Review: Expanded Therapy Plus Lifestyle Change Needed to Reduce CV Risk in Type 2 Diabetes

In clinical trials, researchers look at how a single drug or dietary change cuts the risk that people with diabetes will have a heart attack or stroke. But in the real world, that multifaceted approach—healthy eating, exercise, and expanding therapy to control blood sugar and reduce cholesterol—likely gives the patient the best chance.

That’s what authors call for in a “state-of-the-art review” that summarizes recent evidence for primary prevention of cardiovascular disease (CVD) in diabetes. It condenses guidelines from the American College of Cardiology, the American Diabetes Association, and the American Heart Association. The review, led by Jonathan D. Newman, MD, MPH, of NYU Langone Medical Center, appeared Monday in the Journal of the American College of Cardiology.

The review centers on the core elements of diabetes care: lifestyle management and management of CVD risk factors with therapy. These are the basic tools available to primary care physicians, who handle the bulk of diabetes care for type 2 diabetes (T2D). Evidence shows that patients with T2D may suffer from clinical inertia, as doctors do not treat diabetes more aggressively early on, despite the many choices of therapy available. Yet, fewer than half of US adults with T2D are being treated according to guidelines for CVD prevention, the authors found.

“The authors believe it is imperative that we expand the use of therapies proven to reduce CVD risk in patients with T2D,” they wrote. They also summarized guidelines for lifestyle management—exercise, nutrition, and weight management, with an eye toward slowing the burden of diabetes in the United States. Current estimates suggest that 1 in 3 adults will have diabetes by 2050.

The authors wrote that their review of diabetes interventions suggests that most patients benefit from some combination of diet, exercise, and medication, even though this is rarely studied.

“Taken together, these trials suggest that multifactorial interventions targeting several important risk factors simultaneously result in greater CV [cardiovascular] risk factor control and likely greater reduction in CVD risk compared with single risk factor interventions," the authors wrote.

Areas of recommendation include:

Physical activity. Called the “cornerstone” of clinical care, the guidelines call for at least 150 minutes a week of moderate intensity activity over at least 3 days per week, with no more than 2 consecutive days without exercise. Studies that evaluate the relative benefit of types of exercise found that combining aerobic activity with resistance exercise offers the greatest benefit.

Nutrition. Studies found that Mediterranean diets reduced blood glucose and CVD risk factors, but other diets, including the DASH diet (Dietary Approaches to Stop Hypertension) offered benefits. Replacing carbohydrates with fruits, vegetables, legumes, and whole grains is recommended.

Weight management. Sustained weight loss of 5% offers “clinically meaningful” health benefits. The review cites the findings of the Diabetes Prevention Program, which is scheduled to receive Medicare reimbursement starting in 2018, and is focused on helping people with prediabetes achieve this goal.

Glycemic control. The review lists recommended targets for glycated hemoglobin (A1C) of 7% or less for most patients and 6.5% for patients with recently diagnosed diabetes and “no significant CVD if it can be achieved safely.” Patients with severe hypoglycemia or limited life expectancy could have A1C of 8% or higher. This area discusses the recent findings of a CV benefit for some T2D therapies (empagliflozin, semaglutide, liraglutide; since submission of the paper, canagliflozin). However, these were safety trials and were not designed to determine whether these drugs offer a primary prevention benefit. “Further study in primary prevention populations are needed to demonstrate whether these agents are superior or additive to the CVD risk reduction reported with the use of metformin,” they wrote.

Blood pressure. Recommendations call for achieving a goal of <140/90 mmHg for most patients with diabetes. Younger patients with diabetes should strive for 130/90 mmHg if they have CV risk factors.

Cholesterol. Diabetic patients between the ages of 40 to 75 years with low-density lipoprotein 70-189 mg/dL should receive at least moderate intensity statins; and those with CV risk factors need high-intensity statins.

Aspirin. Diabetes patients can take 75-162 mg starting at age 50 if they have a CV risk factor if no bleeding occurs. Younger patients can start aspirin if they have a CV risk factor.

Reference

Newman JD, Schwartzbard AZ, Weintraub HS, Goldberg IJ, Berger JS. Primary prevention of cardiovascular disease in diabetes mellitus. J Am Coll Cardiol. 2017; 70(7): DOI: 10.1016/j.jacc.2017.07.001