New US Guidelines Address CVD Prevention in Type 2 Diabetes

Miriam E Tucker

August 11, 2015

The American Diabetes Association (ADA) and the American Heart Association (AHA) have issued a newly revised joint scientific statement on prevention of cardiovascular disease in adults with type 2 diabetes.

The statement, which updates the previous one from 2007 (which updated the original one from 1999), was published jointly online August 5 in both Diabetes Care and Circulation by a writing group cochaired by Caroline S Fox, MD, a senior investigator at the National Heart, Lung, and Blood Institute, Bethesda, Maryland, and Sherita Hill Golden, MD, executive vice chair of the department of medicine and professor of medicine at Johns Hopkins University, Baltimore, Maryland.

"Cardiovascular disease is the leading cause of death in people with diabetes, so in terms of morbidity and mortality, risk management is critically important….We feel that this is a one-stop resource to get the newest information in cardiovascular disease prevention," Dr Golden told Medscape Medical News.

The document summarizes information from studies published since 2008, as well as changes in guidelines from the respective organizations based on those data. "We tried to be congruent. This is a joint statement from the ADA and AHA. Many members of the writing group are active in both organizations. The idea was for us to be unified in our recommendations," she said.

Included are diagnostic criteria — including the ADA's 2010 recommendation for use of HbA1c to diagnose diabetes, lifestyle management including physical activity and nutrition, weight management, aspirin use, glucose control, blood-pressure management, lipid management, screening for renal and CVD complications, and a list of controversial areas requiring further research.

Major Changes in ABC of Diabetes Care in Past 8 Years

Dr Golden said that since 2007, major changes have occurred in each of the "ABC" elements of diabetes care. Back in 2007, people were still questioning whether further reducing the upper target of HbA1c (the "A") as 7% would provide further cardiovascular disease benefit.

That was shown not to be the case by three major trials reported in 2008, the Action to Control Cardiovascular Risk in Diabetes (ACCORD) study , the Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified-Release Controlled Evaluation (ADVANCE) trial , and the Veterans Affairs Diabetes Trial (VADT).

"So, that 7% is still a target, but when you're focusing on preventing CVD glucose isn't the main target," Dr Golden said.

Guidelines for blood pressure ("B") in people with diabetes have also recently been loosened from 130/80 mm Hg to 140/90 mm Hg, based on data such as those of the 2010 ACCORD blood pressure trial showing that the goal of 130/80 did not provide further benefit and was associated with more side effects.

"We feel comfortable that our current target is appropriate for CVD prevention," she said.

And for cholesterol, the "C," a major shift came in 2013, with the AHA/American College of Cardiology advising clinicians to stop treating to LDL target but instead base the use of statins on overall CVD risk.

The guideline, which places most people with type 2 diabetes on moderate or high-dose statins, was generally endorsed by ADA.

The section on lifestyle modification notes that the Look AHEAD trial, published in 2013, showed that although intensive lifestyle intervention didn't reduce CVD, it did improve functioning and quality of life and reduced the number of medications that diabetes patients need to take.

Six Areas for Further Research

The ADA/AHA document also lists six main areas in need of further research:

  • The role of glucose-lowering drugs in reducing cardiovascular events.

  • The role of bariatric surgery.

  • The risks of hypoglycemia on the cardiovascular system.

  • The appropriate targets for blood pressure lowering.

  • The role of triglyceride lowering.

  • Imaging for subclinical CVD assessment.

Dr Golden and Dr Fox have no relevant financial relationships. Disclosures for the coauthors are listed in the article.

Diabetes Care. Published online August 5, 2015. Abstract

Circulation. Published online August 5, 2015. Abstract

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