In the United States, less than one in five adults with type 2 diabetes meet goals for reducing the risk of heart disease. Fortunately, the available therapies can help when combined with new approaches that address the social determinants of health and other barriers to care, according to a new scientific statement from the American Heart Association released today in the journal. flagship of the Association. Circulation. A scientific statement is an expert analysis of current research and may inform future clinical practice guidelines.
This new scientific statement is an urgent call to action to follow the latest evidence-based approaches and develop new best practices to advance type 2 diabetes treatment and care and reduce the risk of CVD. Far too few people – less than 20% of people with type 2 diabetes – successfully manage their risk for heart disease, and far too many struggle to quit smoking and lose weight, two key cardiovascular risk factors. Healthcare professionals, the healthcare industry and broader community organizations all have an important role to play in supporting people with type 2 diabetes. ”
Joshua J. Joseph, MD, MPH, FAHA, Chairman of the Statement Writing Group and Assistant Professor of Medicine, Division of Endocrinology, Diabetes, and Metabolism, The Ohio State University College of Medicine in Columbus, Ohio
Type 2 diabetes is the most common form of diabetes, affecting more than 34 million people in the United States, representing nearly 11% of the American population, according to the Centers for Disease Control’s 2020 National Diabetes Statistics Report and Prevention in the United States, and cardiovascular disease (CVD) is the leading cause of death and disability in people with type 2 diabetes (T2DM). Type 2 diabetes occurs when the body is unable to use the insulin it produces effectively or when the pancreas loses its ability to produce insulin. People with T2DM often have other risk factors for cardiovascular disease, including being overweight or obese, high blood pressure, or high cholesterol. Adults with T2DM are twice as likely to die of cardiovascular disease -; including heart attacks, strokes and heart failure -; compared to adults who do not have T2DM.
The new scientific statement, based on the editorial group’s extensive review of clinical trial results through June 2020, bridges the gap between existing evidence on how best to reduce cardiovascular risk in people with T2DM and reality for people living with T2DM. Targets for reducing the risk of CVD in people with T2DM include managing blood sugar, blood pressure, and cholesterol levels; increase physical activity; Healthy eating; obesity and weight management; no smoking; do not drink alcohol; and psychosocial care. Greater adherence to an overall healthy lifestyle in people with T2DM is associated with a significantly lower risk of CVD and CVD mortality.
“In the United States, less than one in five adults with T2D not diagnosed with cardiovascular disease meet the optimal T2D management goals of not smoking and achieving healthy blood sugar, blood pressure and cholesterol levels low density lipoprotein (LDL), also known as “bad” cholesterol, ”Joseph said.
A surprisingly high proportion – up to 90% – of factors for effectively managing cardiovascular disease with T2DM includes modifiable lifestyle and societal factors. “The social determinants of health, which include health-related behaviors, socio-economic factors, environmental factors and structural racism, have been recognized to have a profound impact on cardiovascular disease and the outcomes of type diabetes. 2, “he said. “People with T2DM face many barriers to health, including access to care and equitable care, which must be considered when developing individualized care plans with our patients. “
Shared decision making between patients and healthcare professionals is essential for the successful management of T2DM and CVD. A comprehensive diabetes care plan should be tailored based on individual risks and benefits and taking into account patient preferences; potential cost issues; support to effectively manage T2DM and take prescribed medications, including diabetes education and self-management support; promoting and supporting healthy lifestyle choices that improve cardiovascular health, including nutrition and physical activity; and the treatment of any other risk factors for CVD.
“One way to continue to treat and advance diabetes management is to tear down the four walls of the clinic or hospital through community engagement, clinic-community connections, and university-community partnerships.” -government that can help address and support modifiable lifestyle behaviors such as physical activity, nutrition, smoking cessation and stress management, ”Joseph said.
The statement also highlights recent evidence on the treatment of T2DM that may prompt clinicians and patients to review and update their T2DM management plan to address CVD risk factors as well:
New ways to control blood sugar
The American Heart Association’s latest scientific statement on blood sugar control was released in 2015, just as research began to suggest that hypoglycemic drugs may also reduce the risk of heart attack, stroke, and disease. heart failure or cardiovascular death.
“Since 2015, a number of major national and international clinical trials that have specifically examined new T2DM drugs to reduce the risk of cardiovascular disease and cardiovascular mortality in people with type 2 diabetes have been completed,” Joseph said. “GLP-1 (glucagon-like pepdite-1) receptor agonists have been shown to improve blood sugar and weight, and they’ve been a game-changer in reducing the risk of heart disease, stroke, heart failure. and kidney disease. ” GLP-1 drugs (synthetic injectable hormones such as liraglutide and semaglutide) stimulate the release of insulin to control blood sugar levels, and they also reduce appetite and help people feel full, which can help with blood sugar levels. weight management or weight loss.
In addition, SGLT-2 (sodium-glucose co-transporter 2) inhibitors (oral drugs such as canaglifozin, dapagliflozin, ertugliflozin, and empagliflozin) have also been shown to be effective in reducing the risk of CVD and chronic kidney disease. SGLT-2 inhibitors cause the kidneys to pass excess glucose through the urine, which reduces the risk of heart failure and slows the decline in kidney function that is common in people with T2DM.
“Cost can be a barrier to taking some T2DM medications as prescribed, however, many of these medications are now more commonly covered by more health insurance plans,” Joseph said. “Another hurdle is patient recognition that these new T2DM drugs are also effective in reducing the risk of heart disease, stroke, heart failure and kidney disease. Raising public awareness of the link between CVD and T2DM and providing support, education and tools that help improve T2DM and reduce CVD risk are at the heart of American’s Know Diabetes by Heart ™ initiative. Heart Association and the American Diabetes Association. “
Personalized blood pressure control
The statement emphasizes that individualized approaches to treating high blood pressure are the best. These approaches should consider ways to minimize the side effects of treating hypertension and to avoid overtreating frail patients.
Importance of lowering cholesterol
Statin drugs remain the first line of lipid-lowering therapy, and the Association suggests that other types of drugs may be considered for people who cannot tolerate a statin or who do not meet their LDL cholesterol targets with a statin. These drugs may include ezetimibe, bempodoic acid, bile acid resins, fibrates, and PCSK-9 inhibitors, depending on the person’s general health and other health concerns.
Rethinking the use of aspirin
Seniors (65 years and older) with T2DM are more likely than those without T2DM to take low-dose aspirin daily to help prevent cardiovascular disease. However, it might be time to check if daily low dose aspirin is still appropriate. Recently published research suggests that the increased risk of major bleeding from aspirin may outweigh the benefits, and newer, stronger antiplatelet drugs may be more effective for some people.
The statement reinforces the importance of a comprehensive, multidisciplinary and individualized approach to reducing the risk of CVD in people with T2DM. Optimal care should incorporate interventions aimed at a healthy lifestyle, as well as medications and / or treatments, including surgery, that improve the management of T2DM and promote healthy weights and weight loss. Social determinants of health, structural racism and health equity are important factors that also need to be considered and addressed.
The scientific statement was prepared by the volunteer writing group on behalf of the American Heart Association Diabetes Committee of the Council on Lifestyle and Cardiometabolic Health; the Council on Arteriosclerosis, Thrombosis and Vascular Biology; the Clinical Cardiology Council; and the Hypertension Council. American Heart Association scientific statements promote greater awareness of cardiovascular disease and stroke and help facilitate informed health care decisions. Scientific statements describe what is currently known about a topic and areas requiring further research. While the scientific statements inform the development of the guidelines, they do not make treatment recommendations. The American Heart Association guidelines provide the Association’s official clinical practice recommendations.
American Heart Association
Joseph, JJ, et al. (2022) Comprehensive management of cardiovascular risk factors for adults with type 2 diabetes: a scientific statement from the American Heart Association. Circulation. doi.org/10.1161/CIR.0000000000001040.