2008 Clinical Practice Guidelines - Canadian Diabetes Association

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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.
6. Malmberg K,Yusuf S, Gerstein HC, et al. Impact of diabetes on long-term prognosis in patients with unstable angina and non-Q-wave myocardial infarction: results of the OASIS (Organization to Assess Strategies for Ischemic Syndromes) Registry. Circulation. 2000;102:1014-1019. 7. National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III).Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) final report. Circulation. 2002;106:3143-3421. 8. McPherson R, Frohlich J, Fodor G, et al. Canadian Cardiovascular Society position statement—recommendations for the diagnosis and treatment of dyslipidemia and prevention of cardiovascular disease. Can J Cardiol. 2006;22:913-927. 9. Haffner SM, Lehto S, Ronnemaa T, et al. Mortality for coronary heart disease in subjects with type 2 diabetes and in nondiabetic subjects with and without prior myocardial infarction. N Engl J Med. 1998;339:229-234. 10. Evans JMM,Wang J, Morris AD. Comparison of cardiovascular risk between patients with type 2 diabetes and those who had had a myocardial infarction: cross sectional and cohort studies. BMJ. 2002;324:939-942. 11. Wannamethee SG, Shaper AG, Lennon L. Cardiovascular disease incidence and mortality in older men with diabetes and in men with coronary heart disease. Heart. 2004;90:1398-1403. 12. Turner RC, Millns H, Neil HA, et al. Risk factors for coronary artery disease in non-insulin dependent diabetes mellitus: United Kingdom Prospective Diabetes Study (UKPDS: 23). BMJ. 1998;316:823-828. 13. Fox CS, Sullivan L, D’Agostino RB Sr, et al. The significant effect of diabetes duration on coronary heart disease mortality: the Framingham Heart Study. Diabetes Care. 2004;27:704-708. 14. Selvin E, Marinopoulos S, Berkenblit G, et al. Meta-analysis: glycosylated hemoglobin and cardiovascular disease in diabetes mellitus. Ann Intern Med. 2004;141:421-431. 15. Dinneen SF, Gerstein HC. The association of microalbuminuria and mortality in non-insulin-dependent diabetes mellitus. A systemic overview of the literature. Arch Intern Med. 1997; 157:1413-1418. 16. Mann JF, Gerstein HC, Pogue J, et al. Cardiovascular risk in patients with early renal insufficiency: implications for the use of ACE inhibitors. Am J Cardiovasc Drugs. 2002;2:157-162. 17. Faglia E, Favales F, Calia P, et al. Cardiac events in 735 type 2 diabetic patients who underwent screening for unknown asymptomatic coronary heart disease: 5-year follow-up report from the Milan Study on Atherosclerosis and Diabetes (MiSAD). Diabetes Care. 2002;25:2032-2036. 18. Alexander CM, Landsman PB, Teutsch SM, et al; Third National Health and Nutrition Examination Survey (NHANES III); National Cholesterol Education Program (NCEP). NCEPdefined metabolic syndrome, diabetes, and prevalence of coronary heart disease among NHANES III participants age 50 years and older. Diabetes. 2003;52:1210-1214. 19. Laing SP, Swerdlow AJ, Slater SD, et al. The British Diabetic Association Cohort Study, II: cause-specific mortality in patients with insulin-treated diabetes mellitus. Diabet Med. 1999;16:466-471. 20. Nathan DM, Cleary PA, Backlund JY, et al; Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications (DCCT/EDIC) Study Research Group. Intensive diabetes treatment and cardiovascular disease in patients with type 1 diabetes. N Engl J Med. 2005;353:2643-2653. 21. Schwab KO, Doerfer J, Hecker W, et al; DPV Initiative of the German Working Group for Pediatric Diabetology. Spectrum and prevalence of atherogenic risk factors in 27,358 children, adolescents, and young adults with type 1 diabetes. Cross-sectional data from the German diabetes documentation and quality management system (DPV). Diabetes Care.2006;29:218-225. 22. Barzilay JI, Spiekerman CF, Kuller LH, et al; Cardiovascular Health Study. Prevalence of clinical and isolated subclinical cardiovascular disease in older adults with glucose disorders: the Cardiovascular Health Study. Diabetes Care. 2001;24:1233-1239. 23. Brand FN, Abbott RD, Kannel WB. Diabetes, intermittent claudication, and risk of cardiovascular events. The Framingham Study. Diabetes. 1989;38:504-509. 24. Gazzaruso C, Giordanetti S, De Amici E, et al. Relationship between erectile dysfunction and silent myocardial ischemia in apparently uncomplicated type 2 diabetic patients. Circulation. 2004;110:22-26. 25. Min JK,Williams KA, Okwuosa TM, et al. Prediction of coronary heart disease by erectile dysfunction in men referred for nuclear stress testing. Arch Intern Med. 2006;166:201-206. 26. Chiurlia E, D’Amico R, Ratti C, et al. Subclinical coronary artery atherosclerosis in patients with erectile dysfunction. J Am Coll Cardiol. 2005;46:1503-1506. 27. Rutter MK, Wahid ST, McComb JM, et al. Significance of silent ischemia and microalbuminuria in predicting coronary events in asymptomatic patients with type 2 diabetes. J Am Coll Cardiol. 2002;40:56-61. 28. Chambless LE, Heiss G, Folsom AR, et al. Association of coronary heart disease incidence with carotid arterial wall thickness and major risk factors: the Atherosclerosis Risk in Communities (ARIC) Study, 1987-1993. Am J Epidemiol. 1997; 146:483-494. 29. Raggi P, Shaw LJ, Berman DS, et al. Prognostic value of coronary artery calcium screening in subjects with and without diabetes. J Am Coll Cardiol. 2004;43:1663-1669. 30. Anand DV, Lim E, Hopkins D, et al. Risk stratification in uncomplicated type 2 diabetes: prospective evaluation of the combined use of coronary artery calcium imaging and selective myocardial perfusion scintigraphy. Eur Heart J. 2006;27: 713-721. 31. Scholte AJ, Bax JJ, Wackers FJ. Screening of asymptomatic patients with type 2 diabetes mellitus for silent coronary artery disease: combined use of stress myocardial perfusion S97 COMPLICATIONS AND COMORBIDITIES
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2008 Clinical Practice Guidelines - Canadian Diabetes Association

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