cardiovascular disease and · 2020. 8. 5. · reduce risk based on drug effects and individual...

©Copyright 1999-2020, Diabetes Education Services www.DiabetesEd.net

Cardiovascular Disease and

Diabetes | ADA Standards

Beverly Thomassian, RN, MPH, BC-ADM, CDEPresident, Diabetes Education Services

Welcome Everyone

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Topics

�Cardiovascular Risk &

Reduction Strategies

�American Diabetes

Association Guidelines

for CV Risk Reduction

�Implement Risk

Reduction Strategies

� Lifestyle plus

Medications


Bev has no conflict of interest� She’s not on any speakers

bureau

� Does not invest

� Gathers information from reading package inserts, research and standards

� She does engage in “pill-ow” talk with her husband (who is a PharmD)

Let’s elevate our role

Cardiometabolic risk reduction

Diabetes technology resource

Provide meaningful person-centered care and support the emotional well-being of the whole person.

Ensure that everyone knows what your role is as a core member of the larger care team

Offer care that positively impacts quality and cost and enhances the experience for both the person with diabetes and provider.

10. Cardiovascular Disease and Risk

Management

�Heart disease is the leading cause of mortality and morbidity in diabetes

�Large benefits are seen when multiple risk factors are addressed globally


Insulin Resistance is the Seed

�Muscles are insulin

resistant

� Building muscle decreases

insulin resistance

�Fat cells become more

insulin resistant

� Leads to more Free Fatty

Acids and Triglycerides

� More vascular inflammation

�Pancreas becomes fatty

� Losing wt helps improve

Insulin Resistance


Poll question 1

�Which of the following BEST

describes insulin resistance? a. Lack of sufficient insulin receptors on

fat and muscle cells.

b. Visceral adipose tissue.

c. A physiological condition where

insulin becomes less effective at

lowering blood glucose levels.

d. Excessive triglyceride levels

American College of Endocrinology, 2001

Factors Associated with Insulin

Resistance

�Abdominal obesity

�Sedentary lifestyle

�Genetics / Ethnicity

�Gestational Diabetes

�Polycystic ovary syndrome

�Acanthosis Nigricans

�Obstructive Sleep Apnea

�Cancer


Acanthosis Nigricans

Acanthosis Nigricans (AN)

�Signals high insulin levels in bloodstream

and is a marker of insulin resistance

�Patches of darkened skin over parts of body

that bend or rub against each other

� Neck, underarm, waistline, groin, knuckles, elbows,

toes

� Skin tags on neck and darkened areas around eyes,

nose and cheeks.

�No cure, lesions regress with treatment of

insulin resistance

Risk of CVD Is Elevated

prior to Diagnosis of Type 2 Diabetes

1.00

2.40

3.19

3.64

0.00

1.00

2.00

3.00

4.00

5.00

Non-diabetic

throughout

study

15 yrs or more

before

diagnosis

10-14.9 yrs

before

diagnosis


Natural History of Diabetes

Healthy

FBG


What is Type 2 Diabetes?

�Complex metabolic disorder ….

(Insulin resistance and deficiency)

with social, behavioral and

environmental risk factors unmasking

the effects of genetic susceptibility.

New Diagnosis? Call 800 – DIABETES to request “Getting Started Kit”www.Diabetes.org

Cardio Metabolic Risk -

5 Hypers -

�Hyperinsulinemia (resistance)

�Hyperglycemia

�Hyperlipidemia

�Hypertension

�Hyper”waistline”emia (35” women, 40” men)

Manifestations of Insulin Resistance

Poll question 2

�Which of the following Cardiovascular

Conditions are associated with

diabetes?

A. Congestive Heart Failure

B. Hypervasodilation

C. Acanthosis Nigricans

D. CardioNephritis


Heart Disease & DM = 3-5xs Risk

�CHF � 7.9 % w/ diabetes vs. � 1.1 % no diabetes

�Heart attack � 9.8 % w/ diabetes vs.� 1.8 % no diabetes

�Coronary heart disease � 9.1 % w/ diabetes vs. � 2.1 % no diabetes

�Stroke � 6.6 % w/ diabetes vs. � 1.8 % no diabetes

� 2007 AACE

Cardiovascular Disease and Risk Management

�Cardiovascular disease is the leading cause of mortality and morbidity in diabetes

�Largest contributor to direct and indirect costs

�Controlling cardiovascular risk improves outcomes

�Large benefits are seen when multiple risk factors are addressed globally

Poll question 3

�What is the relationship between

diabetes and cardiovascular disease?

A. Diabetes is associated with a lower rate of

congestive heart failure.

B. Diabetes is associated with decreased

incidence of heart attack and stroke

C. People with diabetes are destined to get CV

complications.

D. People with diabetes can decrease their risk of

a CV event


Diabetes & Heart Disease Motivational

Stats

� Every 18 mg/dl increase in

fasting glucose increases risk

of CV events/death by 17%

� Every 1% increase in A1c

increased:

� CVD events by 18%

� MI events by 19%

� All cause mortality by 12-14%

� Microvascular disease by 35%

ADA Standards of Care

ABCs of Diabetes

�A1c less than 7% (avg 3 month BG)�Pre-meal BG 80-130

�Post meal BG


Discouraged with Type 2“I don’t check my BG, it’s always high”

Clinical Inertia Happens

�Reassess every 3-

6 months

Person with Type 2 in Clinic

�62 yrs old, A1c 10.6%.�100 units Lantus plus

metformin 1000mg BID.

�BMI 39, B/P 138/78�LDL 128, Trig 382 �Other Meds:

atorvastatin, metoprolol, Flonase

�Daily habits�Mostly sedentary,

takes care of older mom

�BMI was 43 last year� Sleep 5-6 hours a

night�Doesn’t drink,

smokes a few cigs a week

�Eats a fast food 4-6 times a week


Reducing Vascular Risk Factors

�Modifiable

�Glucose

�Smoking

�Weight

�Dietary Habits

�Oral Care

�Sleep

�Blood Pressure

� Lipids

� Make small, achievable

goals. We are in this for

the long run.

Poll Question 4

�Which of the following is the

best recommendation to

protect cardiovascular

health?

A. Avoid all fast foods

B. Stop smoking

C. Keep B/P as low as possible

D. Eliminate sugar from diet

Where do We Start?

Get at least 7 hours of sleep a night – Check for sleep apnea


•Ask at every visit

•Assess

•Advise

•Assist with stop smoking

•Arrange for referrals

•Organize your clinic

Smoking and Diabetes

Smoking increases risk of diabetes 30%

Smoking and Diabetes

DASH Diet – Dietary Approaches to Stop

Hypertension

�The DASH diet emphasizes vegetables,

fruits and low-fat dairy foods — and

moderate amounts of whole grains, fish,

poultry, nuts.

�Pt recommendations

� Eat lots of whole grains, fruits, vegetables and

low-fat dairy products.

� Also includes some fish, poultry and legumes,

and encourages a small amount of nuts and

seeds a few times a week.

� Red meat, sweets and fats in small amounts.

� Focus on low saturated fat, cholesterol, total fat.

Mediterranean Diet Pyramid


Benefits of Exercise and Diabetes

�Increase muscle glucose uptake 5-fold

�Glucose uptake remains elevated for 24 - 48 hours (depending on exercise duration)

�Increases insulin sensitivity in muscle, fat, liver.

�Reduce CV Risk factors (BP, cholesterol, A1c)

�Maintain wt loss

�Contribute to well being

�Muscle strength

�Better physical mobility

Periodontal disease and Heart Disease

Heart disease link:

oral bacteria enter the blood

stream, attach to fatty plaques in

coronary arteries increasing clot

formation

inflammation increases plaque

build up, which may contribute

to arterial inflammation

Hyperglycemia = Gingivitis =

Heart Disease

Preventive Action• Brush twice daily• Floss daily• See dental team a

few times a year

Medication Taking Behaviors

� Adequate medication taking is

defined as 80%

� If pt taking meds 80% of time and

treatment goals not met,

intensification should be considered.

� Barriers to taking meds include:

� Forgetting to fill Rx, fear, depression, health

beliefs, medication complexity, cost, system

factors, etc.

� Work on targeted approach for

specific barrier


Section 9- Pharmacologic Approaches to

Glycemic Treatment

�Algorithm for Oral Meds

and Insulin Therapy

�More attention to

considering CVD and CKD

when choosing diabetes

medication

�Updated chart on cost and

attributes of different meds

Person with Type 2 in Clinic

�62 yrs old, A1c 10.6%.

�100 units Lantus plus metformin 1000mg BID.

�BMI 39, B/P 138/78

�LDL 128, Trig 382

�Other Meds: atorvastatin, metoprolol, Flonase

�What class of meds in this person on?

�Any meds missing?

�Any changesneeded?

Meds -Person with Type 2 in Clinic

�62 yrs old, A1c 10.6%.

�100 units Lantus plus metformin 1000mg BID.

�BMI 39, B/P 138/78

�LDL 128, Trig 382

�Other Meds: atorvastatin, metoprolol, Flonase

�What class of meds in this person on?

� Insulin

�Biguanide

�Statin

�Beta blocker for?

�Any meds missing?


ADA Step Wise Approach to

Hyperglycemia 2020

�For all steps, consider including

medications with evidence of ASCVD

and CKD risk reduction, based on drug

specific effects and patient factors.

�Other Factors�Minimize Hypoglycemia

�Minimize wt gain or promote wt loss

�Consider Cost

Biguanide derived from:Goat’s Rue Galega officinalis,French Lilac


SGLT2 Inhibitors- “Glucoretics”

� Action: “Glucoretic” decreases renal reabsorption in the proximal tubule of the kidneys (reset renal threshold and increase glucosuria). Risk of ketoacidosis, Fournier's gangrene

% ‘f

Decreases GlucoseReabsorption

ADA Step Wise Approach to

Hyperglycemia 2020� Step 1 – Metformin + Lifestyle

� Step 2 - If A1c target not achieved after 3 months, Metformin + another med

� If ASCVD, CHF, or CKD, consider adding a second agent to reduce risk based on drug effects and individual factors.

� SGLT-2i - Empagliflozin (Jardiance), canagliflozin (Invokana) and dapagliflozin (Farxiga) – Eval GFR

� GLP-1 RA Semaglutide > liraglutide > dulaglitide > exenatide > lixisenatide

� Step 3 - If A1c target still not achieved after 3 months, combine metformin plus one to two other (2-3 drugs)

� Step 4 - If A1c target not achieved after 3 months, add injectable therapy (GLP-1 RA or Basal insulin) to drug combination.

ADA Standards 2020


Atherosclerotic CV Disease

�ASCVD risk – how is that defined?

�55+ with previous event, coronary, carotid,

lower extremity artery stenosis > 50% or

Left Ventricular Hypertrophy (LVH)

�Preferred Meds:

�SGLT-2s that reduce heart failure, CKD

progression, Cardiovascular Outcomes Trial

(CVOT)

�Empagliflozin (Jardiance), canagliflozin

(Invokana) and dapagliflozin (Farxiga) ADA Stds – InjectablesAlgorithm small print

Heart Failure (HF) or Chronic Kidney

Disease Predominate� If HF or reduced Ejection Fraction (rEF) and Left

Ventricular Ejection Fraction (LVEF) 30 mg/g especially if UACR > 300

� Use SGLT2i if eGFR is adequate

� Empagliflozin (Jardiance), canagliflozin (Invokana),

dapagliflozin (Farxiga)

� If can’t tolerate, use GLP-1 RA � Semaglutide > liraglutide > dulaglitide > exenatide >

lixisenatide

� Insulin Basal next - Risk of hypo; least to most

� Degludec /glargine U300 < glargine U100 < detemir < NPH


�62 yrs old, A1c 10.6%.

�100 units Lantus plus


�BMI 39, B/P 138/78

�LDL 128, Trig 382

�Other Meds:

atorvastatin,

metoprolol, Flonase

� What class of meds in this person on?

� Insulin

� Biguanide

� Statin

� Beta blocker for?

� New meds added?

� Aspirin

� GLP-1 RA or SGLT-2

� Semaglutide (Ozempic)

� Empagliflozin (Jardiance)

� Basal insulin reduced to 80 units


10 - ADA Antiplatelet Agents� Candidates

� Hx of atherosclerotic CV disease + diabetes

� Use aspirin therapy (75–162 mg/day)

� Atherosclerotic CV disease and documented

aspirin allergy, use clopidogrel (75 mg/day)

� Dual antiplatelet therapy (with low-dose aspirin

and a P2Y12 inhibitor) is reasonable for a year

after an acute coronary syndrome and may have

benefits beyond this.

� Primary Prevention?

� Aspirin therapy (75–162 mg/day) in those with diabetes

who are at increased cardiovascular risk, after a

comprehensive discussion on the benefits versus the

comparable increased risk of bleeding.

Principles of AACE Type 2 Management

Algorithm

�Lifestyle modification

�Avoid hypo, wt gain

�Individualize targets

�Therapy choices are person centered and include ease of use, affordability

�Therapy choice considers cardiac, CHF, renal status

�Get to goal ASAP

�Manage co-conditions

� CGM is highly recommended

�Optimal A1c


BP and Diabetes Targets� Calculate ASCVD Risk using calculator:

� BP target


HTN Lifestyle Treatment Strategies

�If BP > 120/80, start with lifestyle

�Lose weight through less calories

�Sodium intake


BP Treatment in addition to Lifestyle

�First Line B/P Drugs

�If B/P ≥ 160 /100 start 2 drug combo� With albuminuria – start with either ACE or ARB

� No albuminuria - Any of the 4 classes of BP meds can

be used to tx hypertension

� ACE Inhibitors, ARBs, thiazide-like diuretics or calcium channel

blockers. (Avoid ACE and ARB at same time)

� Multiple Drug Therapy often required

�For best effect, administer at least one at bedtime

Angiotensin Receptor Blockers


Beta Blockers


�62 yrs old, A1c 7.6%



�BMI 36 B/P 144/78

�LDL 103 Trig 212

�Urinary Albumin 30+

�Other Med Needed?:

atorvastatin 80mg,

metoprolol, Flonase

�Add Losartan (ARB)

� What class of meds in this person on?� Insulin� Biguanide� Statin� Beta blocker for?

� New meds added?� Aspirin� GLP-1 RA and SGLT-2

� Semaglutide (Ozempic)

� Empagliflozin (Jardiance)

� Basal insulin reduced to 80 units

Statin RecommendationsAge ASCVD or 10 yr risk >20% Recommended statin

40 No Moderate

>40 Yes If LDL >70, despite max statin dose

consider adding additional therapy

such as ezetimibe (Zetia) or PCSK9 Inhibitor

ASCVD Risk include: LDL >100, HTN, Smoke, Chronic Kidney Disease, albuminuria, family hx ACSVD. If pt can’t tolerate intended statin dose, use maximally tolerated dose.


Statin Therapy

�High intensity statins (lowers LDL 50%):

� atorvastatin (Lipitor) 40-80mg

� rosuvastatin (Crestor) 20-40mg

�Moderate intensity (lowers LDL 30-50%)

� atorvastatin (Lipitor) 10-20mg

� rosuvastatin (Crestor) 5-10mg

� simvastatin (Zocor) 20-40mg

� pravastatin (Pravachol) 40 – 80mg

� lovastatin (Mevacor) 40 mg

� fluvastatin (Lescol) XL 80mg

� pitavastatin (Livalo) 2-4mg

ABCs of Diabetes

�A1c less than 7% (avg 3 month BG)�Pre-meal BG 80-130�Post meal BG


We Can Make a Big Difference

�62 yrs old, A1c 7.2%



�BMI 36 B/P 134/68

�LDL 103 Trig 212

�Urinary Albumin 30+

�Other Med Needed?:

atorvastatin 80mg,

metoprolol, Flonase

�Losartan (ARB)

�I feel better.�I am sleeping

through the night.�I check my blood

sugars daily, and for the first time they are less than 130!

�Hope – The best gift of all!

Thank You

�Please email us with

any questions.

�[email protected]

�www.diabetesed.net

cardiovascular disease and · 2020. 8. 5. · reduce risk based on drug effects and individual...

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