2008 Clinical Practice Guidelines - Canadian Diabetes Association

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2008 CLINICAL PRACTICE GUIDELINES S102 Vascular Protection in People With Diabetes Canadian Diabetes Association Clinical Practice Guidelines Expert Committee The initial draft of this chapter was prepared by David Fitchett MD FRCPC and Maria Kraw MD FRCPC KEY MESSAGES • The first priority in the prevention of macrovascular complications should be reduction of cardiovascular (CV) risk through a comprehensive, multifaceted approach, integrating both lifestyle and pharmacologic measures. • Treatment with angiotensin-converting enzyme (ACE) inhibitors has been shown to result in better outcomes for people with atherosclerotic vascular disease, recent myocardial infarction, left ventricular impairment and heart failure. In a similar population, angiotensin II receptor antagonists have been shown to be noninferior to ACE inhibitors for vascular protection. • Low-dose acetylsalicylic acid therapy may be considered in people with stable CVD.The decision to prescribe antiplatelet therapy for primary prevention of CV events, however, should be based on individual clinical judgment. VASCULAR PROTECTION In order to reduce the excessive cardiovascular disease (CVD) risk associated with diabetes, all coronary risk factors must be addressed and treated aggressively. The Steno-2 studies (1,2) demonstrated that a target-driven, comprehensive, multifaceted approach to risk factor management applied to high-risk patients with type 2 diabetes and microalbuminuria over a period of 7 years resulted in a >50% reduction of CVD (HR 0.47, 95% CI, 0.24–0.73) *See also “Identification of Individuals at High Risk of Coronary Events,” p. S95 BP = blood pressure CAD = coronary artery disease CV = cardiovascular and microvascular events (nephropathy HR 0.39, 95% CI, 0.17–0.87; retinopathy HR 0.42, 95% CI, 0.21–0.86). It is likely that similar relative benefits would be achieved by applying a comprehensive, multifaceted approach to risk factor control in high-risk patients with diabetes who do not have microalbuminuria. Patients at the highest risk for CV events include those who have diabetes and atherosclerotic vascular disease that includes either clinically recognized disease (e.g. coronary artery disease [CAD], peripheral arterial disease [PAD] and cerebrovascular disease) or clinically silent disease (e.g. silent myocardial ischemia or infarction, and PAD identified by the presence of bruits or abnormal ultrasound or anklebrachial index). Other patients at high risk include those with microvascular disease and multiple risk factors or extreme levels of a single risk factor (Table 1) (see also “Identification of Individuals at High Risk of Coronary Events,” p. S95). When deciding on appropriate treatment strategies, it is important to prioritize treatment goals. Since some of the available treatments, such as angiotensin converting enzyme (ACE) inhibitors and angiotensin II receptor antagonists (ARBs), have potential uses in controlling blood pressure (BP) as well as reducing the risks for CVD and nephropathy, it can be challenging to integrate the data to make recommendations for one application over another.Table 2 summarizes the priorities for vascular and renal protection, while Table 3 summarizes recommended interventions for vascular protection. Table 1. People with diabetes considered at high risk of a CV event* • Men aged ≥45 years, women aged ≥50 years • Men 180 mm Hg) • Duration of diabetes >15 years with age >30 years LDL-C = low-density lipoprotein cholesterol MI = myocardial infarction PAD = peripheral arterial disease
Table 2. Priorities for vascular and renal protection Clinical strategy Target population Step 1: Initiate vascular protection All people with diabetes (see Table 3) Step 2:Treat elevated BP All people with diabetes whose BP remains ≥130/80 mm Hg after applying vascular protective measures (see “Treatment of Hypertension,” p. S115) Step 3: Initiate renal protection BP = blood pressure All people with diabetes who have proteinuria after applying vascular measures and after achieving BP 55 years of age and had proven coronary disease, cerebrovascular disease or PAD, or diabetes plus ≥1 additional risk factor for vascular disease. In the overall population, ramipril 10 mg daily reduced the primary endpoint by 22% (p
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2008 Clinical Practice Guidelines - Canadian Diabetes Association

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