cardiovascular disease and · 2020. 8. 5. · reduce risk based on drug effects and individual...
TRANSCRIPT
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Page 1©Copyright 1999-2020, Diabetes Education Services www.DiabetesEd.net
Cardiovascular Disease and
Diabetes | ADA Standards
Beverly Thomassian, RN, MPH, BC-ADM, CDEPresident, Diabetes Education Services
Welcome Everyone
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530/893-8635
Topics
�Cardiovascular Risk &
Reduction Strategies
�American Diabetes
Association Guidelines
for CV Risk Reduction
�Implement Risk
Reduction Strategies
� Lifestyle plus
Medications
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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)
Let’s elevate our role
Cardiometabolic risk reduction
Diabetes technology resource
Provide meaningful person-centered care and support the emotional well-being of the whole person.
Ensure that everyone knows what your role is as a core member of the larger care team
Offer care that positively impacts quality and cost and enhances the experience for both the person with diabetes and provider.
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
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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
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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
American College of Endocrinology, 2001
Factors Associated with Insulin
Resistance
�Abdominal obesity
�Sedentary lifestyle
�Genetics / Ethnicity
�Gestational Diabetes
�Polycystic ovary syndrome
�Acanthosis Nigricans
�Obstructive Sleep Apnea
�Cancer
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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
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Natural History of Diabetes
Healthy
FBG
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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.
New Diagnosis? Call 800 – DIABETES to request “Getting Started Kit”www.Diabetes.org
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
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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
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Diabetes & Heart Disease Motivational
Stats
� Every 18 mg/dl increase in
fasting glucose increases risk
of 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
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Discouraged with Type 2“I don’t check my BG, it’s always high”
Clinical Inertia Happens
�Reassess every 3-
6 months
Person with Type 2 in Clinic
�62 yrs old, A1c 10.6%.�100 units Lantus plus
metformin 1000mg BID.
�BMI 39, B/P 138/78�LDL 128, Trig 382 �Other Meds:
atorvastatin, metoprolol, Flonase
�Daily habits�Mostly sedentary,
takes care of older mom
�BMI was 43 last year� Sleep 5-6 hours a
night�Doesn’t drink,
smokes a few cigs a week
�Eats a fast food 4-6 times a week
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Reducing Vascular Risk Factors
�Modifiable
�Glucose
�Smoking
�Weight
�Dietary Habits
�Oral Care
�Sleep
�Blood Pressure
� Lipids
� Make small, achievable
goals. We are in this for
the long run.
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
Where do We Start?
Get at least 7 hours of sleep a night – Check for sleep apnea
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Page 12©Copyright 1999-2020, Diabetes Education Services www.DiabetesEd.net
•Ask at every visit
•Assess
•Advise
•Assist with stop smoking
•Arrange for referrals
•Organize your clinic
Smoking and Diabetes
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
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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
Periodontal disease and Heart Disease
Heart disease link:
oral 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
Preventive Action• Brush twice daily• Floss daily• See dental team a
few times a year
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
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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
Person with Type 2 in Clinic
�62 yrs old, A1c 10.6%.
�100 units Lantus plus metformin 1000mg BID.
�BMI 39, B/P 138/78
�LDL 128, Trig 382
�Other Meds: atorvastatin, metoprolol, Flonase
�What class of meds in this person on?
�Any meds missing?
�Any changesneeded?
Meds -Person with Type 2 in Clinic
�62 yrs old, A1c 10.6%.
�100 units Lantus plus metformin 1000mg BID.
�BMI 39, B/P 138/78
�LDL 128, Trig 382
�Other Meds: atorvastatin, metoprolol, Flonase
�What class of meds in this person on?
� Insulin
�Biguanide
�Statin
�Beta blocker for?
�Any meds missing?
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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
Biguanide derived from:Goat’s Rue Galega officinalis,French Lilac
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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
Decreases GlucoseReabsorption
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.
ADA Standards 2020
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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) ADA Stds – InjectablesAlgorithm small print
Heart Failure (HF) or Chronic Kidney
Disease Predominate� If HF or reduced Ejection Fraction (rEF) and Left
Ventricular Ejection Fraction (LVEF) 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
Meds -Person with Type 2 in Clinic
�62 yrs old, A1c 10.6%.
�100 units Lantus plus
metformin 1000mg BID.
�BMI 39, B/P 138/78
�LDL 128, Trig 382
�Other Meds:
atorvastatin,
metoprolol, Flonase
� What class of meds in this person on?
� Insulin
� Biguanide
� Statin
� Beta blocker for?
� New meds added?
� Aspirin
� GLP-1 RA or SGLT-2
� Semaglutide (Ozempic)
� Empagliflozin (Jardiance)
� Basal insulin reduced to 80 units
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10 - ADA Antiplatelet Agents� Candidates
� Hx of atherosclerotic CV disease + diabetes
� Use aspirin therapy (75–162 mg/day)
� Atherosclerotic CV disease and documented
aspirin allergy, use clopidogrel (75 mg/day)
� Dual antiplatelet therapy (with low-dose aspirin
and a P2Y12 inhibitor) is reasonable for a year
after an acute coronary syndrome and may have
benefits beyond this.
� Primary Prevention?
� Aspirin therapy (75–162 mg/day) in those with diabetes
who are at increased cardiovascular risk, after a
comprehensive discussion on the benefits versus the
comparable increased risk of bleeding.
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
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BP and Diabetes Targets� Calculate ASCVD Risk using calculator:
� BP target
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HTN Lifestyle Treatment Strategies
�If BP > 120/80, start with lifestyle
�Lose weight through less calories
�Sodium intake
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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
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Beta Blockers
Meds -Person with Type 2 in Clinic
�62 yrs old, A1c 7.6%
�80 units Lantus plus
metformin 1000mg BID.
�BMI 36 B/P 144/78
�LDL 103 Trig 212
�Urinary Albumin 30+
�Other Med Needed?:
atorvastatin 80mg,
metoprolol, Flonase
�Add Losartan (ARB)
� What class of meds in this person on?� Insulin� Biguanide� Statin� Beta blocker for?
� New meds added?� Aspirin� GLP-1 RA and SGLT-2
� Semaglutide (Ozempic)
� Empagliflozin (Jardiance)
� Basal insulin reduced to 80 units
Statin RecommendationsAge ASCVD or 10 yr risk >20% Recommended statin
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.
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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
ABCs of Diabetes
�A1c less than 7% (avg 3 month BG)�Pre-meal BG 80-130�Post meal BG
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Page 24©Copyright 1999-2020, Diabetes Education Services www.DiabetesEd.net
We Can Make a Big Difference
�62 yrs old, A1c 7.2%
�60 units Lantus plus
metformin 1000mg BID.
�BMI 36 B/P 134/68
�LDL 103 Trig 212
�Urinary Albumin 30+
�Other Med Needed?:
atorvastatin 80mg,
metoprolol, Flonase
�Losartan (ARB)
�I feel better.�I am sleeping
through the night.�I check my blood
sugars daily, and for the first time they are less than 130!
�Hope – The best gift of all!
Thank You
�Please email us with
any questions.
�www.diabetesed.net