CV Risk Reduction in Patients with Type 2 Diabetes

Manesh R. Patel, MD: People ask me about goals for patients with type 2 diabetes. We actually have some changing guidelines and changing care patterns. Just to remind everyone, the ACC [American College of Cardiology]/AHA [American Heart Association] guidelines, consider type 2 diabetes for people with hemoglobin A1C [glycated hemoglobin] greater than 6.5%. They have several recommendations for those patients. First, there are important class 1 recommendations about having a heart-healthy diet. Today we recommend a reasonably high amount of fiber and vegetables, a low amount of carbohydrates or straight sugar, and lean protein. 

We also recommend at least 150 minutes of exercise. Because I have recently thought much more about exercise, I’ll say 150 minutes per week sounds like a lot. But it can be easily broken down into 30 minutes of something you enjoy doing, hopefully actively, at least 5 times a week. And it’s moderate to vigorous. Some patients will ask me, “What does moderate to vigorous exercise mean, Dr Patel?” I describe it as doing any amount of exercise that, if somebody were to call you on the phone, you’d have a little trouble speaking in full sentences. That means you’re exercising enough, getting your heart rate and your respiratory rate up, so you have to take a few pauses and are not able to make full sentences. That’s moderate to vigorous exercise.

Significantly for patients diabetes is reduction of other cardiovascular risk factors. We’ll talk about that in a second. But that certainly speaks to some of our patients with lipids, blood pressure goals, and others. It’s important to recognize that the patient that has other cardiovascular risk factors and has been on lifestyle medication and therapies, including metformin. Based on data from several large trials, both SGLT2 inhibitors and GLP1 receptor agonists are also considered important to improve the patient’s outcome in a class 2a, based on some evidence from large clinical trials. I would suggest that the GLP1 data and certainly the SGLT2 data are increasing, so we’ll think about these therapies for risk reduction for our patients. As for the ACC/AHA guidelines, talk about other agents for therapies, for patients with cardiovascular risk and diabetes. That highlights our overall approach.

Marc P. Bonaca, MD, MPH: There are a number of risk factors that are managed in patients who have diabetes mellitus. When we talk about risk and diabetes, there are several types of risk. For example, there’s the risk of microvascular disease. Those are small vessel issues like kidney disease, eye problems, and retinopathy, and those are very much related to blood sugar levels, which can be managed. Then there’s what’s called macrovascular disease, or disease of the large vessels—things like heart attack, stroke, peripheral artery disease. When we have a patient with diabetes, part of risk-factor management is of course glucose control. We want patients to know what their hemoglobin A1C is. But for macrovascular disease, it’s more important to manage other risk factors, such as keeping LDL [low-density lipoprotein] cholesterol levels very low, optimizing blood pressure, optimizing body weight, exercising, and avoiding tobacco products.

Manesh R. Patel, MD: Our blood pressure goals in general for the overall population are certainly less than 140/90 mmHG and hopefully less than 130/85 mmHG. In diabetics, the lower goal is certainly what we’re searching for. In our patients with diabetes, which is coronary artery disease equivalent, the guidelines also recommend, a moderate to high-intensity statin with the LDL goal, less than seven 70 mg/dL if possible. In thinking about how we try to accomplish that with our patients, it’s certainly complicated. 

In our clinic with my fellows, I often say that changing behavior may be 1 of the hardest things we do in medicine. It’s hard to change our own behavior, much less change our patients’ behavior. We focus on 2 steps. First, no one changes their behavior without some emotional link to why we’re doing it. If I tell my patient, “You’ve got to get your blood pressure down because it will prevent stroke and heart attacks,” that may not have an effect. I could even say to look at the trials. I know from SPRINT that if I lower your blood pressure by 5 mmHG over the next year, I reduce your chance of a stroke. Most of my patients don’t respond to that. However, when I go in and make an emotional connection and then give them the facts, it’s much more likely. I say, “Don’t you want to go for walks with your grandkids? Do you enjoy going to the gym and swimming? Stroke debilitates you.” Most of us don’t want to be a burden on our family. To prevent that, we’re doing this. Once we’ve make the emotional connection and give them the facts, many more people are motivated. If we give them a pathway to where it becomes the easy action, it usually leads to change. But all our patients diabetes are usually looking for therapies that we know work and lead to the outcomes they care about.

Marc P. Bonaca, MD, MPH: Patients with diabetes are at heightened risk of atherothrombosis. That means complications where cholesterol plaque in the artery may rupture and there’s a clot or a thrombosis. That can manifest as a heart attack or as a stroke. In peripheral artery disease it can manifest as acute limb ischemia or amputation. The thrombosis part of that is really important. We know that patients with diabetes have more rapid platelet turnover. We know they tend to have more platelet activation. And so in patients with diabetes and atherosclerotic vascular disease, patients are recommended to receive a single antiplatelet agent, generally aspirin. Although if someone is allergic to aspirin, they might receive clopidogrel monotherapy. 

In addition, for high-risk patients you should consider the addition of a second antithrombotic agent. For patients with a prior myocardial infarction [MI] or a high-risk coronary intervention, it might be the addition of a P2RY12 inhibitor for DAPT [dual antiplatelet therapy] for a period of time. An alternative to that and for a broader population would be the addition of a low-dose anticoagulant like rivaroxaban 2.5 mg twice daily, which you could add to aspirin. That would be in a broader population—not necessarily in a patient with a prior MI but certainly for patients who have concomitant peripheral artery disease, patients who have heart failure and coronary disease, or patients who have complex coronary disease, even without a prior MI. The guidelines say that these should be considered. Of course, you’ll want to consider the ischemic risk and the bleeding risk individualized for patients.

Transcript Edited for Clarity