Diabetes 2020 Session 2 Cardiovascular Risk Reduction Beverly - - PowerPoint PPT Presentation

Diabetes 2020 – Session 2

Cardiovascular Risk Reduction

Beverly Thomassian, RN, MPH, BC-ADM, CDE President, Diabetes Education Services

Welcome Everyone

• Recorded version ready later on same day
• Questions? Bryanna@diabetesed.net
• r phone 530/893-8635

Reading Material

DiabetesEdUniversity.net

Bev has no conflict of interest

She’s not on any speakers

bureau

Does not invest Gathers information from

reading package inserts, research and standards

She does engage in “pill-ow”

talk with her husband (who is a PharmD)

Session 2 Topics

Session 2 – Cardiovascular

Risk Reduction Strategies

ADA and AACE Guidelines

for CV Risk Reduction

Implement Risk Reduction

Strategies

Addressing Hypertension,

Lipids

Let’s elevate our role

• 10. Cardiovascular Disease and Risk

Management

Heart disease is the

leading cause of mortality and morbidity in diabetes

Large benefits are seen

when multiple risk factors are addressed globally

Insulin Resistance is the Seed

Muscles are insulin

resistant

Building muscle decreases

insulin resistance

Fat cells become more

insulin resistant

Leads to more Free Fatty

Acids and Triglycerides

More vascular inflammation

Pancreas becomes fatty

Losing wt helps improve

Insulin Resistance

BMI – Visual Image

Poll question 1

Which of the following BEST

describes insulin resistance?

• a. Lack of sufficient insulin receptors on

fat and muscle cells.

• b. Visceral adipose tissue.
• c. A physiological condition where

insulin becomes less effective at lowering blood glucose levels.

• d. Excessive triglyceride levels

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Factors Associated with Insulin Resistance

Abdominal obesity Sedentary lifestyle Genetics / Ethnicity Gestational Diabetes Polycystic ovary syndrome Acanthosis Nigricans Obstructive Sleep Apnea Cancer

Acanthosis Nigricans

Acanthosis Nigricans (AN)

Signals high insulin levels in bloodstream

and is a marker of insulin resistance

Patches of darkened skin over parts of body

that bend or rub against each other

Neck, underarm, waistline, groin, knuckles, elbows,

toes

Skin tags on neck and darkened areas around eyes,

nose and cheeks.

No cure, lesions regress with treatment of

insulin resistance

Risk of CVD Is Elevated prior to Diagnosis of Type 2 Diabetes

1.00 2.40 3.19 3.64

0.00 1.00 2.00 3.00 4.00 5.00 Non-diabetic throughout study 15 yrs or more before diagnosis 10-14.9 yrs before diagnosis <10 years before diagnosis Relative Risk of MI* or Stroke

*MI = myocardial infarction. Nurses Health Study Adapted from: Hu F, et al. Diabetes Care. 2002;25:1129-1134.

Natural History of Diabetes

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• 3. PreDiabetes is FREAKING ME OUT

86 million people in US 90% don’t know they have

it

In 3-5 years, about 30% of

predm will get diabetes

Associated with higher

rates of heart attack, stroke, neuropathy and vessel disease

Why isn’t is called stage 1

diabetes?

• 3. Prevention or Delay of Type 2

Prediabetes is associated with

heightened cardiovascular risk; therefore, screening for and treatment of modifiable risk factors for cardiovascular disease are suggested.

Standards of Medical Care in Diabetes - 2020. Diabetes Care 2020;43(Suppl. 1)

What is Type 2 Diabetes?

Complex metabolic disorder ….

(Insulin resistance and deficiency)

with social, behavioral and environmental risk factors unmasking the effects of genetic susceptibility.

() *$$+ ,!-./ 01/23

Cardio Metabolic Risk - 5 Hypers -

Hyperinsulinemia (resistance) Hyperglycemia Hyperlipidemia Hypertension Hyper”waistline”emia (35” women, 40”

men)

Manifestations of Insulin Resistance

Poll question 2

Which of the following Cardiovascular

Conditions are associated with diabetes?

• A. Congestive Heart Failure
• B. Hypervasodilation
• C. Acanthosis Nigricans
• D. CardioNephritis

Heart Disease & DM = 3-5xs Risk

CHF

7.9 % w/ diabetes vs. 1.1 % no diabetes

Heart attack

9.8 % w/ diabetes vs. 1.8 % no diabetes

Coronary heart disease

9.1 % w/ diabetes vs. 2.1 % no diabetes

Stroke

6.6 % w/ diabetes vs.

1.8 % no diabetes

2007 AACE

Cardiovascular Disease and Risk Management

Cardiovascular disease is the

leading cause of mortality and morbidity in diabetes

Largest contributor to direct

and indirect costs

Controlling cardiovascular

risk improves outcomes

Large benefits are seen

when multiple risk factors are addressed globally

Poll question 3

What is the relationship between

diabetes and cardiovascular disease?

• A. Diabetes is associated with a lower rate of

congestive heart failure.

• B. Diabetes is associated with decreased

incidence of heart attack and stroke

• C. People with diabetes are destined to get CV

complications.

• D. People with diabetes can decrease their risk of

a CV event

Diabetes & Heart Disease Motivational Stats

Every 18 mg/dl increase in

fasting glucose increases risk

• f CV events/death by 17%

Every 1% increase in A1c

increased:

CVD events by 18% MI events by 19% All cause mortality by 12-14% Microvascular disease by 35%

ADA Standards of Care

ABCs of Diabetes

A1c less than 7% (avg 3 month BG)

Pre-meal BG 80-130 Post meal BG <180

Blood Pressure < 140/90

BP target <130/80

If 10 year CVD Risk > 15%

Cholesterol

Statin therapy indicated?

Vascular Risk Factors

Modifiable

Glucose Blood Pressure Lipids Smoking Weight Dietary Habits Other factors – lack of exercise,

Type A personality

Poll Question 4

Which of the following is the

best recommendation to protect cardiovascular health?

• A. Avoid all fast foods
• B. Stop smoking
• C. Keep B/P as low as possible
• D. Eliminate sugar from diet

• Ask at every visit
• Assess
• Advise
• Assist with stop smoking
• Arrange for referrals
• Organize your clinic

/

Smoking increases risk of diabetes 30%

Smoking and Diabetes

DASH Diet – Dietary Approaches to Stop Hypertension

The DASH diet emphasizes vegetables,

fruits and low-fat dairy foods — and moderate amounts of whole grains, fish, poultry, nuts.

Pt recommendations

Eat lots of whole grains, fruits, vegetables and

low-fat dairy products.

Also includes some fish, poultry and legumes,

and encourages a small amount of nuts and seeds a few times a week.

Red meat, sweets and fats in small amounts. Focus on low saturated fat, cholesterol, total fat.

Mediterranean Diet Pyramid

Benefits of Exercise and Diabetes

Increase muscle glucose uptake 5-fold Glucose uptake remains elevated for 24 - 48

hours (depending on exercise duration)

Increases insulin sensitivity in muscle, fat,

liver.

Reduce CV Risk factors (BP, cholesterol, A1c) Maintain wt loss Contribute to well being Muscle strength Better physical mobility

Using Alcohol Safely

Women 1 or fewer alcoholic drinks a

day

Men 2 or fewer alcoholic drinks a day

1 alcoholic drink equals

12 oz beer, 5 oz glass of wine, or 1.5 oz distilled

spirits (vodka, gin etc)

If drink, limit amount and drink w/

food.

Can cause hypo, worsen neuropathy

and increase triglycerides

Periodontal disease and Heart Disease

Heart disease link:

• ral bacteria enter the blood

stream, attach to fatty plaques in coronary arteries increasing clot formation inflammation increases plaque build up, which may contribute to arterial inflammation Hyperglycemia = Gingivitis = Heart Disease

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“Legacy Effect”

For participants of DCCT and UKPDS

long lasting benefit of early intensive BG

control prevents

Macrovascular complications

42% reduction in CV disease 57% reduction in nonfatal MI, Stroke or CVD death

Microvascular complications Even though their BG levels increased over time

Message – Catch early and

Treat aggressively

Section 9- Pharmacologic Approaches to Glycemic Treatment

Algorithm for Oral Meds

and Insulin Therapy

More attention to

considering CVD and CKD when choosing diabetes medication

Updated chart on cost and

attributes of different meds

Medication Taking Behaviors

Adequate medication taking is

defined as 80%

If pt taking meds 80% of time and

treatment goals not met, intensification should be considered.

Barriers to taking meds include:

Forgetting to fill Rx, fear, depression, health

beliefs, medication complexity, cost, system factors, etc.

Work on targeted approach for

specific barrier

A 78 yr old man, smokes ppd

A1c was 8.1%, History of MI B/P 136/76 AM BG 100, 2 hr pp 190 Chol – TG 54, HDL 46, LDL 98 Meds:

Insulin – 16 units Lantus at HS Benazepril 20 mg Metoprolol 50mg Warfarin 5mg Actos 15 mg

5 ) ! )

ADA Step Wise Approach to Hyperglycemia 2020

For all steps, consider including

medications with evidence of ASCVD and CKD risk reduction, based on drug specific effects and patient factors.

Other Factors

Minimize Hypoglycemia Minimize wt gain or promote wt loss Consider Cost

• 6

178 " 49

SGLT2 Inhibitors- “Glucoretics”

Action: “Glucoretic” decreases renal reabsorption in the

proximal tubule of the kidneys (reset renal threshold and increase glucosuria). Risk of ketoacidosis, Fournier's gangrene % ‘f

'- &

ADA Step Wise Approach to Hyperglycemia 2020

Step 1 – Metformin + Lifestyle

Step 2 - If A1c target not achieved after 3 months, Metformin +

another med

If ASCVD, CHF, or CKD, consider adding a second agent to

reduce risk based on drug effects and individual factors.

SGLT-2i - Empagliflozin (Jardiance), canagliflozin (Invokana)

and dapagliflozin (Farxiga) – Eval GFR

GLP-1 RA Semaglutide > liraglutide > dulaglitide >

exenatide > lixisenatide

Step 3 - If A1c target still not achieved after 3 months, combine

metformin plus one to two other (2-3 drugs)

Step 4 - If A1c target not achieved after 3 months, add injectable

therapy (GLP-1 RA or Basal insulin) to drug combination.

!!/#$#$

Atherosclerotic CV Disease

ASCVD risk – how is that defined?

55+ with previous event, coronary, carotid,

lower extremity artery stenosis > 50% or Left Ventricular Hypertrophy (LVH)

Preferred Meds:

SGLT-2s that reduce heart failure, CKD

progression, Cardiovascular Outcomes Trial (CVOT)

Empagliflozin (Jardiance), canagliflozin

(Invokana) and dapagliflozin (Farxiga)

!!/ + ,: !

Heart Failure (HF) or Chronic Kidney Disease Predominate

If HF or reduced Ejection Fraction (rEF) and Left

Ventricular Ejection Fraction (LVEF) <45%

Kidney disease

CKD: If eGFR 30-60 or Urine Albumin to Creatinine Ratio (UACR) > 30 mg/g

especially if UACR > 300

Use SGLT2i if eGFR is adequate

Empagliflozin (Jardiance), canagliflozin (Invokana),

dapagliflozin (Farxiga)

If can’t tolerate, use GLP-1 RA

Semaglutide > liraglutide > dulaglitide > exenatide >

lixisenatide

Insulin Basal next - Risk of hypo; least to most Degludec /glargine U300 < glargine U100 <

detemir < NPH

AACE/ACE Comprehensive Type 2

Diabetes Management Algorithm 2019

Principles of AACE Type 2 Management Algorithm

Lifestyle

modification

Avoid hypo, wt gain Individualize targets Therapy choices are

person centered and include ease of use, affordability

Therapy choice

considers cardiac, CHF, renal status

Get to goal ASAP Manage co-

conditions

CGM is highly

recommended

Optimal A1c <6.5%

!!;!.#

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Poll Question 5

George type 2, is losing weight

and thirsty with an A1c of 10.3%. Using AACE guidelines, what is appropriate action?

a.

Evaluate lifestyle changes for 3 months

b.

Start insulin therapy

c.

Start metformin immediately

d.

Start metformin plus another agent

Clinical Inertia Happens

Reassess every 3-

6 months

Assess ASCVD and Heart Failure Risk Yearly

Obesity/overweight Hypertension Dyslipidemia Smoking Family history of premature coronary disease Chronic kidney disease Presence of albuminuria Hypoglycemia Risk Therapeutic Treatment Plan and Goal Setting

Lifestyle, meds, monitoring, referral to DSME

ASCVD (Atherosclerotic Cardiovascular Disease) Assessment

ASCVD Risk Calculator

http://tools.acc.org/ASCVD-Risk-Estimator-Plus Evaluate 10 year risk of CV events (age 40-59)

Poll question 6

What is the current B/P goal for

people with diabetes.

• A. 130/80
• B. 140/80
• C. 120/70
• D. 140/90

BP and Diabetes Targets

Calculate ASCVD Risk using calculator: BP target <140/90

If CVD Risk <15%

BP target <130/80

If 10 year CVD Risk > 15%

BP target based on individual assessment and

shared decision making that addresses CV Risk and potential adverse effects of BP meds.

During pregnancy, with previous history of

HTN

B/P Target is ≤135/85

BP Goal

BP Goal based on risk

Measure B/P at every

routine clinical visit.

If B/P elevated, confirm

B/P using multiple readings, including measurements on a separate day, to diagnose HTN

All with diabetes and

HTN should monitor BP at home.

Some may benefit from

B/P 130/80 (younger and achieved with undue tx burden)

HTN Lifestyle Treatment Strategies

If BP > 120/80, start with lifestyle Lose weight through less calories Sodium intake <2,300mg/day Eat more fruits & veggies (8-10 a

day)

Limit alcohol 1-2 drinks a day Increase activity level

BP Treatment in addition to Lifestyle

First Line B/P Drugs If B/P ≥ 160 /100 start 2 drug combo

With albuminuria – start with either ACE or ARB No albuminuria - Any of the 4 classes of BP meds can

be used to tx hypertension

ACE Inhibitors, ARBs, thiazide-like diuretics or calcium channel

• blockers. (Avoid ACE and ARB at same time)

Multiple Drug Therapy often required

For best effect, administer at least one at

bedtime

Angiotensin Receptor Blockers

Beta Blockers

Statin Recommendations

Age ASCVD or 10 yr risk >20% Recommended statin <40 No None + lifestyle <40 Yes High If LDL >70, despite max statin dose consider adding additional therapy such as ezetimibe or PCSK9 Inhibitor >40 No Moderate >40 Yes If LDL >70, despite max statin dose consider adding additional therapy such as ezetimibe (Zetia) or PCSK9 Inhibitor

ASCVD Risk include: LDL >100, HTN, Smoke, Chronic Kidney Disease, albuminuria, family hx ACSVD. If pt can’t tolerate intended statin dose, use maximally tolerated dose.

AACE

Statin Therapy

High intensity statins (lowers LDL 50%):

atorvastatin (Lipitor) 40-80mg rosuvastatin (Crestor) 20-40mg

Moderate intensity (lowers LDL 30-50%)

atorvastatin (Lipitor) 10-20mg rosuvastatin (Crestor) 5-10mg simvastatin (Zocor) 20-40mg pravastatin (Pravachol) 40 – 80mg lovastatin (Mevacor) 40 mg fluvastatin (Lescol) XL 80mg pitavastatin (Livalo) 2-4mg

Coronary Vessel Disease

In those with known CVD, use:

Aspirin Statin B/P Med

In pts with prior MI, Beta Blockers should be continued

at least 2 years after the event

Don’t use Actos or Avandia in pts with CHF Diabetes Meds that significantly decrease CV

events:

SGLT-2i - Empagliflozin (Jardiance), canagliflozin (Invokana) and

dapagliflozin (Farxiga) – Eval GFR

GLP-1 RA Semaglutide > liraglutide > dulaglitide > exenatide >

lixisenatide

ABCs of Diabetes

A1c less than 7% (avg 3 month BG)

Pre-meal BG 80-130 Post meal BG <180

Blood Pressure < 140/90

BP target <130/80

If 10 year CVD Risk > 15%

Cholesterol

Statin therapy indicated?

A 78 yr old man, smokes ppd

A1c was 8.1%, History of MI B/P 136/76 AM BG 100, 2 hr pp 190 Chol – TG 54, HDL 46, LDL 98 Meds:

Insulin – 16 units Lantus at HS Benazepril 20 mg Metoprolol 50mg Warfarin 5mg Actos 15 mg

!)

Thank You

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any questions.

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