Cardiovascular Risk Reduction in Patients with Type 2 Diabetes
Journal of Clinical Outcomes Management. 2017 February;24(2)
References
Pharmacotherapy agents for weight loss have been approved by various regulatory agencies. None has as yet shown a reduction in cardiovascular events. Therefore, these cannot be recommended as therapies for vascular protection at this time.
Bariatric surgery is an effective option for weight loss in patients with diabetes, with marked and sustained improvements in clinically meaningful outcomes when compared with medical management. The longest study of bariatric surgery is the Swedish Obesity Study, a prospective case-control study of 2010 obese patients who underwent bariatric surgery and 2037 matched controls. After a median of 14.8 years of follow-up, there was a reduction in overall mortality (hazard ratio [HR] 0.71) and decreased incidence of diabetes (HR 0.17), myocardial infarction (HR 0.71), and stroke (HR 0.66). Diabetes remission, defined as normal A1c off of anti-hyperglycemic therapy, was increased at 2 years (odds ratio [OR] 13.3) and sustained at 15 years (OR 6.3) [34–36]. Randomized controlled trials of bariatric surgery have thus far been small and do show some decreases in cardiovascular risk factors [37–40]. However, these have not yet been of sufficient duration or size to demonstrate a decrease in cardiovascular event rate. Although local policies may vary in referral recommendation, the Obesity Society, ADA, and CDA recommend that patients with a body mass index greater than 40 kg/m 2, or greater than 35 kg/m 2 with an obesity-related comorbidity such as diabetes, should be referred to a center that specializes in bariatric surgery for evaluation [41–43].
Case Continued
After the initial diagnosis, the patient was seen by a registered dietitian and followed a Mediterranean diet for some time but has since stopped. He is seen regularly for follow-up of his diabetes at 3- to 6-month intervals. He initially lost some weight but has unfortunately regained the weight. He tells you proudly that he finally quit smoking. He was started on metformin about 6 months after diagnosis to address his glycemic control. He continues on the metformin now as his only medication.
The patient returns to clinic for his usual follow-up visit approximately 5 years after initial diagnosis. He is feeling well with no new medical issues. He has no clinically apparent retinopathy or macrovascular complications. On examination, his blood pressure is 140/90 mm Hg and the remainder of the exam is unremarkable. His bloodwork shows an A1c of 8% and a low-density lipoprotein cholesterol (LDL-C) level of 124 mg/dL. His albumin-to-creatinine ratio is normal.
How often should cardiovascular risk be reassessed?
Every patient visit should be seen as an opportunity to assess and reduce cardiovascular risk. The factors to assess include glycemic control, blood pressure, lifestyle, and smoking status. In addition, for the patient not on lipid-lowering therapy, a fasting cholesterol profile should be checked at diagnosis and then periodically every 1 to 5 years thereafter. If therapy is initiated, this interval should be decreased to every 3 to 6 months. Patients should be screened for microvascular complications at least once per year after diagnosis, with a complete foot examination, urinary albumin-to-creatinine ratio, and dilated retinal examination ( Table 2
