Cardiovascular Risk Management in Patients With Diabetes - Episode 2

Cardiovascular Disease Risk Assessment and Interventions

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Strategies used to help determine patients’ risk for cardiovascular disease and the role of lifestyle management in helping reduce the risk for events in patients with type 2 diabetes.

Marc P. Bonaca, MD, MPH: As part of routine medical care and preventive care, physicians will generally estimate patients’ risk using very commonly available in guideline-endorsed tools for atherosclerotic vascular disease. We can calculate a 10-year risk. Some of that is based on who the patient is—their age, family history—and some of it is based on biomarkers like lipids and blood pressure. But routine care and preventive care should include a risk assessment for cardiovascular disease. Diagnostic testing for vascular disease is generally done either for further enhancement of risk stratification, such as for coronary calcium, even in an asymptomatic patient who’s at intermediate risk or for symptomatic patients. For example, for a patient who has chest pain when they exert themselves and you’re worried about angina, you might do a stress test. For a patient who has leg pain when they walk and you’re worried about clot, you might do an ankle-brachial index.

Many of the risk factors for atherosclerotic vascular disease are acquired over time. For example, although the average cholesterol level may be at a certain place, that’s not necessarily normal when we look at populations that don’t eat a developed diet or a Western diet or people who are more active. And so what we consider average may not be normal. Many of the risk factors for atherosclerotic vascular disease are acquired: a sedentary lifestyle, obesity, high blood pressure due to sodium intake, lipid levels, smoking certainly. Lifestyle intervention can be extremely effective at addressing the risk factors and reducing the risk of atherosclerotic vascular disease. In fact, from genetic studies, we see that the lifetime attributable risk to these risk factors is enormous, even more when you look at short-term interventions with drugs. No. 1 when we talk about atherosclerotic vascular disease risk factors is lifestyle intervention, including healthy diet—here’s the Mediterranean diet, but several could be utilized—an active lifestyle, smoking cessation, and maintenance of normal body weight.

Manesh R. Patel, MD: Three-point MACE [major adverse cardiovascular event] outcomes, are certainly critical. In our clinical trials, many people ask me what are the MACE outcomes I think about, just to make sure we’re all thinking about those points. MACE stands for major adverse cardiovascular event. These are important events that we’ve traditionally studied in clinical trials of agents. They include myocardial infarction [MI]. This has a definition agreed upon by the World Health Organization. There are several increased sensitivity tests with proponents, but it’s generally chest discomfort or a cardiovascular-related symptom that’s associated with an elevated up and down of cardiac biomarkers, or elevated proponent. This is associated with some evidence of myocardial necrosis clinically, which is either with an angiogram or with some loss of muscle tissue on an imaging study. That’s a type 1 MI. 

All types of myocardial infarctions are usually counted in the MACE definition: death of myocardial cells and things we think of as clinical MI. The second component of a MACE outcome is stroke. We often think about stroke as a sudden acute insult to your brain. That leads you to have a neurological deficit that usually lasts more than 24 hours. Stroke is caused by vascular disease, either in your carotids or in your super vasculature. Some of the same processes with diabetes and lipids cause that. Finally, cardiovascular death is the third component of a classic MACE definition. Cardiovascular death is associated with any death that’s felt to be associated with a cardiovascular-underlying reason. It can be heart failure, myocardial infarction, stroke. A lot of those arrhythmogenic deaths and others—sudden cardiac death at home—go into cardiac death. Those are the components of MACE. That’s different from the components of MALE, or major adverse limb events, which you’ll hear about also. Those are events associated with your limbs that lead to amputation in vascular interventions or acute ischemic.

Transcript Edited for Clarity