Cardiovascular

Disease and Risk

Management
YHANG L TAMA
Macrovascular complication
CAD 3-5x higher ,leading cause of death in T2DM
ischemic stroke( 2-3x higher for men and 2-5x
higher for women, level of glycaemia and HbA1c
level is a predictor of the risk of stroke)
peripheral arterial disease (risk of foot gangrene is
30x higher and risk of lower extremity amputation
is 15x higher)
Target Of Blood Pressure in
DM and HT
• For individuals high cardiovascular risk ASCVD risk >15% BP target is
<130/80 mmHg (Level C)
• For individuals lower cardiovascular risk ASCVD risk <15% BP target is
<140/ 90 mmHg. (Level A)
• In pregnant patients blood pressure target of 110– 135/85mmHg can
reduce the risk for accelerated maternal hypertension (Level A) and
minimizing impaired fetal growth. (Level E)
Statin Therapy
Statin Therapy
 Intensify lifestyle therapy and optimize glycemic control for
patients with elevated triglyceride levels >150 mg/dL
and/or low HDL cholesterol <40 mg/dL for men, <50 mg/dL
for women. (Level C)
 Monitoring statin therapy 4-12 weeks after initiation or
change in dose. (Level E)
 For patients with diabetes aged 40–75 years without
atherosclerotic CVD, use moderate-intensity statin therapy
(Level A)
 For patients with diabetes aged 20–39 years with
atherosclerotic CVD, can initiate statin therapy (Level C)
 For patients with diabetes aged 50–70 years with multiple
atherosclerotic CVD, use High-intensity statin therapy
(Level B)
 For patients with diabetes aged >75 years with can
continue statin therapy (Level B)
 Target LDL cholesterol levels for adults with diabetes are
<100 mg/dl; HDL cholesterol levels are >40 mg/dl ; and
triglyceride levels are <150 mg/dl. In women, who tend to
have higher HDL cholesterol levels than men, an HDL goal
10 mg/dl higher may be appropriate.
Antiplatelet Agents
 Combination therapy with aspirin plus low-dose rivaroxaban should
be considered for patients with stable coronary and/or peripheral
artery disease and low bleeding risk to prevent major adverse limb
and cardiovascular events. (level A)
 Strategy Use Aspirin (75-162 mg) AND/OR a P2Y12 inhibitor can
prevent patient with diabetes from atherosclerotic cardiovascular
disease and it must discuss with the patient on the benefits versus
the comparable increased risk of bleeding.
Management Diabetes in
Cardiovascular disease
 SGLT2 and GLP 1 is recommended and has cardiovascular benefit in
management and prevent cardiovascular disease with diabetes
(Level A)
 ACE inhibitor and ARB therapy is recommended to reduce the
cardiovascular event (Level A)
 In patient with prior myocardial infarction, Beta blocker should be
continued for 3 years after event. (Level B)
 In Patient with T2DM with stable heart failure, metformin may be
continued if eGFR >30 but should be avoided in unstable or
hospitalized patient with HF. (Level B)
Microvascular
Management and
Footcare
Screening Guidelines for
Diabetic Retinopathy
type 1 DM
◦ screen after 5 yr
◦ all patients over 12 yr and/or entering
puberty

type 2 DM
◦ Screen at time of diagnosis, then annually

pregnancy
◦ ocular exam in 1st trimester, close follow-up throughout as
pregnancy can exacerbate DR
Clinical Features
Management
tight glycemic control (delays onset, decreases
progression), tight lipid control, manage HTN,
smoking cessation
ophthalmological treatments available
◦ Panretinal Laser Photocoagulation Therapy
◦ Intravitreous injection of anti vascular endothelial growth
factor
Diabetic Nephropathy
20-40% of persons with T1DM (after 5-10 yr) and 4-
20% with T2DM have progressive nephropathy
Treatment and Prevention
 appropriate glycemic control
 appropriate blood pressure control (<130/80 mmHg)
 use either ACEI or ARB to delay progression of CKD (often used first
line for their CVD protection)
 limit use of nephrotoxic drugs and dyes
 Stop Smoking
Diabetic Neuropathy
approximately 50% of patients within 10 yr of onset of T1DM and T2DM
Screening
• 128 Hz tuning fork or 10 g monolament
• begin screening annually at diagnosis for all T2DM, and >5 yr after
diagnosis of T1DM for post pubertal patients
Treatment and Management
 tight glycemic control
 for neuropathic pain syndromes: tricyclic antidepressants (e.g.
amitriptyline), pregabalin, duloxetine,
 anti-epileptics (e.g. carbamazepine, gabapentin), and capsaicin
 foot care education
 Jobst® tted stocking and tilting of head of bed may decrease
symptoms of orthostatic hypotension
 treat gastroparesis with domperidone and/or metoclopramide
(dopamine antagonists), erythromycin (stimulates motilin receptors)
 medical, mechanical, and surgical treatment for erectile dysfunction
 Foot Care
 Perform a comprehensive foot EVALUATION AT LEAST
ANNUALLY to identify risk factors for ulcers and amputations. B
 Patients with evidence of sensory loss or prior ulceration or amputation
should have their feet inspected at every visit. B
 Obtain a prior history of ulceration, amputation, Charcot foot,
angioplasty or vascular surgery, cigarette smoking, retinopathy, and renal
disease and assess current symptoms of neuropathy (pain, burning,
numbness)and vascular disease (leg fatigue, claudication). B
 The examination should include inspection of the skin, deformities,
neurological and vascular. B
 Patients with symptoms of claudication or decreased or absent pedal
pulses should be referred for ankle-brachial index and for further
vascular assessment as appropriate. C
o A multidisciplinary approach is
recommended
o Provide general preventive foot self-care
education to all patients with diabetes.
Level B
o The use of specialized therapeutic
footwear Level B
references
American Diabetes Association, 2021. Introduction: Standards of
Medical Care in Diabetes—2021.
Mirali, Sara. Essential Med Notes 2020: Comprehensive Medical
Reference and Review for USMLE II and MCCQE. Thieme Medical
Publishers, Incorporated, 2020