COMMENTARY

Multifactorial Approach to Prevent Cardiovascular Disease in Type 2 Diabetes

Michel Marre, MD, PhD

Disclosures

July 21, 2014

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Identifying Diabetes and Cardiovascular Risks

Hello. My name is Michel Marre, head of the diabetes department at Bichat-Claude Bernard University Hospital in Paris, France. I will say a few words about the European Society of Cardiology (ESC)/European Association for the Study of Diabetes (EASD) guidelines on diabetes and cardiovascular risk.[1]

Diabetes mellitus is a metabolic disorder caused by both a defect in insulin secretion and in insulin action. It is an important contributor to vascular damage. Remember that by definition, diabetes induces microvascular complications, and it is also a huge risk factor for macrovascular complications.

To detect patients at risk of developing diabetes mellitus, you can use the Finnish Diabetes Risk Score (FINDRISC), which is a score that takes into account both the glycemia level, the cardiovascular risk factors of the patient, and the family prevalence of diabetes mellitus.

You can take some prevention measures, which include lifestyle interventions that can reduce the risk for diabetes by 50%. If this is not enough, you can add in some pharmacotherapy; for instance, alpha-glucosidase inhibitors, metformin, glitazones, insulin, and angiotensin II receptor blockers (ARBs) have some evidence that they can delay or postpone the progression to diabetes mellitus.

In fact, an individual evaluation must include an assessment of the classic risk factors, the glycemic status, the macrovascular disease, and the microvascular disease:

The classic risk factors are family history, lifestyle, smoking, hypertension, and dyslipidemia;

Macrovascular disease: coronary status, cerebral vascular disease, peripheral arterial disease, and heart failure;

Microvascular disease: retinopathy, nephropathy, and neuropathy; and

Don't forget arrhythmias, especially atrial fibrillation.

A Multifactorial and Multidisciplinary Approach to Risk Factor Control

Cardiovascular risk requires multifactorial management, with an emphasis on lifestyle intervention. Look at what the patient eats and drinks. I am from the Mediterranean area, and believe me, if you are on a Mediterranean diet from your birth date, then your life expectancy will be much longer than if you are not.

With respect to the control of classic risk factors, the key targets for the prevention of cardiovascular disease include:

Maintaining blood pressure below 140/85 mm Hg. This is the objective for patients without any renal impairment. If the patient has a slight increase in microalbuminuria, then the blood pressure objective must be below 130/80 mm Hg.

Look at the patient's low-density lipoprotein (LDL) cholesterol level, which must be below 1.8 mmol/L (70 mg/dL).

Glycemic control, as assessed by A1c, must be below 7%.

These targets should be applied with the individual needs of the patient taken into account. Multifactorial management includes the following:

For blood pressure lowering, do not forget to prescribe as first-line therapy a renin-angiotensin-aldosterone inhibitor. This is mandatory.

For lipid control, use a statin for first-line therapy, and prescribe an appropriate dose.

Antiplatelet therapy is recommended for secondary prevention of cardiovascular disease.

Often, you have to combine several antidiabetic agents to achieve good glycemic control, but as most of our patients are overweight or obese, use metformin as much as possible in first-line therapy.

The approach to the risk for cardiovascular disease in patients with diabetes mellitus must be multidisciplinary -- with general practitioners, and specialists in cardiology, diabetology, ophthalmology, nephrology, and psychiatry. Please do not forget those who are assigned with us to take care of patients -- the caregivers, nurses, dietitians, podiatrists and physiotherapists, all of whom are important collaborators. Thank you.

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