ADA Updates Guidelines for Cardiovascular Risk Management in Diabetes
In the new ADA guideline, recommendations were made regarding managing hypertension and blood pressure, abnormal lipid profiles, coronary heart disease, and lifestyle interventions.
The American Diabetes Association (ADA) has published its 2018 Clinical Standards of Medical Care guidelines focused on recommendations for the identification and management of cardiovascular (CV) risk factors in patients with diabetes.
A literature review of high-quality diabetes trials was performed by the ADA Professional Practice Committee, a group composed of physicians, diabetes educators, registered dietitians, epidemiologists, and public health experts.
An A, B, C, or E rating was attributed to each recommendation based on the following levels of clinical evidence:
A rating: Recommendation is based on high-quality meta-analyses or well-designed, multicenter, large clinical trials
B rating: Recommendation is based on well-conducted cohort studies
C rating: Recommendation is based on uncontrolled studies
E rating: Recommendation is based on expert consensus for when there is no clinical trial evidence, there is conflicting evidence, or the clinical trial data that do exist are impractical
In the guideline, the committee offered new evidence-based recommendations to identify and manage hypertension and blood pressure, abnormal lipid profiles, coronary heart disease, and lifestyle interventions in patients with diabetes. Throughout each of these topics, recommendations were made on screening and diagnosis, treatment and lifestyle goals, and monitoring.
2018 ADA Clinical Guideline Update for Standards of Medical Care in Diabetes
- Diabetes patients should have blood pressure measured at each routine visit as well as at home and multiple readings on separate days should be used to identify hypertension (≥140/90 mm Hg; Grade B recommendation).
- Hypertensive patients with diabetes should be treated to achieve a systolic blood pressure of <140 mm Hg and a diastolic blood pressure of <90 mm Hg (Grade A recommendation), whereas lower pressure ratios (eg, 130/80 mm Hg) should be the goal for patients with diabetes deemed at high risk for cardiovascular disease (CVD; Grade C recommendation).
- Lifestyle interventions, including exercise, weight loss, smoking cessation, and reducing trans fat and cholesterol intake, are recommended for lowering blood pressure (Grade B recommendation) and lipids (Grade A recommendation).
- At diabetes diagnosis and/or initiation of statins or other lipid-lowering treatment, a lipid profile should be obtained at initial medical evaluation as well as every 5 years following evaluation if the patient is age <40 (Grade E recommendation).
- Lifestyle therapy should be an adjunct to high-intensity statin therapy in patients with diabetes and atherosclerotic CVD (ASCVD; Grade A recommendation).
- Patients with diabetes age <40 with other ASCVD risk factors (Grade C recommendation) as well as patients between 40 and 75 (Grade A recommendation) and >75 (Grade B recommendation) without ASCVD are recommended to undergo moderate-intensity statin therapy in addition to lifestyle intervention.
- In patients with diabetes and ASCVD who have low-density lipoprotein cholesterol ≥70 mg/dL and who are taking a maximally tolerated statin dose, additional low-density lipoprotein cholesterol-lowering treatments are recommended, including ezetimibe or a PCSK9 (proprotein convertase subtilisin/kexin type 9) inhibitor (Grade A recommendation).
- Patients with diabetes who have a history of ASCVD should use 75 to162 mg/d of aspirin for secondary prevention (Grade A recommendation), whereas patients with an aspirin allergy are recommended to take 75 mg/d of clopidogrel (Grade B recommendation).
- Patients with either type 1 or 2 diabetes at an increased risk for CVD (eg, family history of ASCVD, dyslipidemia, smoking, hypertension, or albuminuria) but no risk for bleeding may use 75 to162 mg/d of aspirin as their primary prevention strategy (Grade C recommendation).
- As long as ASCVD risk factors are effectively treated, asymptomatic patients are not recommended to undergo routine screening for coronary artery disease (Grade A recommendation).
- Known ASCVD should be managed with an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker therapy to reduce CV event risk (Grade B recommendation).
- Patients with diabetes with a history of myocardial infarction should be treated with beta-blockers for ≥2 years following the event (Grade B recommendation).
- In cases of stable congestive heart failure only, patients with diabetes may be treated with metformin if estimated glomerular filtration rate is sustained at >30 mL/min (Grade B recommendation).
Clinical and Economic Rationale for the Guidelines
The utilization of the ADA's 2018 recommendations may hold both clinical and economic benefits, considering that “ASCVD, defined as coronary heart disease, cerebrovascular disease, or peripheral artery disease, is the leading cause of morbidity and mortality in persons with diabetes and is the largest contributor to the direct and indirect costs of diabetes.”
Dr Chamberlain reports other support from Novo Nordisk, Sanofi Aventis, Janssen, and Merck outside the submitted work. Dr Johnson reports personal fees from Novo Nordisk, Medtronic, and Sanofi outside the submitted work. Dr Rhinehart reports employment with and stock ownership in Glytec. Dr Shubrook reports personal fees from Novo Nordisk, Lilly Diabetes, and Intarcia outside the submitted work.
Chamberlain JJ, Johnson EL, Leal S, et al. Cardiovascular disease and risk management: review of the American Diabetes Association Standards of Medical Care in Diabetes 2018 [published online April 3, 2018]. Ann Intern Med. doi:10.7326/M18-0222