Journal of Cardiovascular Nursing

Vol. 31, No. 3, pp 198Y200 x Copyright B 2016 Wolters Kluwer Health, Inc. All rights reserved.

Progress in Prevention

Preventing Cardiovascular Disease in Patients

With Diabetes
New Evidence Informs Changes in Standards of Care
Jane Nelson Worel, MS, RN, ANP-BC, FAHA, FPCNA; Laura L. Hayman, PhD, RN, FAAN, FAHA

doses.4 In the Action in Diabetes

C ardiovascular disease (CVD)
is the leading cause of morbid-
ity and mortality for individuals
betes. The global management of
multiple CVD risk factors yields
even greater results.2
and Vascular Disease: Preterax
and Diamicron MR Controlled
with diabetes. At least 68% of An estimated 70% to 80% of EvaluationVBlood Pressure trial,
adults 65 years or older with diabe- people with diabetes are also hy- there was a significant CVD pre-
tes die of some form of CVD, pertensive. The presence of hyper- vention benefitVfewer major CVD
whereas 16% die of stroke. Adults tension in this population increases events and fewer deaths attrib-
with diabetes are 2 to 4 times more the risk of myocardial infarction uted to CVD as well as all cause
likely to have heart disease or stroke (MI), stroke, heart failure, nephrop- mortalityVin those who were ran-
than adults without diabetes.1 Hy- athy, and all-cause mortality.3 Ep- domized to the treatment arm and
pertension and dyslipidemia are idemiological studies show that given a fixed-dose combination of
major risk factors for CVD, and blood pressure (BP) readings greater angiotensin converting enzyme in-
they commonly coexist in people than 115/75 mm Hg are associated hibitor (perindopril) and thiazide
with diabetes.2 An added concern is with increased CVD events and diuretic (indapamide). The base-
that diabetes itself is independently mortality. Given the relationship line BP among study subjects was
associated with increased CVD between lower BP and better long- 145/81 mm Hg. The treatment
risk.3 A number of large clinical term clinical outcomes, 2 landmark arm achieved an average BP of
trials have demonstrated the ben- trials, Action to Control Cardiovas- 136/73 mm Hg, not nearly as low
efits of controlling hypertension or cular Risk in Diabetes (ACCORD)4 or aggressive as those achieved in
dyslipidemia in preventing and and Action in Diabetes and Vascular the ACCORD trial, but with fewer
slowing CVD in adults with dia- Disease: Preterax and Diamicron side effects and less cost.5
Jane Nelson Worel, MS, RN, ANP-BC, MR Controlled EvaluationVBlood These trials, taken together with
FAHA, FPCNA Pressure,5 were conducted to evalu- previous epidemiologic observa-
Nurse Practitioner, Phases Primary Care for ate the clinical benefit of achieving tional studies, have resulted in
Women, Madison, Wisconsin.
tight BP control in those with type slightly higher thresholds for treat-
Laura L. Hayman, PhD, RN, FAAN,
FAHA 2 diabetes mellitus (DM2). ment in patients with diabetes. The
Associate Vice-Provost for Research and The ACCORD trial assessed 2015 American Diabetes Associa-
Professor of Nursing, College of Nursing whether a systolic BP of less than tion (ADA) Standards for Medical
and Health Sciences, University of
Massachusetts Boston. 120 mm Hg provided greater CVD Care in Diabetes amended their
The authors have no funding or conflicts of risk reduction compared with the recommended BP threshold to
interest to disclose. accepted systolic BP goal of 130 to 140/90 mm Hg, up from previous
Correspondence 140 mm Hg. The findings showed recommendation of 130/80 mm Hg.
Jane Nelson Worel, MS, RN, ANP-BC, no additional benefit in achieving They do state, however, that lower
FAHA, FPCNA, Phases Primary Care for
Women, 2955 Triverton Pike Dr, the more aggressive target; yet, there treatment targets may be appropri-
Madison, WI 53711 were increased costs and more ate for individuals who are at high
([email protected]). adverse events associated with the risk for stroke or chronic kidney
DOI: 10.1097/JCN.0000000000000333 use of more medications at higher disease or younger patients who can

198

Copyright 2016 Wolters Kluwer Health, Inc. All rights reserved.

 Preventing CVD in Patients With Diabetes 199

easily achieve lower BP levels with- poprotein cholesterol (HDL-C) are risk in those on combination ther-
out undue treatment burden.2 the most prevalent pattern of dys- apy.7 Combination therapy with
Patients with DM2 have an in- lipidemia in persons with DM2. niacin is therefore not recommended.
creased prevalence of lipid abnor- The evidence base for medications The ADA standards suggest that the
malities, contributing to their high that target these lipid particles is use of niacin and fibric acid deriva-
risk of CVD. Subgroup analysis of much less robust than that for statin tives may be limited to patients with
diabetic patients within large clin- therapy. The ADA standards recom- hypertriglyceridemia and low HDL-C
ical trials and trials in patients with mend dietary and lifestyle modifica- levels who are intolerant of statins.2
diabetes showed significant reduc- tions as first line of management of Lifestyle intervention including
tions in incident and recurrent hypertriglyceridemia, unless the dietary changes, increased physical
cardiovascular events and CVD- triglyceride level is greater than activity, weight loss, and smoking
related mortality. Meta-analyses 1000 mg/dL, in which case imme- cessation, together with medica-
including data from over 18 000 diate pharmacologic therapy with tion management, is helpful in
patients with diabetes from 14 ran- omega-3 fatty acids or fibric acid managing many CVD risk factors,
domized trials of statin therapy derivatives may reduce the risk of including hypertension and dyslip-
demonstrate a 9% proportional re- acute pancreatitis.2 In a large clini- idemia. Nutrition intervention
duction in all-cause mortality and cal trial specific to diabetic patients, should be individualized with a gen-
13% reduction in vascular mortal- fenofibrate showed no benefit for eral focus on reducing saturated fat,
ity for each mmol/L reduction in CVD risk reduction. In the AC- cholesterol, and trans-fat intake
low-density lipoprotein cholesterol CORD study, combination therapy while increasing omega-3 fatty
(LDL-C). Statins are the drug of with simvastatin and fenofibrate acids and viscous fiber. Glycemic
choice for LDL-C lowering and showed no added CVD risk reduc- control can also help to improve
cardio-protection.2 tion benefit when compared with plasma lipid levels, particularly in
Most trials of statins and CVD simvastatin alone.6 patients with very high triglyceride
outcomes tested specific doses of The Atherothrombosis Interven- levels and poor glycemic control.2
statins against placebo or other tion in Metabolic Syndrome With Lifestyle interventions targeting
statins rather than aiming for spe- Low HDL/High Triglycerides: Im- weight loss through decreased ca-
cific LDL-C targets. With consid- pact on Global Health Outcomes loric intake and increased physical
eration of the conduct and trial evaluated the benefit of statin activity as implemented in the Ac-
outcomes of these trials, the 2015 plus extended-release niacin in pa- tion for Health in Diabetes (Look
ADA Standards of Care were re- tients with established CVD, low AHEAD) trial may be considered
vised to recommend when to initi- LDL-C and HDL-C levels, and high for improving glucose control, fit-
ate and intensify statin therapy triglyceride levels; about a third of ness, and some CVD risk factors.
based on a patients risk level the study population were also However, the trial was stopped early
(Table 1).2 The standards recom- diabetic. The trial was halted early on the basis of a futility analysis that
mend screening lipid panels at the because of lack of efficacy in rela- demonstrated no reduction in the
time of diagnosis of diabetes and tion to the primary CVD outcome rate of CVD events in overweight
at least annually thereafter mainly (death from coronary heart disease, or obese adults with DM2 as a res-
to evaluate for adherence to med- nonfatal MI, ischemic stroke, hos- ult of intensive lifestyle intervention.8
ication therapy. pitalization for acute coronary syn- One explanation of these findings
Hypertriglyceridemia and low drome, or revascularization) and a is that those with improved CVD
cardio-protective high-density li- possible increase in ischemic stroke risk factor profiles stopped taking
known cardioprotective therapies
TABLE 1 such as statins for dyslipidemia.3
Recommendations for Statin Therapy in Adults With
Thus, it is reassuring to know that
Diabetes (Type 2 Diabetes Mellitus)
there was no increase in CVD events
Age Risk Factor Profile Statin Dose in those who were able to control
G40 y None None risk factors with accepted lifestyle
CVD risk factor(s) Moderate or high changes.
Known CVD High
Antiplatelet therapy with aspi-
40Y75 y None Moderate
CVD risk factors High rin has been shown to be effective
Overt CVD High in reducing CVD morbidity and
975 y None Moderate mortality in high-risk patients with
CVD risk factors Moderate or high previous MI or stroke (secondary
Overt CVD High
prevention). It is less clear whether
Abbreviation: CVD, cardiovascular disease. aspirin is helpful in people without

Copyright 2016 Wolters Kluwer Health, Inc. All rights reserved.

200 Journal of Cardiovascular Nursing x May/June 2016

CVD, including those with diabetes prevalence of diabetes increased in 4. ACCORD Study Group; Cushman
(primary prevention). Two random- the overall population and in all WC, Evans GW, et al. Effects of in-
tensive blood-pressure control in type
ized controlled trials that specifi- subgroups evaluated.10 Given these 2 diabetes mellitus. N Engl J Med.
cally looked at aspirin use in adults growing numbers and the strong 2010;362:1575Y1585.
with diabetes, failed to show a sig- association between diabetes and 5. Patel A; ADVANCE Collaborative
nificant reduction in CVD end CVD risk, it is imperative that we Group; MacMahon S, et al. Effects
adopt an all hands on deck men- of a fixed combination of perindopril
points. The Antithrombotic Trialists
and indapamide on macrovascular
collaborators published a meta- tality when it comes to management and microvascular outcomes in pa-
analysis of 6 large trials of aspirin of diabetes and its coexisting meta- tients with type 2 diabetes mellitus
for primary prevention in the gen- bolic CVD risk factors. Nurse-led (the ADVANCE trial): a randomised
eral population. Of the 95 000 par- diabetes self-management programs controlled trial. Lancet. 2007;370:
have demonstrated benefit with re- 829Y840.
ticipants included in this analysis, 6. ACCORD Study Group; Ginsberg HN,
approximately 4000 were diabetic. gard to improved glycemic control Elam MB, et al. Effects of combina-
The effects of aspirin on major vas- and reduction in CVD risk factors.11 tion lipid therapy in type 2 diabetes
cular events (MI and stroke) were These programs should be used mellitus. N Engl J Med. 2010;362:
similar for patients with or without and expanded to meet the growing 1563Y1574.
demand. Healthcare providers in 7. AIM-HIGH Investigators; Boden
diabetes: relative risk of 0.88 (95% WE, Probstfield JL, et al. Niacin in pa-
confidence interval, 0.67Y1.15) all community, primary and cardio- tients with low HDL cholesterol levels
and 0.87 (95% confidence interval, vascular care settings must be em- receiving intensive statin therapy.
0.79Y0.96), respectively.9 Aspirin powered to screen and treat CVD N Engl J Med. 2011;365:2255Y2267.
seems to have a modest effect on risk factors in people with diabetes 8. Look AHEAD Research Group;
with current, evidenced-based life- Wadden TA, West DS, et al. The Look
CVD event reduction, with the AHEAD study: a description of the
greatest benefit for those with the style and pharmacologic interventions lifestyle intervention and the evi-
highest CVD risk. The benefit of to reduce risk and prevent disease. dence supporting it. Obesity (Silver
aspirin use must be evaluated in Spring). 2006;14:737Y752.
9. Antithrombotic Trialists (ATT) Col-
context with the risk of gastroin-
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Copyright 2016 Wolters Kluwer Health, Inc. All rights reserved.