2008 Clinical Practice Guidelines - Canadian Diabetes Association

2008 CLINICAL PRACTICE GUIDELINES
S96
Subclinical vascular disease is common in people with diabetes
(22), and the detection of unrecognized disease will
immediately place a person at a high risk for CAD events. A
history of chest discomfort, unexplained dyspnea, exertional
leg pain (23) or erectile dysfunction (24-26) may indicate
CAD or peripheral arterial disease.The presence of a carotid
or femoral bruit or a low ankle brachial index (27) suggests
vascular disease, and a duplex ultrasound study should be
considered to establish the presence of atherosclerotic disease.
Measurement of the carotid intima thickness (28) and
detection of coronary calcification (29-31) and silent
myocardial ischemia (32) are additional tests that can be considered
in the person at risk. However, their role in the routine
screening of the younger person with diabetes for risk
stratification is not yet established.
RISK TABLES
Risk tables and equations such as the UKPDS allow the calculation
of the absolute global risk of a coronary or CV
event for an individual with type 2 diabetes with no prior
history of MI or stroke (33). In the future, the SCORE risk
engine (34) may be valuable in helping clinicians establish
absolute vascular risk for a Canadian population. Other
available risk tables, such as PROCAM (35), the CV Life
Expectancy Model (36) and the Strong Heart Study (37),
have limitations that may reduce their accuracy to predict
outcomes, especially in a younger population with diabetes.
RISK MANAGEMENT OF PATIENTS WITH
DIABETES WITHOUT CVD
Strategies to reduce CV events by initiating pharmacologic
vascular protective measures could include the following: 1)
a population health strategy of treating all patients with diabetes;
2) a baseline risk strategy of treating only patients at
moderate to high risk; 3) an individual risk-factor strategy of
treating only patients with LDL-C above a certain threshold;
and 4) an age cutoff strategy of treating patients above an age
when the average risk crosses from intermediate to high risk
(i.e. a combination of strategies 1 and 2).An analysis of these
4 strategies (38) showed that the fourth strategy, based on
the age cutoff, was a good compromise between high effectiveness
and high efficiency in reducing CV events. The age
transition from intermediate to high risk for CAD events of
47.9 years for men and 54.3 years for women is based on
Canadian observations (2) and provides the basis for the recommendations
for vascular protection.
OTHER RELEVANT GUIDELINES
Screening for the Presence of Coronary Artery Disease, p. S99
Vascular Protection in People With Diabetes, p. S102
Dyslipidemia, p. S107
Treatment of Hypertension, p. S115
Management of Acute Coronary Syndromes, p. S119
Treatment of Diabetes in People With Heart Failure, p. S123
RECOMMENDATIONS
1.Assessment for CAD risk should be performed periodically
in people with diabetes and should include [Grade
D, Consensus]:
• CV history (dyspnea, chest discomfort)
• Lifestyle (smoking, sedentary lifestyle, poor eating
habits)
• Duration of diabetes
• Sexual function history
• Abdominal obesity
• Lipid profile
• Blood pressure
• Reduced pulses or bruits
• Glycemic control
• Presence of retinopathy
• Estimated glomerular filtration rate and random
albumin to creatinine ratio
• Periodic electrocardiograms as indicated (see
“Screening for the Presence of Coronary Artery
Disease,” p. S99).
2.The following individuals with diabetes should be
considered at high risk for CV events:
• Men aged ≥45 years, women aged ≥50 years
[Grade B, Level 2 (2)].
• Men 180 mm Hg)
• Duration of diabetes >15 years with age >30 years.
REFERENCES
1. Lee WL, Cheung AM, Cape D, et al. Impact of diabetes on
coronary artery disease in women and men: a meta-analysis of
prospective studies. Diabetes Care. 2000;23:962-968.
2. Booth GL, Kapral MK, Fung K, et al. Relation between age
and cardiovascular disease in men and women with diabetes
compared with non-diabetic people: a population-based retrospective
cohort study. Lancet. 2006;368:29-36.
3. Lloyd-Jones DM, Leip EP, Larson MG, et al. Prediction of lifetime
risk for cardiovascular disease by risk factor burden at 50
years of age. Circulation. 2006;113:791-798.
4. Gerstein HC. Reduction of cardiovascular events and
microvascular complications in diabetes with ACE inhibitor
treatment: HOPE and MICRO-HOPE. Diabetes Metab Res Rev.
2002;18(suppl 3):S82-S85.
5. Malmberg K, Ryden L. Myocardial infarction in patients with
diabetes mellitus. Eur Heart J. 1988;9:259-264.