Cardiovascular Disease (CVD) & Diabetes
CVD Screening and Treatment
CVD Screening and Treatment
Screening
Asymptomatic patients: routine CAD screening not recommended; treatment of CVD risk factors is focus
Overt CVD: consider ACEI, and use aspirin and statin to reduce CV event risk
Asymptomatic patients: routine CAD screening not recommended; treatment of CVD risk factors is focus
Overt CVD: consider ACEI, and use aspirin and statin to reduce CV event risk
Prior MI: continue use of beta-blockers for ≥2 yrs after event
Symptomatic heart failure: avoid TZDs
Treatment
Metformin
• Stable heart failure: may use metformin in presence of normal renal function
• Avoid metformin in unstable or hospitalized heart failure patients
Management of High Blood Pressure
Screening
Measure BP at every visit; confirm elevated BP at separate visit
Screening
Measure BP at every visit; confirm elevated BP at separate visit
Treatment targets
Diabetes and hypertension: SBP
Diabetes and hypertension: SBP
• Lower SBP targets (eg,
Diabetes: DBP
Treatment
Treatment and targets for pregnant women
Treatment
BP >120/80 mm Hg: lifestyle changes
• Weight loss (if overweight)
• DASH-style diet including sodium restriction, potassium increase
• Moderate alcohol intake
• Increased physical activity
BP >140/80 mm Hg: lifestyle changes + pharmacologic therapy
• Diabetes and hypertension: ACEI or ARB†
• ≥2 agents at max doses usually required to achieve targets
• Administer ≥1 agent at bedtime
• ACEI, ARB, diuretic: monitor serum creatinine/eGFR and serum potassium
Treatment and targets for pregnant women
Diabetes and hypertension: 110-129/65-79 mm Hg target
ACEI, ARB contraindicated
*In certain individuals, if achieved without treatment burden ; †If one class not tolerated, substitute other class
Management of Dyslipidemia
Screening
Measure fasting lipids at least annually
Measure fasting lipids at least annually
Every 2 yrs for adults with low-risk lipid values: LDL-C 50 mg/dL (1.3 mmol/L), TG
Targets
• No overt CVD: LDL-C
Targets
• No overt CVD: LDL-C
• Overt CVD: LDL-C
Treatment
• If targets not achieved on max statin therapy: ~30-40% LDL-C reduction from baseline
Treatment
Lifestyle modification
• Reduce saturated fat, trans fat, cholesterol intake
• Increase omega-3 fatty acids, viscous fiber, plant stenols/sterols intake
• Weight loss (if indicated)
• Increase physical activity
Statin therapy* and lifestyle changes in patients with
• Overt CVD
• No CVD, aged >40 yrs, ≥1 CVD risk factor†
• Consider statins in lower-risk patients (no overt CVD, aged 100 mg/dL or if multiple CVD risk factors
Combination therapy not recommended
*Contraindicated in pregnancy
†Hypertension, smoking, dyslipidemia, albuminuria, family history of CVD
Antiplatelet therapy
Aspirin: Primary prevention
Aspirin: Primary prevention
75-162 mg/day: type 1 and type 2 diabetes at increased CVD risk
(10-yr risk >10%)*
Low-risk patients (10-yr risk
bleeds likely offsets potential benefits
Men
Aspirin: Secondary prevention
(10-yr risk 5%-10%): use clinical judgment
Aspirin: Secondary prevention
75-162 mg/day: diabetes and CVD history
CVD and aspirin allergy Clopidogrel 75 mg/day
Dual antiplatelet therapy Reasonable for ≤1 year after ACS
*Includes most men aged >50 yrs or women aged >60 yrs with ≥1 add’l major risk factor: family
history of CVD, hypertension, smoking, dyslipidemia, or albuminuria
