Primary Prevention of Cardiovascular Diseases in People With Diabetes Mellitus: A Scientific Statement from the American Heart Association and the American Diabetes Association

John B. Buse, MD, PHD, CO-CHAIR; Henry N. Ginsberg, MD, CO-CHAIR; George L. Bakris, MD; Nathaniel G. Clark, MD, MS, RD; Fernando Costa, MD; Robert Eckel, MD; Vivian Fonseca, MD; Hertzel C. Gerstein, MD, MSC, FRCPC; Scott Grundy, MD, PHD; Richard W. Nesto, MD; Michael P. Pignone, MD, MPH; Jorge Plutzky, MD; Daniel Porte, MD; Rita Redberg, MD; Kimberly F. Stitzel, MS, RD; Neil J. Stone, MD

Disclosures

Diabetes Care. 2007;30(1):162-172. 

In This Article

Abstract and Introduction

The American Heart Association (AHA) and the American Diabetes Association (ADA) have each published guidelines for cardiovascular disease prevention: the ADA has issued separate recommendations for each of the cardiovascular risk factors in patients with diabetes, and the AHA has shaped primary and secondary guidelines that extend to patients with diabetes. This statement will attempt to harmonize the recommendations of both organizations where possible but will recognize areas in which AHA and ADA recommendations differ.

Diabetes is a disease defined by abnormalities of fasting or postprandial glucose and is frequently associated with disorders of the eyes, kidneys, nerves, and circulatory system. Circulatory disorders associated with diabetes include coronary heart disease (CHD), stroke, peripheral arterial disease, cardiomyopathy, and congestive heart failure. Diabetes generally results in early death from cardiovascular diseases (CVDs). In 1999, the American Diabetes Association (ADA) and the American Heart Association (AHA) published a joint statement with the National Heart, Lung, and Blood Institute (NHLBI), the National Institute of Diabetes and Digestive and Kidney Diseases, and the Juvenile Diabetes Foundation International indicating the need for multiorganizational cooperation for prevention of CVD in patients with diabetes.[1] The present statement represents a joint response of the ADA and AHA to this challenge.

The ADA and AHA each have published guidelines for CVD prevention that overlap with the present statement: The ADA has issued separate recommendations for each of the cardiovascular risk factors in patients with diabetes, and the AHA has shaped primary and secondary guidelines that extend to patients with diabetes. The present document will attempt to harmonize the recommendations of both organizations where possible but will recognize areas in which ADA and AHA recommendations differ.

Clear clinical trial evidence published over the past decade suggests that broad-based treatment of dyslipidemia, hypertension, and hypercoagulability (as well as interventional cardiology and cardiovascular surgery during the acute coronary syndrome[2]) can improve the event-free survival rate in people with diabetes who already have clinical CVD. However, a much smaller body of clinical trial data addresses the issue of primary prevention of CVD in patients with diabetes and no known CVD. This is a critical issue because patients with diabetes have twice the risk of incident myocardial infarction and stroke as that of the general population. Furthermore, large numbers of people with diabetes do not survive their first event, and if they do survive, their mortality rate over the subsequent months to years is generally greater than that of the general population. As many as 80% of patients with type 2 diabetes will develop and possibly die of macrovascular disease. This represents a great societal cost, with major loss of life expectancy and quality of life.[3,4] Although the incidence of CVD events in patients with diabetes seems to have declined over the past decade,[5] implementation of preventive strategies is often inadequate.[6]

To facilitate clinical practice, the present statement is condensed into essential recommendations. No endeavor is made to recapitulate all of the clinical trial evidence that is thoroughly documented in the ADA and AHA reports on management of individual risk factors. For each of the risk factors, a sampling of relevant studies is discussed and referenced. Recommendations are made on the totality of evidence in the field, including studies of several types, such as controlled clinical trials ( Table 1 ). When possible, studies under way that will further address these issues are also noted. With the exception of recommendations related to control of hyperglycemia, the recommendations provided in this document are appropriate for people both with and without diabetes; however, because of their higher risk for CVD, people with diabetes should derive even more benefit from these recommendations.

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