is rich in nutrients, protein, and fiber (Mayo Clinic, 2020e; 2021c). This diet has been shown to help diabetic patients lose weight and maintain a more stable blood sugar. Salt should be limited. Foods that are low in sodium and contain no added salt should be chosen. Salt should not be on the table during meals. No more than one teaspoon of salt per day should be consumed (Mayo Clinic, 2020e; 2021c). Patients who smoke should be referred to smoking cessation programs. Smoking constricts and damages blood vessels and increases hypertension risk (Mayo Clinic, 2021c). Lipid management Lifestyle modifications that focus on weight loss if needed, dietary changes as needed (reduce intake of saturated fat, trans fat, and cholesterol; increase intake of n-3 fatty acids, fiber, and plant stanols/sterols), and glycemic control are central to lipid management (American Diabetes Association, 2021a). The American Diabetes Association (2021a) offers the following recommendations for lipid management: ● For adults not taking lipid-lowering therapy, obtain a lipid profile at the time of diabetes diagnosis, at an initial medical evaluation, and every 5 years thereafter if younger than 40 years of age. Testing may be done more frequently as needed. ● A lipid profile should be obtained at the start of lipid- lowering therapy 4 to 12 weeks after starting therapy or when there is a change in dosage and annually thereafter. ● In adults not taking statins or other lipid-lowering therapy, it is reasonable to obtain a lipid profile at the time of diabetes diagnosis, at an initial medical evaluation, and every five years thereafter if under the age of 40 years, or more frequently if indicated. ● For patients with diabetes aged 40–75 years without atherosclerotic cardiovascular disease, use moderate- intensity statin therapy in addition to lifestyle therapy. ● For patients with diabetes aged 20–39 years with additional atherosclerotic cardiovascular disease risk factors, it may be reasonable to initiate statin therapy in addition to lifestyle therapy. ● In patients with diabetes at higher risk, especially those with multiple atherosclerotic cardiovascular disease risk factors or aged 50–70 years, it is reasonable to use high-intensity statin therapy. ● In adults with diabetes and 10-year atherosclerotic cardiovascular disease risk of 20% or higher, it may be reasonable to add ezetimibe to maximally tolerated statin therapy to reduce LDL cholesterol levels by 50% or more. Antiplatelet agents for the management of CVD Research findings indicate that aspirin has been shown to help reduce cardiovascular morbidity and mortality in patients who are high risk and who have had previous heart attack or stroke. However, its overall benefit in primary prevention among adults with no previous cardiovascular events (heart attack or stroke) is controversial for patients with or without a history of diabetes. Aspirin is not recommended for persons at low risk of ASCVD (men and women younger than 50 years of age with no other major ASCVD risk factors). This is because the low potential benefit is outweighed by the risks for bleeding (American Diabetes Association, 2021a). Following are recommendations regarding aspirin therapy (American Diabetes Association, 2018j): ● Use aspirin therapy (75 to 162 mg/day) as a secondary prevention strategy for persons with diabetes and a history of ASCVD.
Finally, patients must be instructed in stress management techniques. Relaxation training, deep breathing exercises, guided imagery, and exercise all have been shown to facilitate stress reduction. Equally important is to help patients identify stressors in their lives and how to deal with them. For example, financial issues may prove to be significant stressors. The costs of a chronic illness, even with insurance coverage, can place a financial burden on patients and families. Relaxation techniques may be helpful, but patients may also need referral to financial counseling or resources that may be able to help defray the cost of medications and other treatments (Mayo Clinic, 2021c). ● For patients of all ages with diabetes and atherosclerotic cardiovascular disease, high-intensity statin therapy should be added to lifestyle therapy. ● For patients with diabetes and atherosclerotic cardiovascular disease considered very high risk using specific criteria, if LDL cholesterol is ≥70 mg/dL on maximally tolerated statin dose, consider adding additional LDL-lowering therapy (such as ezetimibe or PCSK9 inhibitor). Ezetimibe may be preferred because of lower cost. ● For patients who do not tolerate the intended intensity, the maximally tolerated statin dose should be used. ● In adults with diabetes aged >75 years already on statin therapy, it is reasonable to continue statin treatment. ● In adults with diabetes aged >75 years, it may be reasonable to initiate statin therapy after discussion of potential benefits and risks. ● Statin therapy is contraindicated in pregnancy. ● For patients with fasting triglyceride levels ≥500 mg/dL, evaluate for secondary causes of hypertriglyceridemia and consider medical therapy to reduce the risk of pancreatitis. ● In adults with moderate hyper-triglyceridemia (fasting or non-fasting triglycerides 175–499 mg/dL), clinicians should address and treat lifestyle factors (obesity and metabolic syndrome), secondary factors (diabetes, chronic liver or kidney disease and/or nephrotic syndrome, hypothyroidism), and medications that raise triglycerides. ● In patients with atherosclerotic cardiovascular disease or other cardiovascular risk factors on a statin with controlled LDL cholesterol but elevated triglycerides (135–499 mg/dL), the addition of icosapent ethyl can be considered to reduce cardiovascular risk. ● Statin plus fibrate combination therapy has not been shown to improve atherosclerotic cardiovascular disease outcomes and is generally not recommended. ● Statin plus niacin combination therapy has not been shown to provide additional cardiovascular benefit above statin therapy alone, may increase the risk of stroke with additional side effects, and is generally not recommended. ● Use clopidogrel (75 mg/day) for those patients with ASCVD and documented aspirin allergy. ● The use of dual antiplatelet therapy (low-dose aspirin and a P2Y12 inhibitor) is deemed reasonable for a year after an acute coronary syndrome and may have benefits beyond one year. ● Long-term treatment with dual antiplatelet therapy should be considered for patients with prior coronary intervention, high ischemic risk, and low bleeding risk to prevent major adverse cardiovascular events. ● 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. ● Aspirin therapy (75 to 162 mg/day) may be considered as a primary prevention strategy for those patients with type 1 or type 2 diabetes who have increased cardiovascular risk.
Screening and treatment recommendations for cardiovascular disease The American Diabetes Association (2021a) does not recommend routine screening for coronary artery disease in asymptomatic patients if ASCVD risk factors are treated. Investigations for coronary artery disease should be considered if any of the following is present: ● Unexplained dyspnea
● Chest discomfort ● Carotid bruits ● Transient ischemic attack ● Stroke ● Claudication ● Peripheral arterial disease
Book Code: ANCCUS2423
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