AHA: Address social determinants of health to reduce CV risk in type 2 diabetes
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Clinicians must use multifaceted tools to reduce CV risk in type 2 diabetes, combining newer therapies with efforts to address social determinants of health, according to a new American Heart Association scientific statement.
The AHA scientific statement, published in Circulation, is based on an extensive review of clinical trial results through June 2020 and addresses “the gap between existing evidence on how best to lower CV risk in people with type 2 diabetes and the reality for people living with type 2 diabetes.” Targets to reduce CVD risk among people with type 2 diabetes include managing blood glucose, BP and cholesterol levels; increasing physical activity; healthy nutrition; obesity and weight management; not smoking; not drinking alcohol; and psychosocial care.
‘Urgent call to action’
“This new scientific statement is an urgent call to action to follow the latest evidence-based approaches and to develop new best practices to advance type 2 diabetes treatment and care and reduce CVD risk,” Joshua J. Joseph, MD, MPH, FAHA, chair of the statement writing group and assistant professor of medicine in the division of endocrinology, diabetes and metabolism at The Ohio State University College of Medicine in Columbus, said in a press release. “Far too few people — less than 20% of those with type 2 diabetes — are successfully managing their heart disease risk, and far too many are struggling to stop smoking and lose weight, two key CVD risk factors. Health care professionals, the health care industry and broader community organizations all have an important role to play in supporting people with type 2 diabetes.”
The statement is an update to 2015 guidance, published when there was still limited evidence to suggest glucose-lowering medications reduce risk for CV events.
“At present, several large randomized controlled trials with newer antihyperglycemic agents have been completed, demonstrating CV safety and reduction in CV outcomes, including CV death, MI, stroke and heart failure,” the researchers wrote.
Key messages
The statement includes several key recommendations:
- Patient-centered, culturally appropriate recommendations through diabetes self-management education and support and medical nutrition therapy are key to meeting individualized goals for behavioral change and diabetes self-management. “Developing pathways and programs for patients with diabetes to catalyze improvements in lifestyle behaviors is mission critical,” Joseph told Healio.
- Among patients with established atherosclerotic CVD, SGLT2 inhibitors or GLP-1 receptor agonists with demonstrated CV benefit are recommended, with preference for a SGLT2 inhibitors in those at high risk for HF. In most patients who require the greater glucose-lowering effects of an injectable medication, the American Diabetes Association (ADA) guidelines initially prefer GLP-1 receptor agonists over insulin. “Novel diabetes medications like GLP-1 receptor agonists and SGLT2 inhibitors are effective for CV risk reduction,” Joseph told Healio. “Increasing prescription and utilization for diabetes patients with CVD is critical to ameliorating inequalities in CV death for people with diabetes.”
- Although treatment algorithms are similar, there are noteworthy differences in hypertension definitions and goals between the 2017 American College of Cardiology/AHA Guideline for the Prevention, Evaluation and Management of High BP in Adults and the 2017 ADA Position Statement on Diabetes and Hypertension. The ADA does not promote a uniform BP target and instead risk-stratifies to avoid overtreatment in frail patients with comorbidities. “Given the significant clinical heterogeneity of patients with type 2 diabetes, treatment strategies should be patient-centered with shared decision-making,” the researchers wrote. “A multidisciplinary approach to ensure patients safely achieve BP goals should be incorporated because the rigorous protocols and intensive follow-up utilized in randomized controlled trials are difficult to reproduce in real-world clinical practice.”
- “Timely and aggressive” lipid-lowering therapy is warranted for both primary and secondary prevention in diabetes as a component of comprehensive CV risk reduction, and lifestyle- and behavioral-focused approaches are recommended for all people with diabetes as the cornerstone to addressing dyslipidemia. In those with established ASCVD, the highest-intensity statin tolerated should be initiated or continued with the aim of reducing LDL by at least 50%, with a more individualized approach for those aged at least 75 years. For primary prevention in type 2 diabetes, at least a moderate-intensity statin should be considered based on age, absolute ASCVD risk or the presence of risk-enhancing factors. Nonstatin therapies, including ezetimibe, PCSK9 inhibitors, icosapent ethyl (Vascepa, Amarin), bile acid resins and fibrates, should be considered after thorough evaluation of risk, LDL after optimal statin therapy and presence of hypertriglyceridemia.
- For primary prevention of CVD in type 2 diabetes, the relative benefits of antithrombotic approaches must be weighed carefully against risks using a patient-centered approach.
- Clinicians must also address social determinants of health in the delivery of care, both during clinic visits and within health care systems with social workers, patient navigators and community health workers, or through referral-based pathway programs. “Clinical care and treatment accounts for 10% to 20% of the modifiable contributors to healthy outcomes,” the researchers wrote in the statement. “The other 80% to 90% are the social determinants of health, which includes health-related behaviors, socioeconomic factors, environmental factors and racism, which have been recognized to have a profound impact on CVD and type 2 diabetes and their outcomes by the AHA and American Diabetes Association.”
“A large number of randomized controlled trials have demonstrated that the risk of CV events can be significantly reduced by incorporating evidence-based therapies for control/modification of multiple cardiometabolic abnormalities in patients with type 2 diabetes,” the researchers wrote. “We recommend a comprehensive approach to management of all cardiovascular risk factors in patients with type 2 diabetes, including glycemia, BP, lipid abnormalities, thrombotic risk, obesity and smoking, using lifestyle and pharmacological approaches with proven benefit using a patient-centered approach. A patient-centered approach in this context means reframing our clinical encounters to think about patients as people who live in families, communities and societies that must be considered in their CV risk management.”
For more information:
Joshua J. Joseph, MD, MPH, FAHA, can be reached at joshua.joseph@osumc.edu; Twitter: @joshuajosephmd.
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