The scientific statement reviews recent important updates on the control of CVD risk factors in the primary prevention of cardiovascular disease (CVD) in patients with type 2 diabetes, including current literature and key clinical trials on blood pressure and glucose control, cholesterol management, aspirin therapy, and lifestyle changes; new recommendations and clinical targets are presented, including screening for renal and subclinical CVD.
The first statement on this topic was jointly developed and published by the AHA and ADA in 1999 and was updated in 2007. Since that time, new clinical trials have emerged that have changed the clinical practice of CVD risk management in patients with diabetes. Since 2010, the ADA has included A1c in its diabetes diagnostic recommendations, suggesting that A1c > 6.5% can be used in the diagnosis of diabetes, as well as fasting glucose > 126 mg/dl or non-fasting glucose > 200 mg/dl. The AHA/ADA statement discusses the advantages and limitations of A1c, noting that this diagnostic update is based on current evidence (A1c is associated with long-term The AHA/ADA statement discusses the advantages and limitations of A1c, stating that this diagnostic update is based on current evidence (A1c is associated with long-term complications).
CVD risk factor management: Nutrition: Overweight or obese patients should reduce energy intake (ADA LOE A); all patients with diabetes require individualized medical nutrition therapy (ADA LOE A); carbohydrate monitoring should be an important treatment in glycemic control (ADA LOE B); fruits, legumes, vegetables, whole grains, and dairy products should be consumed in place of other carbohydrate sources (ADA LOE B); recommend Mediterranean dietary pattern to improve glycemic control and CVD risk factors (ADA LOE B); limit sodium intake to <2,300 mg/d (ADA LOE B). Obesity: Lifestyle changes to achieve 3-5% weight loss are recommended for overweight and obese patients to achieve meaningful health benefits (ACC/AHA Class I, LOE A), and bariatric surgery may be considered for those with a body mass index >40 or >35 with obesity-related complications (AHA/ACC Class IIa, LOE A).
Blood glucose: reduce A1c to <7% in most patients (ADA LOE B); more stringent targets (e.g., <6.5%) may be considered for selected patients, such as those with short disease duration, long life expectancy, and no significant CVD, provided this target is achieved without severe hypoglycemia or adverse effects (ADA LOE C); those with prior severe hypoglycemia, limited life expectancy, with severe comorbidities, and Patients with prior severe hypoglycemia, limited life expectancy, with severe comorbidities, cognitive impairment, or extensive comorbidities may use a more lenient target (e.g., <8% or more lenient) (ADA LOE B) Blood pressure: For most patients who achieve a blood pressure target of <140/90 mm Hg, some patients may have a lower target (Expert Opinion, Grade E), and recommended medications include ACEI or ARB (ADA LOE B); for those with chronic kidney disease, ACEI or ARB should be included in antihypertensive therapy (Expert Opinion, Grade E). Grade E); systolic blood pressure control to <140 mm Hg (ADA LOE A), but lower goals (e.g., <130 mm Hg) may be appropriate for some patients, such as younger patients, if these goals can be achieved without an overtreatment burden (ADA LOE C). Cholesterol: Patients with diabetes aged 40-75 years with LDL-C 70-189 mg/dl should be treated with a moderate-intensity statin (ACC/AHA Class I, LOE A, ADA LOE A) and a high-intensity statin (ACC/AHA Class IIa, LOE B) if the 10-year estimated risk of ASCVD is >7.5%. The benefit of statin therapy should be evaluated in those aged <40 years or >75 years (ACC/AHA Class IIa, LOE C); fasting triglycerides >500 mg/dl need to be evaluated and treated.
In addition, low-dose aspirin (75-162 mg/d) is reasonable in patients with a 10-year risk of CVD ≥10% and no increased risk of bleeding (ACC/AHA Class IIa, LOE B, ADA LOE C) and in diabetic patients with a 10-year risk of CVD of 5-10% (intermediate risk) (ACC/AHA Class IIb, ADA LOE C, ADA LOE C). LOE C, ADA LOE Expert Opinion).