Treating to current standards of care still leaves residual CV risks in patients with T2D

Advances in the management of CV risk factors have reduced the rate of cardiovascular events. However, residual CV risk remains a significant concern for cardiologists and endocrinologists.

Residual risk remains a significant concern for cardiologists and endocrinologists

Recommended treatment approach

The ADA-recommended multifactorial approach has shown clear benefits associated with modifying CV risk factors in patients. Their approach includes1,2:

  • Lifestyle modification
  • Platelet inhibition
  • Blood pressure control
  • Glycemic control
  • Management of dyslipidemia

Understand the link between CVD and T2D

Diabetes-related complications have declined with better management, but considerable residual CV risk remains

With better management of glucose levels and CV risk factors over the past 20+ years, overall morbidity has declined, but death and complication rates are still much higher in patients with diabetes.3

Adults with diabetes experience more CV events than adults without diabetes

Adult populations with or without diabetes

Top graph represents rates between 0 and 150 events per 10,000 patients with diagnosed diabetes.

Bottom graph represents rates between 0 and 10 events per 10,000 of the overall patient population, with or without diabetes.


Even with a multifactorial treatment approach per standards of care, patients with T2D have substantial risk of CVD and microvascular disease 4

Even with a multifactorial treatment approach per the best standards of care, patients with T2D have substantial risk of CVD and microvascular disease4

CARDS Study5,6,a

Treatment

Atorvastatin

Reduction

37% reduction in acute CHD events, coronary revascularization, or stroke

Remaining risk

Nearly 10% of these patients had cardiac events

TNT Study5,7,b

Treatment

80 mg atorvastatin daily

Reduction

25% reduction in major CV events    

Remaining risk

14% to 18% of patients experienced an event, even with therapy

Primary prevention trials1

Treatment

Aspirin

Reduction/Remaining risk

Mixed results in the reduction of CV morbidity and mortality in patients with diabetes


 

Anti-hypertensive trials8,9

Treatment

Antihypertensives

Reduction/Remaining risk

Reduction in morbidity and mortality; however, the reduction was not as great in patients with diabetes


 

Intensive therapy also falls short when it comes to reducing CV risk

Two large studies indicate that aggressive A1C reductions do not always correlate with reduced CV risk.10,11

 

Study showing CV risk with conventional vs intensive therapy

Study showing CV risk with conventional vs intensive therapy

Even intensive therapyc for CVD leaves residual CV risk in patients with diabetes (STENO-2 study)d,12,13

  • In the STENO-2 study, death from CVD was reduced by 62% but not eliminated12

 


Patients with T2D may present CV risk differently


Whether your patients with T2D have had a prior CV event or not, there are multiple risk factors to consider when managing CV risk. Even patients who are meeting their treatment targets with the established standards of care have residual CV risk.


Think about what more you can do to address CV risk with your patients.

African American male - age 52

Diabetes duration: 6 years

A1C: 7.5%                  TG: 180 mg/dL
HDL: 35 mg/dL            BMI: 32
LDL: 80 mg/dL
Blood pressure: 130/80 mm Hg

CV medication: hydrochlorothiazide 50 mg, simvastatin 40 mg, aspirin 80 mg

Anti-hyperglycemic medication: metformin 1000 mg BID, glimepiride 2 mg

Additional comorbidities: Moderate renal impairment (eGFR 45), prior myocardial infarction


Caucasian female - age 65

Diabetes duration: 13 years

A1C: 7.1%            TG: 130 mg/dL
HDL: 50 mg/dL      BMI: 28
LDL: 90 mg/dL  
Blood pressure: 125/80 mm Hg

CV medication: HCTZ 25 mg, lisinopril 20 mg, atorvastatin 20 mg

Anti-hyperglycemic medication: metformin 500 mg + sitagliptin 50 mg

Additional comorbidities: Peripheral artery disease, ankle-brachial index <0.9

These are not real patients.

Professional resources

Hear from your peers and access additional resources such as diabetes treatment guidelines

CVD=cardiovascular disease; T2D=type 2 diabetes; CV=cardiovascular 

aThe Collaborative Atorvastatin Diabetes Study (CARDS) included 2838 patients aged 40 to 75 years in 132 centers in the UK and Ireland. Patients had no previous history of cardiovascular disease and at least one of the following: retinopathy, albuminuria, current smoking, or hypertension. Patients were randomized to placebo (n=1410) or atorvastatin 10 mg daily (n=1428). The primary endpoint was time to first occurrence of acute coronary heart events, coronary revascularization, or stroke.6

bThe Treating to New Targets (TNT) study included 1501 patients with diabetes and CHD, with LDL cholesterol levels <130 mg/dL. Patients were randomized to receive either atorvastin 10 mg/day (n=753) or 80 mg/day (n=748) and were followed for a median of 4.9 years. The primary endpoint was the time to first major cardiovascular event.7

cIntensive therapy was target-driven approach with both behavioral and pharmacological treatment following a structured approach.12

dThe original intervention of the Steno-2 trial included 160 patients with T2D and microalbuminuria who were randomized to receive either conventional therapy (n=80) or intensified, multifactorial treatment including both behavioral and pharmacological approaches (n=80). After 7.8 years the study continued as an observational follow-up, lasting a total of 21.2 years, with all patients receiving intensified, multifactorial treatment. Patients were still analyzed based on their original groupings, with the first follow-up assessment including 40 patients from the original conventional therapy group and 56 patients from the original intensive therapy group. The primary endpoint of the follow-up was difference in median survival time between the original treatment groups with and without incident cardiovascular disease.12

References:

  1. American Diabetes Association. Standards of medical care in diabetes—2017. Diabetes Care. 2017;40(Suppl1):S1-S135.
  2. Rydén L, Grant PJ, Anker SD, et al. ESC Guidelines on diabetes, pre-diabetes, and cardiovascular diseases developed in collaboration with the EASD. Eur Heart J. 2013;34:3035-3087.
  3. Gregg EW, Li Y, Wang J, et al. Changes in diabetes-related complications in the United States, 1990-2010. N Engl J Med. 2014;370(16):1514-1523.
  4. Rees A. Excess cardiovascular risk in patients with type 2 diabetes: do we need to look beyond LDL cholesterol? Br J Diabetes Vasc Dis. 2014;14:10-20.
  5. Nesto RW, Singh PP. Diabetes and residual risk of coronary heart disease. Nat Clin Pract Endocrinol Metab. 2007;3(2):71. 
  6. Colhoun HM, Betteridge DJ, Durrington PN, et al; CARDS Investigators. Primary prevention of cardiovascular disease with atorvastatin in type 2 diabetes in the Collaborative Atorvastatin Diabetes Study (CARDS): multicenter randomized placebo-controlled trial. Lancet. 2004;364:685-696.
  7. Shepherd J, Barter P, Carmena R, et al. Effect of lowering LDL cholesterol substantially below currently recommended levels in patients with coronary heart disease and diabetes. Diabetes Care. 2006;29:1220-1226.
  8. Kotecha D, Manzano L, Altman DG; Beta-Blockers in Heart Failure Collaborative Group. Individual patient data meta-analysis of beta-blockers in heart failure: rationale and design. Syst Rev. 2013;2:1-9.
  9. Heart Outcomes Prevention Evaluation (HOPE) Study Investigators. Effects of ramipril on cardiovascular and microvascular outcomes in people with diabetes mellitus. Lancet. 2000;355:253-259.
  10. Gerstein HC, Miller ME, Genuth S, et al; ACCORD Study Group. Long-term effects on intensive glucose lowering on cardiovascular outcomes. N Eng J Med. 2011;364:818-828. 
  11. Stolar M. Glycemic control and complications in type 2 diabetes mellitus. Am J Med. 2010;123:S3-S11.
  12. Gæde P, Oellgaard J, Carstensen B, et al. Years of life gained by multifactorial intervention in patients with type 2 diabetes mellitus and microalbuminuria: 21 years follow-up on the Steno-2 randomised trial. Diabetologia. 2016;59(11):2298-2307.
  13. Gæde P, Vedel P, Larsen N, et al. Multifactorial intervention and cardiovascular disease in patients with type 2 diabetes. N Engl J Med. 2003;348(5):383-393.