2014糖尿病指南: 心血管疾病与糖尿病Cardiovascular Disease (CVD) & Diabetes

Cardiovascular Disease (CVD) & Diabetes

CVD Screening and Treatment

Screening
Asymptomatic patients: routine CAD screening not recommended; treatment of CVD risk factors is focus
Overt CVD: consider ACEI, and use aspirin and statin to reduce CV event risk

Prior MI: continue use of beta-blockers for ≥2 yrs after event

Symptomatic heart failure: avoid TZDs

Treatment
Metformin

    • Stable heart failure: may use metformin in presence of normal renal function

    • Avoid metformin in unstable or hospitalized heart failure patients
 

Management of High Blood Pressure

Screening
Measure BP at every visit; confirm elevated BP at separate visit
 

Treatment targets
Diabetes and hypertension: SBP <140 mm Hg

   • Lower SBP targets (eg, <130 mm Hg) may be appropriate*

   Diabetes: DBP <80 mm Hg

Treatment

BP >120/80 mm Hg: lifestyle changes

   • Weight loss (if overweight)

   • DASH-style diet including sodium restriction, potassium increase

   • Moderate alcohol intake

   • Increased physical activity
 

BP >140/80 mm Hg: lifestyle changes + pharmacologic therapy

    • Diabetes and hypertension: ACEI or ARB†

    • ≥2 agents at max doses usually required to achieve targets

    • Administer ≥1 agent at bedtime

    • ACEI, ARB, diuretic: monitor serum creatinine/eGFR and serum potassium

Treatment and targets for pregnant women

Diabetes and hypertension: 110-129/65-79 mm Hg target

ACEI, ARB contraindicated

*In certain individuals, if achieved without treatment burden ; †If one class not tolerated, substitute other class

Management of Dyslipidemia

Screening
Measure fasting lipids at least annually
 

Every 2 yrs for adults with low-risk lipid values: LDL-C <100 mg/dL (2.6 mmol/L), HDL-C >50 mg/dL (1.3 mmol/L), TG <150 mg/dL (1.7 mmol/L)

Targets
• No overt CVD: LDL-C <100 mg/dL (2.6 mmol/L)

• Overt CVD: LDL-C <70 mg/dL (1.8 mmol/L), with high-dose statin*

• If targets not achieved on max statin therapy: ~30-40% LDL-C reduction from baseline

Treatment

Lifestyle modification

  • Reduce saturated fat, trans fat, cholesterol intake

  • Increase omega-3 fatty acids, viscous fiber, plant stenols/sterols intake

  • Weight loss (if indicated)

  • Increase physical activity
 

Statin therapy* and lifestyle changes in patients with

  • Overt CVD

  • No CVD, aged >40 yrs, ≥1 CVD risk factor†

  • Consider statins in lower-risk patients (no overt CVD, aged <40 yrs) if LDL-C >100 mg/dL or if multiple CVD risk factors

 

Combination therapy not recommended
 

*Contraindicated in pregnancy
 

†Hypertension, smoking, dyslipidemia, albuminuria, family history of CVD
 

Antiplatelet therapy

Aspirin: Primary prevention
 

75-162 mg/day: type 1 and type 2 diabetes at increased CVD risk

(10-yr risk >10%)*
 

Low-risk patients (10-yr risk <5%):† not recommended; potential for

bleeds likely offsets potential benefits
 

Men <50 yrs, women <60 yrs with multiple other risk factors

(10-yr risk 5%-10%): use clinical judgment

Aspirin: Secondary prevention
 

75-162 mg/day: diabetes and CVD history

CVD and aspirin allergy Clopidogrel 75 mg/day
 

Dual antiplatelet therapy Reasonable for ≤1 year after ACS
 

*Includes most men aged >50 yrs or women aged >60 yrs with ≥1 add’l major risk factor: family

history of CVD, hypertension, smoking, dyslipidemia, or albuminuria