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Sheldon Gottlieb, M.D.
02-04-2011
- Cardiovascular disease (CVD) includes: coronary heart disease (CHD) including asymptomatic disease or manifestations of angina, myocardial infarction, or sudden death; congestive heart failure (CHF) ; valvular heart disease; and cerebrovascular disease (stroke). Coronary artery disease (CAD) includes disease of the coronary arteries: epicardial coronary arteries, branching arteries, and subendocardial vessels.
- Even in the absence of known CVD, the American Diabetes Association,the American Heart Association, and the American College of Cardiology identify diabetes as a high-risk condition for macrovascular disease.
- Coronary heart disease major cause of death worldwide (Yusuf).
- Risk for CHD begins to increase at age 40 and increases greatly above age 70; age is the strongest risk factor for CVD (Vasan; Wald).
- Other CVD risk factors include: family history, male gender, abnormal lipids, smoking, hypertension, diabetes, abdominal obesity, psychosocial factors, level of consumption of fruits, vegetables, and alcohol [lack of moderate consumption], and lack of regular physical activity (Yusuf).
- Definitions of poor, intermediate and ideal cardiovascular health and NHANES 2005-2006 prevalence estimates for AHA 2020 goals are given in Lloyd-Jones table 3. See also: http://circ.ahajournals.org/cgi/content/full/106/25/3143. Up to 80% of individuals with type 2 diabetes will develop CVD (AHA/ADA consensus statement).
- Diabetes is a major risk factor for CVD (Yusuf). Individuals with diabetes have a 2-4 times higher prevalence of CVD compared to the general population (Redberg). Prevalence of subclinical CVD detected using coronary CT in asymptomatic persons with coronary risk factors but no known CVD was significantly higher in persons with diabetes versus no diabetes (i.e. coronary plaques found in 91% versus 68% of individuals, respectively) (Iwaskaki).
- Diabetes traditionally considered a CVD risk factor equivalent (i.e. patients with diabetes and no history of previous MI have a similar risk (~20%) of a major cardiovascular event in the next 7 years as persons with a history of previous myocardial infarction but no diabetes) (Haffner).
- CVD is the primary cause of death in persons with diabetes and mortality from acute myocardial infarction (MI) is much higher in persons with diabetes compared to their counterparts (Grundy).
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Clinical suspicion: those at highest risk of future CVD events are those with previous history of CHD, CHF or stroke.
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History: family history of early onset CVD (< 55 years in men, < 65 years in women) is an important risk factor and strongest when present in both a parent and sibling (Nasir). Drawing family pedigree for diabetes and heart disease is important during initial assessment. See: http://www.americanheart.org/downloadable/heart/1170790567218Family%20Tree%20Flyer%20b-w_2007.pdf
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Labs: measure non-fasting total cholesterol and HDL-cholesterol and their ratio. Ratio of > 3.1 is associated with progression of carotid intimal thickness (see Emerging risk factors collaboration). High-sensitivity-CRP may be be helpful in persons with intermediate CVD risk (Pearson).
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Electrocardiogram (ECG): on a standard resting ECG, left atrial enlargement, LVH, long corrected QT interval, atrial fibrillation, frequent PAC or PVC, absence of respiratory variability in heart rate (Pop-Busui)
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Stress testing: graded exercise treadmill stress test preferred where possible. If uninterpretable resting ECG (i.e. left bundle-branch block or major ST-T abnormalities) do stress imaging. Pharmacological stress imaging for persons who cannot undergo leg exercise (See module on physical activity and exercise. Persons with diabetes at are intermediate risk at baseline and imaging studies should be used if available. Both echo and nuclear stress imaging have high negative predictive value for left main or extensive triple vessel disease (Metz).
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Imaging: echocardiography for LVH, LV size and function, and carotid ultrasound for intimal thickness are useful.
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Coronary CT: can be a useful imaging test to establish coronary risk for those at intermediate risk (this will include all persons with diabetes above age 45; Hecht). Coronary artery calcium (CAC) scores directly measure coronary artery disease burden. A significant number of persons with diabetes, at intermediate to high risk based on risk factor scoring may have CAC scores that place them at low risk (Hecht) and high risk (Hadamitzky). CAC use in diabetes may be clinically useful and cost effective (Hecht). Radiation dose is 2 mSv, about the same as background radiation over 8 months. See www.radiologyinfo.org
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Vascular studies: see module on peripheral vascular disease.
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Chest X-ray: calcification of the aortic knob is often seen in patients with diabetes and is a marker for duration of diabetes, and likelihood of multivessel coronary artery disease. A cardiothoracic ratio of >0.5 is a marker for cardiac enlargement and heart failure.
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Genomic Testing: genes for type 2 diabetes and coronary heart disease are beginning to be identified but no recommendations currently exist for their routine use in diagnostic evaluation.
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Symptoms: any complaint of chest discomfort (from midabdomen to jaw) with exertion, any limitation in walking or decreased exercise tolerance, snoring or sleep disturbance, increasing fatigue in persons middle aged and older. Description of chest discomfort may vary depending on age, gender, education, ethnicity, duration of diabetes.
- Patients with diabetes and CVD are often asymptomatic, especially women.
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Signs on physical examination: BP >135/80, resting HR > 80 bpm, respiratory rate >15, arcus corneus, poor dentition, periodontal disease, stiff blood vessels on exam, increased pulse pressure (>50 mm Hg), carotid bruit or murmur of aortic stenosis, a loud S4 or any S3 gallop, any signs of neuropathy, decreased ankle or knee jerks, decreased pedal pulses, any ulcerations or severe calluses on the feet.
- Tests of cognition, such as the mini-mental exam, should be part of the intake exam for patients with diabetes and CVD who are at risk of cognitive decline over time.
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Erectile dysfunction in younger men is associated with an increased likelihood of CAD (Miner).
- Risk calculator: computerized risk model, based on clinical data or clinical plus lab and imaging data.
- "QRISK" risk calculator: (available at QRISK.org) is very effective when calculated with the patient at a workstation, the graphics are effective and it calculates a "relative risk" over a 10 year span and a "heart age". This risk calculator will identify patients at intermediate risk for coronary heart disease. However, all persons with diabetes above age 45-55 are at intermediate risk. The coronary calcium score will reclassify a significant portion of these patients into lower or higher risk category.
- The Framingham Heart Study risk calculator may underestimate CVD risks for people with diabetes since the study included relatively few persons with diabetes (available at http://hin.nhlbi.nih.gov/atpiii/calculator.asp?usertype=prof).
- Other risk calculators specifically for use in diabetes include: UKPDS http://www.dtu.ox.ac.uk/riskengine/index.php, ARIC study http://www.aricnews.net/riskcalc/html/RC1.html, and the ADA's Diabetes PhD http://www.diabetes.org/living-with-diabetes/complications/diabetes-phd/ as seen in the American Diabetes Association position statement
- Optimize risk factors: smoking cessation; BP: <130/85 although limited data on efficacy for lower BP in elderly patients who may become orthostatic; lipids: ratio of total cholesterol to HDL-cholesterol <3.1, LDL < 100 mg/dl (target for persons with known CVD is probably <70mg/dl), triglycerides <150 mg/dl (for persons with known disease, target probably <100mg/dl); A1C <7.0 (benefits for reducing risk of CVD below this level are uncertain and probably minimal with a high "number needed to treat" (Yudkin, Pfeffer)
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Diabetes: the only glucose lowering medications that have shown net cardiovascular benefit in long-term studies of patients with type 2 diabetes are metformin and acarbose. Both drugs have pleiotropic effects. Recent studies suggest the importance of glycemic control in CVD prevention (Selvin), (Hanefeld, Zhou).
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Hypertension: treatment of BP is essential; angiotensin converting enzyme inhibitors often first choice for persons with diabetes. Combinations of drugs used a on half recommended doses may be most effective with fewest side effects (Laws).
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Carvedilol may be particularly effective for BP lowering in African-American persons with diabetes.
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Diuretics also good for BP control, the negative effect on glycemic control is minimal when used at one half dose, such as chlorthalidone 12.5 mg daily.
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Dyslipidemia: persons taking statins often complain of myalgias without CK elevations. Effective lipid control may often be obtained using potent and long lasting statins such as rosuvastatin 5 to 20 mg every other day.
- Given that diabetes is a high risk condition for CVD, the NHLBI Adult Treatment Panel III (ATP III) lists diabetes as a "CVD risk equivalent" when determining LDL goals
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Weight loss: . bariatric surgery may have an important place in the treatment of type 2 diabetes and prevention of CVD but patients must have capacity for full understanding of the risks and potential benefits of the procedure, that include improvement in hypertriglyceridemia, low levels of HDL, hypertension, and hyperuricemia (Sjöström).
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Lifestyle modification (diet and exercise): see modules on diet and principles of physical activity and exercise
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Aspirin therapy: indicated in all persons with history of CVD and in persons with diabetes who have >10% risk of CVD over the next 10 years (See module on Routine Preventive Care for more details)
- Most patients with diabetes have some degree of subclinical CVD; prevalence increases with duration of disease. Preventive screening for CVD may be appropriate, especially in those with other CVD risk factors.
- Diabetes has been called diabetes a CVD "risk equivalent" but use of the term may be contentious given considerable variability in risk for CVD (Grundy)
- Once a person has diabetes, they are at intermediate risk for having CVD. Smoking, family history of early cardiac disease, abdominal obesity, low HDL, erectile dysfunction in young men, ankle brachial index < 0.9 all point to increased risk.
- Risk of cardiovascular mortality rises with age in an exponential fashion.
- Approximately 15 percent of persons with diabetes may be reclassified as "low risk" based on coronary calcium score of 0 (Hecht).
- We prefer use of a stress test for CVD risk stratification in symptomatic individuals, and in asymptomatic individuals at high risk for CVD prior to recommending an exercise program (see physical activity and exercise).
- Absence of symptoms does not exclude presence of CVD in persons with diabetes; many will be asymptomatic.
- Optimize modifiable risk factors for CVD including smoking cessation, hypertension, dyslipidemia, and encourage weight loss.
- Example of an effective medication list for most patients with type 2 diabetes and CVD: lisinopril (ACE inhibitors), carvedilol (beta-blockers), chlorthalidone (diuretics), aspirin, statin, metformin, and other diabertes medications..
- The goal for patients with diabetes and CVD is self-management supplemented by appropriate education and feedback (Clar) and team management or case management as needed.
- American Diabetes Association;
Standards of medical care in diabetes--2010.;
Diabetes Care;
2010; Vol.
33 Suppl 1; pp.
S11-61;
ISSN:
1935-5548;
PUBMED: 20042772
Rating:
Basis for recommendation
Comments:Specific authoritative recommendations, evaluated and updated yearly.
- Lloyd-Jones DM, Hong Y, Labarthe D, et al.;
Defining and setting national goals for cardiovascular health promotion and disease reduction: the American Heart Association's strategic Impact Goal through 2020 and beyond.;
Circulation;
2010; Vol.
121; pp.
586-613;
ISSN:
1524-4539;
PUBMED: 20089546
Rating:
Basis for recommendation
Comments:Ex Cathedra statement from the American Heart Association re: prevention and treatment of CVD. Section on behavioral medicine pp 424-426 should be read by all medical practitioners.
- American Diabetes Association;
Standards of medical care in diabetes--2010.;
Diabetes Care;
2010; Vol.
33 Suppl 1; pp.
S11-61;
ISSN:
1935-5548;
PUBMED: 20042772
Rating:
Basis for recommendation
Comments:Summary of American Diabetes Association recommendations for routine preventive care.
- Skyler JS, Bergenstal R, Bonow RO, et al.;
Intensive glycemic control and the prevention of cardiovascular events: implications of the ACCORD, ADVANCE, and VA diabetes trials: a position statement of the American Diabetes Association and a scientific statement of the American College of Cardiology Foundation and the American Heart Association.;
Diabetes Care;
2009; Vol.
32; pp.
187-92;
ISSN:
1935-5548;
PUBMED: 19092168
Rating:
Basis for recommendation
Comments:Joint statement ADA, AHA, ACC incorporating findings from ACCORD, ADVANCE and VA-Diabetes studies
- Buse JB, Ginsberg HN, Bakris GL, et al.;
Primary prevention of cardiovascular diseases in people with diabetes mellitus: a scientific statement from the American Heart Association and the American Diabetes Association.;
Diabetes Care;
2007; Vol.
30; pp.
162-72;
ISSN:
0149-5992;
PUBMED: 17192355
Rating:
Basis for recommendation
Comments:Joint statement by AHA and ADA on recommendations for primary prevention of CVD.
- Yusuf S, Hawken S, Ounpuu S, et al.;
Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study.;
Lancet;
2004; Vol.
364; pp.
937-52;
ISSN:
1474-547X;
PUBMED: 15364185
Rating:
Basis for recommendation
Comments:"Abnormal lipids, smoking, hypertension, diabetes, abdominal obesity, psychosocial factors, level of consumption of fruits, vegetables, and alcohol [lack of moderate consumption], and lack of regular physical activity account for most of the risk of myocardial infarction worldwide in both sexes and at all ages in all regions."
- Grundy SM, Benjamin IJ, Burke GL, et al.;
Diabetes and cardiovascular disease: a statement for healthcare professionals from the American Heart Association.;
Circulation;
1999; Vol.
100; pp.
1134-46;
ISSN:
1524-4539;
PUBMED: 10477542
Rating:
Basis for recommendation
Comments:The first presentation by the American Diabetes Association and the American Heart Association of diabetes as a CVD.
- Peabody FW;
Landmark article March 19, 1927: The care of the patient. By Francis W. Peabody.;
JAMA;
1984; Vol.
252; pp.
813-8;
ISSN:
0098-7484;
PUBMED: 6379210
Rating:
Basis for recommendation
Comments:Classic essential article, written by Peabody as he was dying.
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http://www.cms.gov/CardiovasDiseaseScreening/ accessed October 5, 2010.;
Rating:
Basis for recommendation
Comments:CMS web site reviews cholesterol screening benefit for Medicare beneficiaries, who must have no signs or symptoms of CVD and must be fasting for 12 hours. There is no co-pay or deductible and the test may be ordered every 5 years.
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