Diabetes without Manifest Cardiovascular Disease: A Novel Approach in Risk Stratification and Treatment Selection

Author(s): Emile Andari, Samir Arnaout, Sami T. Azar*, Elie Chammas, Selim Jambart, Mounzer Saleh, Rita Nemr, Antoine Sarkis

Journal Name: Current Diabetes Reviews

Volume 16 , Issue 8 , 2020


Become EABM
Become Reviewer
Call for Editor

Abstract:

Background: Cardiovascular disease (CVD), the main macro vascular complication of type 2 diabetes (T2D), increases the risk of death significantly in patients with T2D.

Introduction: Most of the patients with T2D do not have obvious CVD symptoms. Due to the paucity of data, CVD screening in asymptomatic patients with T2D remains highly controversial.

Methods: This has driven a panel of experts to establish a novel consensus on how to approach patients with T2D at high CVD risk. The panel formulated a stepwise algorithm by which patients with T2D undergo initial risk stratification into low, intermediate and high risk using the ASCVD calculator. In patients with intermediate risk, coronary artery calcium measurement is used to further stratify those patients into new low and high-risk categories.

Results and Conclusion: The panel recommends using standard diabetes care in low risk patients and using SGLT2 inhibitors and GLP1 agonists with cardio protective effect, on top of standard care, in high risk individuals.

Keywords: Diabetes mellitus, cardiovascular disease, risk stratification, SGLT2 inhibitors, GLP1 agonists, macrovascular complications.

[1]
Stamler J, Vaccaro O, Neaton JD, Wentworth D, Group TMRFITR. Diabetes, other risk factors, and 12-yr cardiovascular mortality for men screened in the Multiple Risk Factor Intervention Trial. Diabetes Care 1993; 16(2): 434-44.
[http://dx.doi.org/10.2337/diacare.16.2.434] [PMID: 8432214]
[2]
Finelli C, Sommella L, Gioia S, La Sala N, Tarantino G. Should visceral fat be reduced to increase longevity? Ageing Res Rev 2013; 12(4): 996-1004.
[http://dx.doi.org/10.1016/j.arr.2013.05.007] [PMID: 23764746]
[3]
Morrish NJ, Wang SL, Stevens LK, Fuller JH, Keen H. Mortality and causes of death in the WHO Multinational Study of Vascular Disease in Diabetes. Diabetologia 2001; 44(Suppl. 2): S14-21.
[http://dx.doi.org/10.1007/PL00002934] [PMID: 11587045]
[4]
Whiting DR, Guariguata L, Weil C, Shaw J. IDF diabetes atlas: global estimates of the prevalence of diabetes for 2011 and 2030. Diabetes Res Clin Pract 2011; 94(3): 311-21.
[http://dx.doi.org/10.1016/j.diabres.2011.10.029] [PMID: 22079683]
[5]
Bin Hussain AK, Abdelgadir E, Rashid F, Al Haj A, Thadani P, Bashier AMK. Should metformin still be the first-line of treatment in type 2 diabetes mellitus? A comprehensive review and suggested algorithm. Diabetes Metab Syndr 2019; 13(3): 1935-42.
[http://dx.doi.org/10.1016/j.dsx.2019.04.028] [PMID: 31235118]
[6]
Chatterjee S, Khunti K, Davies MJ. Type 2 diabetes. Lancet 2017; 389(10085): 2239-51.
[http://dx.doi.org/10.1016/S0140-6736(17)30058-2] [PMID: 28190580]
[7]
UK Prospective Diabetes Study (UKPDS) Group. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet 1998; 352(9131): 837-53.
[http://dx.doi.org/10.1016/S0140-6736(98)07019-6] [PMID: 9742976]
[8]
Bennett WL, Maruthur NM, Singh S, et al. Comparative effectiveness and safety of medications for type 2 diabetes: an update including new drugs and 2-drug combinations. Ann Intern Med 2011; 154(9): 602-13.
[http://dx.doi.org/10.7326/0003-4819-154-9-201105030-00336] [PMID: 21403054]
[9]
Hong J, Zhang Y, Lai S, et al. SPREAD-DIMCAD Investigators. Effects of metformin versus glipizide on cardiovascular outcomes in patients with type 2 diabetes and coronary artery disease. Diabetes Care 2013; 36(5): 1304-11.
[http://dx.doi.org/10.2337/dc12-0719] [PMID: 23230096]
[10]
Lamanna C, Monami M, Marchionni N, Mannucci E. Effect of metformin on cardiovascular events and mortality: a meta-analysis of randomized clinical trials. Diabetes Obes Metab 2011; 13(3): 221-8.
[http://dx.doi.org/10.1111/j.1463-1326.2010.01349.x] [PMID: 21205121]
[11]
Fox CS, Golden SH, Anderson C, et al. American Heart Association Diabetes Committee of the Council on Lifestyle and Cardiometabolic Health; Council on Clinical Cardiology, Council on Cardiovascular and Stroke Nursing, Council on Cardiovascular Surgery and Anesthesia, Council on Quality of Care and Outcomes Research; American Diabetes Association. Update on Prevention of Cardiovascular Disease in Adults With Type 2 Diabetes Mellitus in Light of Recent Evidence: A Scientific Statement From the American Heart Association and the American Diabetes Association. Diabetes Care 2015; 38(9): 1777-803.
[http://dx.doi.org/10.2337/dci15-0012] [PMID: 26246459]
[12]
Dormandy JA, Charbonnel B, Eckland DJA, et al. PROactive Investigators. Secondary prevention of macrovascular events in patients with type 2 diabetes in the PROactive Study (PROspective pioglitAzone Clinical Trial In macroVascular Events): a randomised controlled trial. Lancet 2005; 366(9493): 1279-89.
[http://dx.doi.org/10.1016/S0140-6736(05)67528-9] [PMID: 16214598]
[13]
[https://www.ncbi.nlm.nih.gov/pubmed/?term=Pioglitazone+ use+and+heart+failure+in+patients+with+type+2+diabetes+and+preexisting+cardiovascular +disease%3A+data+from+the+PROactive+study+(PROactive+08)]
[14]
Scirica BM, Bhatt DL, Braunwald E, et al. SAVOR-TIMI 53 Steering Committee and Investigators. Saxagliptin and cardiovascular outcomes in patients with type 2 diabetes mellitus. N Engl J Med 2013; 369(14): 1317-26.
[http://dx.doi.org/10.1056/NEJMoa1307684] [PMID: 23992601]
[15]
White WB, Cannon CP, Heller SR, et al. EXAMINE Investigators. Alogliptin after acute coronary syndrome in patients with type 2 diabetes. N Engl J Med 2013; 369(14): 1327-35.
[http://dx.doi.org/10.1056/NEJMoa1305889] [PMID: 23992602]
[16]
Green JB, Bethel MA, Armstrong PW, et al. TECOS Study Group. Effect of Sitagliptin on Cardiovascular Outcomes in Type 2 Diabetes. N Engl J Med 2015; 373(3): 232-42.
[http://dx.doi.org/10.1056/NEJMoa1501352] [PMID: 26052984]
[17]
McGuire DK, Alexander JH, Johansen OE, Perkovic V, Rosenstock J, Cooper ME, et al. Linagliptin Effects on Heart Failure and Related Outcomes in Individuals With Type 2 Diabetes Mellitus at High Cardiovascular and Renal Risk in CARMELINA. Circulation 2019; 139(3): 351-61.
[18]
Mahaffey KW, Neal B, Perkovic V, de Zeeuw D, Fulcher G, Erondu N, et al. Canagliflozin for Primary and Secondary Prevention of Cardiovascular Events: Results From the CANVAS Program (Canagliflozin Cardiovascular Assessment Study). Circulation 2018; 137(4): 323-4.
[19]
Zinman B, Wanner C, Lachin JM, Fitchett D, Bluhmki E, Hantel S, et al. Empagliflozin, Cardiovascular Outcomes, and Mortality in Type 2 Diabetes. N Engl J Med 2015; 373(22): 2117-8.
[20]
Marso SP, Daniels GH, Brown-Frandsen K, Kristensen P, Mann JFE, Nauck MA, et al. Liraglutide and Cardiovascular Outcomes in Type 2 Diabetes. N Engl J Med 2016. 375-22.(4): 311-22..
[21]
Wiviott SD, Raz I, Bonaca MP, Mosenzon O, Kato ET, Cahn A, et al. Dapagliflozin and Cardiovascular Outcomes in Type 2 Diabetes. N Engl J Med 2019; 380(4): 347-57.
[22]
Marso SP, Bain SC, Consoli A, Eliaschewitz FG, Jódar E, Leiter LA, et al. Semaglutide and Cardiovascular Outcomes in Patients with Type 2 Diabetes. N Engl J Med 2016; 375(19): 1834-44.
[23]
American Diabetes Association. 8. Pharmacologic Approaches to Glycemic Treatment: Standards of Medical Care in Diabetes-2018. Diabetes Care 2018; 41(Suppl. 1): S73-85.
[http://dx.doi.org/10.2337/dc18-S008] [PMID: 29222379]
[26]
Garber AJ, Abrahamson MJ, Barzilay JI, et al. Consensus statement by the american association of clinical endocrinologists and american college of endocrinology on the comprehensive type 2 diabetes management algorithm - 2018 executive summarY. Endocr Pract 2018; 24(1): 91-120.
[http://dx.doi.org/10.4158/CS-2017-0153] [PMID: 29368965]
[28]
Upchurch CT, Barrett EJ. Clinical review: Screening for coronary artery disease in type 2 diabetes. J Clin Endocrinol Metab 2012; 97(5): 1434-42.
[http://dx.doi.org/10.1210/jc.2011-2122] [PMID: 22419711]
[29]
Bax JJ, Young LH, Frye RL, Bonow RO, Steinberg HO, Barrett EJ. ADA. Screening for coronary artery disease in patients with diabetes. Diabetes Care 2007; 30(10): 2729-36.
[http://dx.doi.org/10.2337/dc07-9927] [PMID: 17901530]
[30]
[https://spectrum.diabetesjournals.org/content/21/3/166]
[32]
Goff David C, Lloyd-Jones Donald M. ACC/AHA Guideline on the Assessment of Cardiovascular Risk. Circulation 129(2): 49- 79. 2013.
[33]
Masson W, Epstein T, Huerín M, et al. Cardiovascular Risk Stratification in Patients with Metabolic Syndrome Without Diabetes or Cardiovascular Disease: Usefulness of Metabolic Syndrome Severity Score. High Blood Press Cardiovasc Prev 2017; 24(3): 297-303.
[http://dx.doi.org/10.1007/s40292-017-0209-0] [PMID: 28502055]
[34]
Nasir K, Rubin J, Blaha MJ, et al. Interplay of coronary artery calcification and traditional risk factors for the prediction of all-cause mortality in asymptomatic individuals. Circ Cardiovasc Imaging 2012; 5(4): 467-73.
[http://dx.doi.org/10.1161/CIRCIMAGING.111.964528] [PMID: 22718782]
[35]
Greenland P, Blaha MJ, Budoff MJ, Erbel R, Watson KE. Coronary Calcium Score and Cardiovascular Risk. J Am Coll Cardiol 2018; 72(4): 434-7.
[36]
Agarwal S, Morgan T, Herrington DM, et al. Coronary calcium score and prediction of all-cause mortality in diabetes: the diabetes heart study. Diabetes Care 2011; 34(5): 1219-24.
[http://dx.doi.org/10.2337/dc11-0008] [PMID: 21398528]
[37]
Schurgin S, Rich S, Mazzone T. Increased prevalence of significant coronary artery calcification in patients with diabetes. Diabetes Care 2001; 24(2): 335-8.
[http://dx.doi.org/10.2337/diacare.24.2.335] [PMID: 11213888]
[38]
Raggi P, Shaw LJ, Berman DS, Callister TQ. Prognostic value of coronary artery calcium screening in subjects with and without diabetes. J Am Coll Cardiol 2004; 43(9): 1663-9.
[http://dx.doi.org/10.1016/j.jacc.2003.09.068] [PMID: 15120828]


Rights & PermissionsPrintExport Cite as

Article Details

VOLUME: 16
ISSUE: 8
Year: 2020
Published on: 10 September, 2020
Page: [869 - 873]
Pages: 5
DOI: 10.2174/1573399816666200120122929
Price: $65

Article Metrics

PDF: 41
HTML: 2