CV Risk Assessment in Diabetes Mellitus

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Questions and Answers

What is the estimated increased risk of developing cardiovascular disease (CVD) in individuals with Type 2 Diabetes Mellitus (T2DM)?

No increased risk

Two to four-fold (correct)

Five to six-fold

One to two-fold

Which of the following is NOT a cardiovascular risk factor that should be assessed in individuals with diabetes?

Dyslipidemia

Hypertension

Anemia (correct)

Obesity/overweight

Which condition is essential to consider when assessing cardiovascular risk in individuals with T2DM?

Presence of a family pet

Severe target-organ damage (correct)

Orthopedic disorders

Mental health history

What should be systematically assessed at least annually in all people with diabetes?

Cardiovascular risk factors Signup and view all the answers

Which of the following indicates the most severe form of target-organ damage (TOD) related to diabetic complications?

Presence of microvascular disease in at least three different sites Signup and view all the answers

What type of therapy is recommended for patients with T2D to help mitigate ASCVD risk?

High-intensity statin therapy Signup and view all the answers

What is the purpose of the SCORE2-Diabetes algorithm?

To estimate 10-year cardiovascular disease risk Signup and view all the answers

Which of the following factors is NOT integrated into the SCORE2-Diabetes risk estimation?

Family medical history Signup and view all the answers

What does a coronary artery calcium (CAC) score of >100 Agatston units indicate?

High CVD risk Signup and view all the answers

Which blood pressure medication class is recommended for T2D patients regardless of blood pressure levels?

ACE inhibitors / ARBs Signup and view all the answers

Which of the following assessments is associated with increased risk of CVD events?

Arterial stiffness assessed by pulse wave velocity Signup and view all the answers

What are the two drug classes recommended for CVD reduction in individuals with T2D?

SGLT2 inhibitors and GLP-1 receptor agonists Signup and view all the answers

Which of the following is NOT a component of the ASCVD risk calculator, Risk Estimator Plus?

Presence of kidney disease Signup and view all the answers

What is a key recommendation for managing weight in patients with diabetes and cardiovascular disease?

Regular physical activity Signup and view all the answers

What screening method is recommended for assessing chronic kidney disease in individuals with type 2 diabetes?

Urine albumin to creatinine ratio testing Signup and view all the answers

Which treatment is cited as a kidney-protective therapy for patients with type 2 diabetes and chronic kidney disease?

Sodium-glucose cotransporter 2 inhibitors Signup and view all the answers

What is the primary recommendation for glycemic control in individuals with an eGFR greater than 15 mL/min per 1.73 m2?

GLP-1 receptor agonists Signup and view all the answers

What is the recommended approach to smoking cessation in patients with both diabetes and cardiovascular disease?

Using nicotine replacement therapies Signup and view all the answers

What is a significant cardiovascular risk factor in patients with diabetes?

Poor glycemic control Signup and view all the answers

How prevalent is chronic kidney disease among individuals with type 2 diabetes?

30% to 40% Signup and view all the answers

What is indicated for those with chronic kidney disease who have an eGFR of 30 mg/g?

SGLT2 inhibitors Signup and view all the answers

Signup and view all the answers

Study Notes

CV Risk Assessment in DM

Individuals with type 2 diabetes mellitus (T2DM) have a significantly higher risk (two- to four-fold) of developing cardiovascular disease (CVD) throughout their lifetime.
This risk is alongside other CVD manifestations including coronary artery disease (CAD), stroke, heart failure (HF), atrial fibrillation (AF), and peripheral artery disease (PAD).
Many patients with CVD have undiagnosed T2DM.
Diabetes and CVD, especially at a younger age, significantly impacts prognosis.
Screening for diabetes in CVD patients & assessing CV risk in diabetes patients is crucial to evaluating them for CVD and kidney disease.

Risk Factors Assessment

For both atherosclerotic cardiovascular disease (ASCVD) prevention and heart failure management, cardiovascular risk factors must be assessed at least annually in all people with diabetes.
These factors involve the duration of diabetes, obesity/overweight, high blood pressure (hypertension), dyslipidemia (lipid disorders), smoking, family history of premature coronary disease, chronic kidney disease (CKD), and albuminuria.

Assessing CV Risk in T2DM

When assessing CV risk in individuals with T2DM, consider medical and family history, symptoms, examination findings, laboratory tests, and other diagnostic results.
Evaluate for the presence of ASCVD (atherosclerotic CVD or severe target-organ damage (TOD)).

Severe TOD

Estimated glomerular filtration rate (eGFR) <45 mL/min/1.73 m² irrespective of albuminuria
eGFR 45-59 mL/min/1.73 m² with microalbuminuria (UACR 30–300 mg/g). Stage A2
Proteinuria (UACR >300 mg/g). Stage A3
Presence of microvascular disease in at least three different places (e.g., microalbuminuria (stage A2) with retinopathy and neuropathy).

ASCVD Risk-mitigating Therapies

High-intensity statin therapy and non-statin LDL cholesterol-lowering therapies, with aggressive LDL cholesterol targets.
ACE inhibitors/ARBs, independent of blood pressure (BP) consideration, & aggressive systolic BP targets.
Healthy lifestyle counseling, emphasizing physical activity engagement, healthy diet, weight management, and smoking abstinence.
Prescription of sodium-glucose co-transporter-2 inhibitors (SGLT2i) and glucagon-like peptide-1 receptor agonists (GLP-1 RAs) to reduce CVD in patients with T2DM or high risk for ASCVD.
Data from randomized controlled trials supports this approach.

SCORE2-Diabetes

Patients aged ≥40 years with T2DM without ASCVD or severe TOD, are recommended to use the SCORE2-Diabetes algorithm to estimate 10-year CVD risk.
SCORE2-Diabetes integrates conventional CVD risk factors (age, smoking status, systolic blood pressure, total/HDL cholesterol) with diabetes-specific information (diabetes diagnosis age, HbA1c, eGFR).
The model is calibrated for different CVD risk levels (low, moderate, high, very high) across various countries.

Cardiovascular Risk Categories in Type 2 Diabetes

Categorizing cardiovascular risks provides clinicians with a framework to assess treatment strategies.
Categories defined by 10-year CVD risk using SCORE2-Diabetes, in relation to the presence of clinically established ASCVD or severe TOD.

Recommendations to Assess Cardiovascular Risk

Screen patients with diabetes for severe TOD.
Assess medical history and symptoms suggestive of ASCVD in patients with diabetes.
Estimate 10-year CVD risk in patients with T2DM without symptomatic ASCVD or severe TOD using SCORE2-Diabetes
Specific guidelines and classifications, represented by classes and levels, are suggested.

American College of Cardiology ASCVD Risk Calculator

The Risk Estimator is a tool to calculate the 10-year CVD risk of first ASCVD events.

Improving CVD Risk Prediction

Coronary artery calcium (CAC) scoring enhances CVD risk prediction and reclassifies risk when integrated with conventional risk factors.
A CAC score >100 Agatston units or ≥75th percentile for age, sex, and ethnicity favours up-classification of CVD risk.

Updates in the Management of CVD and DM

Update recommendations to address cardiovascular risk in people with type 2 diabetes.
Include assessment of systematic risk using SCORE2-Diabetes.
Measurement of blood pressure to control hypertension
Using glucose-lowering medicines such as SGLT2i and GLP-1 receptor agonists for improved results and reduced risks when appropriate.
Screen for atrial fibrillation and monitor complications related to diabetes (ASCVD, CKD, HF).
Recommendations on weight reduction, healthy diet, smoking cessation, physical activity, and glycemic control in the management of CVD in diabetes.

CVD Risk Reduction

The management of risks and treatments related to CVD in the context of diabetes.
The diagram shows various factors involved in cardiovascular risk, including weight, physical activity, diet, nutrients, glycemic targets,, and smoking cessation.

Recommendation for Reducing Weight

Recommendations to encourage weight reduction in people with diabetes mellitus (DM) and cardiovascular disease (CVD). Emphasis on lifestyle changes (physical exertion and improved weight control) with or without medical interventions.

Recommendation for Nutrition

Recommendations for dietary practices in the management of individuals with diabetes and CVD, notably suggesting the Mediterranean or plant-based diet.
High emphasis on unsaturated fats to reduce cardiovascular risk.

Recommendations for Physical Activity

Recommendations to increase physical activity in patients with type 2 diabetes and cardiovascular disease or not.
Focus on endurance training and possible adjustments tailored to existing comorbidities.

Recommendation for Smoking Cessation

Recommendations for smoking cessation to reduce cardiovascular risk in individuals with diabetes and CVD.
Include therapies like nicotine replacement, counseling or other treatment options.

Recommendation for Glycemic Targets

Importance of tight glycemic control using HbA1c(<7%) to minimize the risks of microvascular complications with diabetes in the management of cardiovascular disease.
Individualization of targets based on comorbidities, life expectancy, and duration of diabetes.

Risk Assessment for T2DM

Risk assessment based on the presence of ASCVD/severe target-organ damage (TOD) and 10-year CVD risk estimation via SCORE2-Diabetes helps further guide treatment recommendations for different risk levels (low, moderate, high, and very high).

Glucose-Lowering Medications

Prioritizing glucose-lowering agents with proven cardiovascular (CV) benefits (e.g., SGLT-2 inhibitors and GLP-1 receptor agonists), over agents without such proof, in the management of T2DM & ASCVD.

Other Glucose-Lowering

Metformin & pioglitazone are potential options when additional glucose control is necessary for patients with T2DM and ASCVD or those without HF, respectively.

Diabetes and Chronic Kidney Disease

Approximately 30-40% of people with T2DM develop chronic kidney disease (CKD).
Guidelines promote screening strategies for CKD in individuals with T2DM, emphasizing routine eGFR measurement and urine albumin-to-creatinine ratio testing.

Kidney-Protective Effects of SGLT2is

SGLT2 inhibitors, along with ACE inhibitors/ARBs and finerenone, are integral in evidence-based kidney protection for T2DM and CKD patients.
GLP-1 RAs are recommended for suitable glycemic control in individuals with eGFR above 15 mL/min per 1.73 m², as evidenced in the 2023 guidelines.

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Description

This quiz delves into the cardiovascular risks associated with type 2 diabetes mellitus (T2DM). It emphasizes the importance of assessing cardiovascular risk factors annually for effective management and prevention of complications like coronary artery disease and heart failure. Understand the critical relationship between diabetes and cardiovascular disease.