Cardiometabolic Risk 2015
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Transcript of Cardiometabolic Risk 2015
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Cardiometabolic Risk,Type 2 Diabetes and
Cardiovascular Disease
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Learning Objectives
Identify !y discussing cardiometabolicrisk "C#R$ factors it! patients it! orat risk for prediabetes and type 2diabetes can positively impact t!eir
!ealt! Implement screening strategies to
promote early detection and prevention
Discuss it! patients !o preventing
risk factors can positively impact !ealt! List risk factor treatment options and
define goals of treatment
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T!e %tate of Risk
2 out of & 'mericans are overeig!t orobese
T!ere are an estimated () million
'mericans it! prediabetes
*early + in 2 -%- adults !as !ig!c!olesterol
+ in & 'merican adults !as !ig! bloodpressure
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*umber and .ercentage of -%- .opulationit! Diagnosed Diabetes +/0(12+
CDC3s Division of Diabetes Translation- *ational Diabetes %urveillance %ystem-
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4eart Disease 5acts
+ in ) deat!s eac! year in t!e -%- is from!eart disease-
4eart disease is t!e leading cause of deat! for
men and omen-
6+0, 'mericans !ave a !eart attack eac!year-
020, are a first !eart attack- +/, !appen in people !o !ave already
!ad a !eart attack-
CDC3s Division of 4eart Disease and %troke .revention-
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Cardiometabolic Risk
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Cardiometabolic Risk 5actors
*on7#odifiable
'ge
Race8et!nicity
9ender
5amily !istory
#odifiable
Overeig!t
'bnormal lipid
metabolism Inflammation
4ypertension
%moking
.!ysical inactivity n!ealt!y diet
Insulin resistance
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3.5
18.8 20.2
45.0
P
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?!at 're ?e to Do@
Current approac!es for C
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%creening 5or Diabetes
Testing at least every & yrs starting at age ;0
'merican Diabetes 'ssociation- Diabetes Care. 2+0=&("%uppl- +$> %&+7%&2-
Test .rediabetes Diabetes
5.9 +7+20 mg8dL A+2) mg8dL
O9TT +;7+// mg8dL A2 mg8dL
'+C 0-67)-;B A)-0B
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ounger8#ore 5reuent Testing
If patient is overeig!t or obese and !as + or more oft!e folloing risk factors "or 2 if not overeig!t$>
+stdegree relative it! diabetes
.!ysically inactive
Certain race8et!nicity
Elevated blood glucose 4ypertension
Lo 4DL c!olesterol and8or !ig! triglyceride level
4istory of 9D#
Delivering baby eig!ing F/ lbs .olycystic ovary syndrome ".CO%$
'merican Diabetes 'ssociation- Diabetes Care. 2+0=&("%uppl- +$> %&+7%&2-
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'+C A )-BI59 and I9TG Ot!er5eatures
Lifestyle intervention
and8or metformin,follo7up H) mo
Intervention and 5ollo7p
%creen for Diabetes>'+C 7 or 75.9 1 or 7
27!our, 607g O9TT
*ormal
Re7evaluate in &years if risk
factors remain
METFORMIN IS NOT F! !""RO#E FOR "RE#ENTION
Lifestyle
intervention,follo7up H+ year
'+C A 0-6BI59 or I9T DI'ETE%
Lifestyle intervention
plus metformin,follo7upH& mo
'merican Diabetes 'ssociation- Diabetes Care. 2+0=&("%uppl- +$> %&+7%&2-
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.rediabetes
.rediabetes is an important risk factorfor future diabetes and cardiovasculardisease
%tudies !ave s!on t!at lifestylemodification can reduce t!e rate ofprogression from prediabetes to diabetes
'merican Diabetes 'ssociation- Diabetes Care. 2+0=&("%uppl- +$> %&+7%&2-
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$%&%'a(i)eInc
idence
ofia*e(e+
,-.
Year+
40
30
20
10
0
0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0
"'ace*o
Me(for&in
/ife+('e
Jnoler ?C, et al- NEJM- 22=&;)>&/&7;&-
Diabetes .revention .rogram
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Lifestyle #odification
Lose 6B of body eig!t
Reduce calories and dietary fat
'c!ieve %D' recommendations fordietary fiber and !ole grains
Limit intake of sugar7seetenedbeverages
'merican Diabetes 'ssociation- Diabetes Care. 2+0=&("%uppl- +$> %&+7%&2-
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enefits of .!ysical 'ctivity
Increased insulin sensitivity
Improved lipid levels
Loer blood pressure
?eig!t control
Improved blood glucose control
Reduced risk of C
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;% Trial
27
45
231
0
10
20
30
40
50
"'ace*o Si&)a+(a(in "'ace*o Si&)a+(a(in
n:22
&2BRisk Reduction
.atients?it! #ajor
CoronaryEvent "B$
00BRisk Reduction
.yrMlM et al- Diabetes Care- +//6=2>)+;-
n:;2;2NC4D deat! or nonfatal #I
Nondiabetic.atientsDiabetic.atients
%tatins reduce coronary events
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Lipid #anagement
%creening for 'dultsTime of first diagnosis=
't initial medical evaluation= and8or
't age ; years and every +72 yearst!ereafter
'merican Diabetes 'ssociation- Diabetes Care. 2+0>&("%uppl- +$> %;/7%06-
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Lipid #anagement
Intensify lifestyle t!erapy and optimieglycemic control in patients it!>
Triglycerides A+0 mg8dL= and8or
Lo 4DL c!olesterol
P; mg8dL for men
P0 mg8dL for omen
'merican Diabetes 'ssociation- Diabetes Care. 2+0>&("%uppl- +$> %;/7%06-
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%tatin T!erapy
'merican Diabetes 'ssociation- Diabetes Care. 2+0>&("%uppl- +$> %;/7%06-
'ge Risk factors Recommendedstatin doseN #onitoringit! lipidpanel
P;years
*one *one 'nnually
or asneeded tomonitorad!erence
C
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%tatin T!erapy
'merican Diabetes 'ssociation- Diabetes Care. 2+0>&("%uppl- +$> %;/7%06-
'ge Risk factors Recommendedstatin doseN #onitoringit! lipidpanel
;760years
*one #oderate
's neededto monitorad!erence
C
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%tatin T!erapy
'merican Diabetes 'ssociation- Diabetes Care. 2+0>&("%uppl- +$> %;/7%06-
'ge Risk factors Recommendedstatin doseN #onitoringit! lipidpanel
F60years
*one #oderate
's neededto monitorad!erence
C
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J.D% lood .ressure %tudy
Tig!t blood pressure control "+;;8(2 mm4g$lead to>
&2B reduction in diabetes deat!s
;;B reduction in stroke
&6B reduction in microvascularcomplications
#Q- +//( %ep +2=&+6"6+)$>6&7+&-
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4ypertension
9oals for people it! diabetes and!ypertension
Loer targets "P+& mm4g, P( mm49$may be appropriate for certain individuals"younger patients$ if it can be ac!ievedit!out undue treatment burden-
lood .ressure 9oal
%ystolic P+; mm4gDiastolic P/ mm4g
'merican Diabetes 'ssociation- Diabetes Care. 2+0>&("%uppl- +$> %;/7%06-
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Treatment . A+;8/ mm4g
Lifestyle t!erapy G prompt initiation8timelytitration of drugs to ac!ieve goals-
Include 'CE in!ibitor or an angiotensinreceptor blocker "'R$-
#ultiple7drug t!erapy "2 or more agentsat maKimal doses$ is generally reuired-
'dminister + or more anti!ypertensivemedications at bedtime-
'merican Diabetes 'ssociation- Diabetes Care. 2+0>&("%uppl- +$> %;/7%06-
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J.D%> Legacy EffectS
After median 8.8 years post-trial follow-up
!rea(e Endoin( 17 2007
!n dia*e(e+ re'a(ed endoin( RRR: 12
P: 0.02 0.040
Micro)a+c%'ar di+ea+e RRR: 25 24
P: 0.00 0.001
Mocardia' infarc(ion RRR: 1 15
P: 0.052 0.014
!''-ca%+e &or(a'i( RRR: 13
P: 0.44 0.007RRR Re'a(i)e Ri+6 Red%c(ion " /o Ran6
4olman RR, et al- New England Journal of Medicine2(= &0/>+0667+0(/-
'CCORD>
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'CCORD>EKploring loer targets
N Engl J Med. &)&"&$>2&&72;;, 2+- T!e Lancet, &6) "/6&/$>;+/&, 2+- N Engl JMed.&0(>20;070/, 2(- N Engl J Med. &)2"+6$>+0607(0, 2+- N Engl J Med.&)2"+6$>+0)&76;, 2+-
T!ree randomiations T!ree results
'+C target P)B vs 67(B #ore intensive glycemic controlmicrovascular benefitno C
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Individualied 9lycemic Targets
#ore or less stringent goals may be
appropriate for individual patients-
'+C P6-B
.reprandial plasma
glucose
(7 +& mg 8dL
.eak postprandialplasma glucose
P +( mg 8dL
'merican Diabetes 'ssociation- Diabetes Care. 2+0>&("%uppl- +$> %&&7%;-
'ntiplatelet Trialists3
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'ntiplatelet Trialists3Collaboration
n:;02 P
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'spirin T!erapy
.rimary prevention strategy in t!ose it!increased cardiovascular risk !o !ave at leastone additional major risk factor
most men aged F0 years
most omen aged F) years %econdaryprevention strategy in t!ose it! diabetes it!a !istory of C&("%uppl- +$> %;/7%06-
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%moking
Is t!e smoker illing to uit@
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%ummary
Routinely assess patients3 C#R
Recommend multiple prevention andmanagement strategies to ac!ieve goals
Lifestyle Ot!er appropriate treatments
Evaluate patients it! C#R for ot!er riskfactors
Discuss risk for diabetes, !eart diseaseand stroke 1 and 1 benefits ofprevention
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%tandards of #edical Care
'n update of %tandards of #edicalCare in Diabetes appearsannually in t!e Qanuary
supplement of t!e journalDiabetes Care
Care-DiabetesQournals-org
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Continuing Education
Online self assessments,ebcasts and in7person
education opportunities>
.rofessional-Diabetes-org8ce
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.atient Education #aterials
+$ 5ree, reproducible patient !andouts in Englis!and %panis!
diabetes-org8toolkit
2$ Diabetes Risk Test
diabetes-org8risktest
&$ #y 4ealt! 'dvisor 1 ( and + year C#R
calculator
diabetes-org8#4'