cardiovascular disease and diabetes | ada standards

Cardiovascular Disease and

Diabetes | ADA Standards

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

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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

<10 years

before

diagnosis

Re

lati

ve

Ris

k o

f M

I* o

r S

tro

ke

*MI = myocardial infarction. Nurses Health Study

Adapted from: Hu F, et al. Diabetes Care. 2002;25:1129-1134.

Natural History of Diabetes

Healthy

FBG <100

Random <140

A1c <5.7%

Prediabetes

FBG 100-125

Random 140 - 199

A1c ~ 5.7- 6.4%

50% working pancreas

Diabetes

FBG 126 +

Random 200 +

A1c 6.5% or +

20% working pancreas

Development of type 2 diabetes happens over years or decades

Yes! NO

3. PreDiabetes is FREAKING ME OUT

�86 million people in US�90% don’t know they have

it�In 3-5 years, about 30% of

predm will get diabetes�Associated with higher

rates of heart attack, stroke, neuropathy and vessel disease

�Why isn’t is called stage 1 diabetes?

3. Prevention or Delay of Type 2

�Prediabetes is associated with

heightened cardiovascular risk;

therefore, screening for and

treatment of modifiable risk factors

for cardiovascular disease are

suggested.

Standards of Medical Care in Diabetes - 2020. Diabetes Care 2020;43(Suppl. 1)

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 <180

�Blood Pressure < 140/90

�BP target <130/80

� If 10 year CVD Risk > 15%

�Cholesterol � Statin therapy indicated?

It’s Worth IT! You are Worth IT!�Legacy Effect

�For participants of DCCT and UKPDS � long lasting benefit of early intensive BG

control prevents�Macrovascular complications 42% reduction in CV disease

57% reduction in nonfatal MI, Stroke or CVD death

�Microvascular complications

�Even though their BG levels increased over time

�Message – Catch early and

Treat aggressively

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) <45%

� Kidney disease� CKD: If eGFR 30-60 or

� Urine Albumin to Creatinine Ratio (UACR) > 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 <6.5%AACE/ACE Comprehensive Type 2 Diabetes Management Algorithm 2020

Poll question 5

�What is the current B/P goal for

people with diabetes.�A. 130/80

�B. 140/80

�C. 120/70

�D. 140/90

BP and Diabetes Targets� Calculate ASCVD Risk using calculator:

� BP target <140/90

� If CVD Risk <15%

� BP target <130/80

� If 10 year CVD Risk > 15%

�BP target based on individual assessment and

shared decision making that addresses CV

Risk and potential adverse effects of BP meds.

�During pregnancy, with previous history of HTN� B/P Target is ≤135/85

ASCVD (Atherosclerotic Cardiovascular Disease)

Assessment

�ASCVD Risk Calculator �http://tools.acc.org/ASCVD-Risk-Estimator-Plus

�Evaluate 10 year risk of CV events (age 40-59)

�

BP GoalBP Goal based on risk� Measure B/P at every

routine clinical visit.

� If B/P elevated, confirm B/P using multiple readings, including measurements on a separate day, to diagnose HTN

� All with diabetes and HTN should monitor BP at home.

� Some may benefit from B/P 130/80 (younger and achieved with undue txburden)

HTN Lifestyle Treatment Strategies

�If BP > 120/80, start with lifestyle

�Lose weight through less calories

�Sodium intake <2,300mg/day

�Eat more fruits & veggies (8-10 a

day)

�Limit alcohol 1-2 drinks a day

�Increase activity level


�62 yrs old, A1c 7.6%



�BMI 36 B/P 144/78

�LDL 103 Trig 212

�Urinary Albumin 30+

�Other Med Needed?:

atorvastatin,

metoprolol, Flonase

� What class of meds in this person on?

� Insulin

� Biguanide

� Statin

� Beta blocker for?

� New meds added?

� Aspirin

� GLP-1 RA and SGLT-2




Please see standards for second half

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



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




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

<40 No None + lifestyle

<40 Yes High

If LDL >70, despite max statin dose

consider adding additional therapy

such as ezetimibe or PCSK9 Inhibitor

>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 <180

�Blood Pressure < 140/90

�BP target <130/80� If 10 year CVD Risk > 15%

�Cholesterol � Statin therapy indicated?

We Can Make a Big Difference

�62 yrs old, A1c 7.2%



�BMI 36 B/P 134/68

�LDL 103 Trig 212



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 diabetes | ada standards

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