Case-Based Review

Cardiovascular Risk Reduction in Patients with Type 2 Diabetes

Journal of Clinical Outcomes Management. 2017 February;24(2)

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From the Division of Endocrinology, Department of Medicine, University of Toronto, Ontario, Canada.

Abstract

Objective: To review the assessment of cardiovascular risk and prevention of vascular disease in patients with type 2 diabetes mellitus (T2DM).
Methods: Literature and guidelines were reviewed and the evidence is presented around a clinical case.
Results: T2DM has a high prevalence and confers significant lifetime risk for macrovascular disease, including stroke, heart disease, and peripheral arterial disease. There is strong evidence to support nonpharmacologic interventions, such as smoking cessation and weight loss, and pharmacologic interventions, such as statin therapy, in order to decrease lifetime risk. The effectiveness of an intervention as well as the strength of the evidence supporting an intervention differs depending on the stage of the disease.
Conclusion: Once a patient is diagnosed with T2DM, it is important to recognize that their lifetime risk for vascular disease is high. Starting at this stage and continuing throughout the disease course, cardiovascular risk should be assessed in an ongoing manner and evidence-based interventions should be implemented whenever they are indicated. Using major guidelines as a framework, we provide an evidence-based approach to the reduction of vascular risk in these patients.

Key words: cardiovascular disease, diabetes, prevention, risk assessment, risk factors.

Type 2 diabetes (T2DM) is considered epidemic in the developed world, and is rapidly increasing in the developing world. Since 1980, there has been a near quadrupling of the number of adults with diabetes worldwide to an estimated 422 million in 2014 [1]. Because diabetes affects the whole body vascular system, there is a significant burden of vascular complications directly attributable to diabetes. Although the rates of diabetes-related complications are declining, the burden of disease remains high due to the increasing prevalence of diabetes [2]. The tremendous burden of diabetes and its complications on the population make it imperative that all health care practitioners understand the vascular effects of diabetes as well as evidence-based interventions that can mitigate them. In this review, we present an approach to the assessment, prevention, and treatment of cardiovascular disease in patients with T2DM.

Case Study

A 38-year-old male presents to his family physician’s office for a routine check-up. He is obese and a smoker, has no other health issues, and is taking no medications. He is sent for routine bloodwork and his A1c and fasting glucose are elevated and are diagnostic for diabetes. He returns to the clinic to discuss his results.

How are cardiovascular risk and risk factors assessed in a patient with diabetes?

There are many risk scores and risk calculators available for assessing cardiovascular risk. The Framingham Risk Score is the most commonly employed and takes into account the most common risk factors for cardiovascular risk, including cholesterol level, age, gender, and smoking status. Unfortunately, because a patient with diabetes may have a high lifetime risk but low or moderate short-term risk, these risk scores tend to underestimate overall risk in the population with diabetes [3,4]. Furthermore, since early intervention can decrease lifetime risk, it is important to recognize the limitations of these risk scores.