysfunction) and, as a consequence, accelerates cardiovascular age. Persons with diabetes generally have a cardiovascular age 10 to 15 years in advance of their chronological age (1). Advanced cardiovascular age substantially increases both the proximate and lifetime risk for CVD events, resulting in a reduced life expectancy of approximately 12 years (2). Although young patients with diabetes rarely will have a high proximate risk for CVD events, they have a relative proximate risk many fold greater than that of individuals without diabetes (1). All adults with diabetes require chronic disease care strategies that include health behaviour education and, for many individuals, pharmacological vascular protection, in order to promote CVD event risk reduction. The requirement for pharmacological vascular protection therapies (statins, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers and acetylsalicylic acid) should be determined by both an individual’s proximate and lifetime CVD event risk.
Highlights of Revisions Two chapters from the 2008 guidelinesd“Identification of Individuals at High Risk of Coronary Events” and “Vascular Protection in People with Diabetes”dhave been combined into one chapter. A new recommendation eliminates the need to determine the risk status for patients before deciding on vascular protective medication use. The chapter now provides a more precise definition of the people who should receive vascular protective medications (angiotensin converting enzyme [ACE] inhibitor, angiotensin II receptor blocker [ARB], statin, or acetylsalicylic acid [ASA]). It is now recommended that ASA not be routinely used for primary prevention in diabetes.
RECOMMENDATIONS 1. All individuals with diabetes (type 1 or type 2) should follow a comprehensive, multifaceted approach to reduce cardiovascular risk, including: Achievement and maintenance of healthy body weight Healthy diet Regular physical activity Smoking cessation Optimal glycemic control (usually A1C 7%) Optimal blood pressure control (<130/80 mm Hg) Additional vascular protective medications in the majority of adult patients (see Recommendations 2 to 6 below) [Grade D, Consensus, for type 1 diabetes, children/adolescents; Grade A, Level 1 (1,2), for type 2 diabetes] 2. Statin therapy should be used to reduce cardiovascular risk in adults with type 1 or type 2 diabetes) with any of the following features: i. Clinical macrovascular disease [Grade A, Level 1 (3)] ii. Age 40 years [Grade A, Level 1 (3,4), for type 2 diabetes; Grade D, Consensus, for type 1 diabetes] 1499-2671/$ e see front matter Ó 2013 Canadian Diabetes Association http://dx.doi.org/10.1016/j.jcjd.2013.02.022
iii.
Age <40 years and 1 of the following: Diabetes duration >15 years and age >30 years [Grade D, Consensus] Microvascular complications [Grade D, Consensus] Warrants therapy based on the presence of other risk factors according to the 2012 Canadian Cardiovascular Society Guidelines for the Diagnosis and Treatment of Dyslipidemia (5) [Grade D, Consensus]
3. ACE inhibitor or ARB, at doses that have demonstrated vascular protection, should be used to reduce cardiovascular risk in adults with type 1 or type 2 diabetes with any of the following: i. Clinical macrovascular disease [Grade A, Level 1 (6,7)] ii. Age 55 years [Grade A, Level 1 (6,7), for those with an additional risk factor or end organ damage; Grade D, Consensus, for all others] iii. Age <55 years and microvascular complications [Grade D, Consensus] Note: Among women with childbearing potential, ACE inhibitors, ARBs or statins should only be used if there is reliable contraception. 4. ASA should not be routinely used for the primary prevention of cardiovascular disease in people with diabetes [Grade A, Level 2 (8)]. ASA may be used in the presence of additional cardiovascular risk factors [Grade D, Consensus]. 5. Low-dose ASA therapy (81e325 mg) may be used for secondary prevention in people with established cardiovascular disease [Grade D, Consensus]. 6. Clopidogrel 75 mg may be used in people unable to tolerate ASA [Grade D, Consensus]. Abbreviations: A1C, glycated hemoglobin; ACE, angiotensin-converting enzyme; ARB, angiotensin receptor blocker; ASA, acetylsalicylic acid.
References 1. Gaede P, Vedel P, Larsen N, et al. Multifactorial intervention and CAD in patients with type 2 diabetes. N Engl J Med 2003;348:383e93. 2. Gaede P, Lund-Andersen H, Parving HH, Pedersen O. Effect of a multifactorial intervention on mortality in type 2 diabetes. N Engl J Med 2008;358:580e91. 3. Collins R, Armitage J, Parish S, et al. MRC/BHF Heart Protection Study of cholesterol-lowering with simvastatin in 5963 people with diabetes: a randomised placebo controlled trial: Heart Protection Study Collaborative Group. Lancet 2003;361:2005e16. 4. Colhoun HM, Betteridge DJ, Durrington PN, et al. Primary prevention of cardiovascular disease with atorvastatin in type 2 diabetes in the Collaborative Atorvastatin Diabetes Study (CARDS): multicentre randomised placebocontrolled trial. Lancet 2004;364:685e96. 5. Anderson TJ, Grégoire J, Hegele RA, et al. 2012 Update of the Canadian Cardiovascular Society Guidelines for the Diagnosis and Treatment of Dyslipidemia for the Prevention of Cardiovascular Disease in the Adult. Can J Cardiol 2013;29:151e67. 6. Gerstein HC, Yusuf S, Mann JFE, et al, The Heart Outcomes Prevention Evaluation (HOPE) Study Investigators. Effects of ramipril on CAD and microvascular outcomes in people with diabetes mellitus: results of the HOPE study and MICRO-HOPE substudy. Lancet 2000;355:253e9. 7. Yusuf S, Teo K, Pogue J, et al. Telmisartan, ramipril, or both in patients at high risk for vascular events. N Engl J Med 2008;358:1547e59. 8. de Berardis G, Sacco M, Strippoli GF, et al. Aspirin for primary prevention of cardiovascular events in people with diabetes: meta-analysis of randomised controlled trials. BMJ 2009;339:b4531.