New 2018 Diabetes Canada Guidelines - Cardiovascular Protection

We know that reducing the risk of heart attacks and strokes in people with diabetes includes much more than just having good blood sugar control.

So what's new in the Cardiovascular Protection chapter of the Diabetes Canada Guidelines since the last Guidelines in 2013?  Well, as for every chapter, there are now...


KEY MESSAGES FOR PEOPLE WITH DIABETES: 

Ask your doctor about the ABCDEs to reduce your risk of heart attack and stroke:

A = A1C - blood sugar control (the target is usually 7% or less)

B = BP - blood pressure control (less than 130/80)

C = Cholesterol - LDL cholesterol less than 2.0 mmol/L.  Your health care profider may advise you to start cholesterol lowering medication.

D - Drugs to protect your heart - these include blood pressure pills (ACE inhibitors or ARBs), cholesterol lowering medication ('statins'),  and in people with existing cardiovascular disease, certain blood glucose lowering medications, which can protect your heart even if your BP and/or LDL cholesterol are already at target

E = Exercise/Eating - Regular physical activity, healthy eating, and achievement and maintenance of a healthy body weight.

S = Stop smoking and manage stress.


The recommendations for ACE/ARB have loosened a little bit.  While it was recommended in 2013 that anyone over the age of 55 with diabetes should be on an ACE or ARB provided no contraindications, this recommendation has now been modified, as no studies have clearly demonstrated CV benefit for people with diabetes over 55 without any additional cardiovascular risk factors.  However, ACE/ARB is still recommended for:

• anyone with clinical cardiovascular disease
• anyone with microvascular complications
• age 55 or older with an additional cardiovascular risk factor or organ damage (protein in the urine, retinopathy, left ventricular hypertrophy)

So, since most people with diabetes age 55 or older have at least one additional cardiovascular risk factor, the vast majority of people over age 55 will still be recommended to take an ACE or ARB.

As far as cholesterol medication goes, guidelines for treatment with statins are unchanged.  If LDL cholesterol goals (LDL of less than 2 mmol/L, or greater than 50% reduction from baseline) are not achieved, consideration for the addition of ezetimibe is recommended. In people with diabetes who also have cardiovascular disease, a PCSK9 inhibitor may be used.

And, as blogged last week, for people with type 2 diabetes and established cardiovascular disease, consideration should be given for using a glucose lowering medication that has been shown to reduce the risk of cardiovascular events. 

Aspirin continues to be recommended for patients with established cardiovascular disease, at a dose now of 81-162mg daily (in line with the Canadian antiplatelet therapy guidelines). 

One of the Key Messages is also that there is emerging evidence that heart failure, even in the absence of a previous heart attack, is an important (and often unrecognized) complication of diabetes.  Health care professionals should be on the lookout for heart failure in their patients with diabetes.

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