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Risk factor modification essential to reduce CVD in diabetes, metabolic syndrome
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PHILADELPHIA — Few patients with diabetes or metabolic syndrome are reaching goal targets for cardiovascular risk factors including blood pressure, LDL cholesterol and HbA1c, revealing a significant treatment gap and an opportunity to further reduce disease burden through risk factor modification, according to a speaker at the Heart in Diabetes Conference.
Nathan D. Wong, PhD, FACC, FAFA, director of the Heart Disease Prevention Program and professor of medicine at the University of California, Irvine, said CV risk must be carefully assessed in patients with type 2 diabetes and/or metabolic syndrome, beginning with global risk scoring using traditional factors, but also considering additional factors like duration of diabetes, and the presence and extent of subclinical atherosclerosis.
“Atherosclerotic complications are really responsible for a vast majority of mortality in people who have diabetes, as well as a majority of hospitalizations,” Wong said during his presentation here. “It’s important to note that 50% of patients with diabetes have a preexisting coronary artery disease and one-third of people with myocardial infarction have undiagnosed diabetes ... [showing] the importance of screening for diabetes in patients.”
Multiple studies now show that not all patients with diabetes are coronary heart disease-risk equivalent, Wong said. Adults with diabetes and prior CVD — whether MI or stroke — will experience more life-years lost compared with people who have diabetes without CVD, Wong said, particularly patients aged younger than age 60 years. Evidence from meta-analyses of observational studies show that adults with diabetes without preexisting CVD have only about half the risk of experiencing a future MI when compared with those with preexisting MI alone.
Global risk assessment, Wong said, demonstrates that approximately one-third of men and half of women with diabetes, and many with metabolic syndrome, should not be considered as CVD-risk equivalent, which is defined as a 20% or greater risk of experiencing a CHD event within 10 years.
“We also performed a global risk assessment on the NHANES [participants] who had diabetes, using the Framingham total CVD risk score, and we found roughly one-third of men and half of women not to meet that 20% threshold for the CV risk equivalent, nor did they have preexisting CVD,” Wong said.
A recent study from researchers at Kaiser Permanente Northern California similarly compared the risk for a CHD event among individuals with and without a history of diabetes or CHD; the analysis focused on more than 1.6 million adults over 10 years. Prevalent diabetes was associated with approximately double the risk and prior coronary heart disease with approximately triple the risk for coronary heart disease among adults with a history of diabetes or CHD, compared with those without a history of diabetes or CHD.
Further, “we see this in both woman and men across all the ages studied, starting at age 30 (years),” Wong said.
Clinical trial and epidemiologic evidence has demonstrated that controlling CV risk factors, in particular BP and lipids, can greatly improve outcomes, Wong said. However, the status of risk factor control among patients remains poor, and composite target attainment is even worse, he said.
“We know that there are dramatic effects on reducing effects on reducing CV outcomes from the rather small STENO-2 ... clinical trial: a 53% risk reduction and, from extended follow-up, a substantial reduction in mortality after 13 years,” Wong said. Additionally, “we also used the United Kingdom Prospective Diabetes Study risk engine, and we projected certain levels of aggressive risk factor reduction [in] systolic BP, cholesterol, as well as HbA1c, and we get exactly the same number as STENO-2 — a 53% reduction in CHD events projected over 10 years.”
However, in a study combining diabetes cases from the Atherosclerosis Risk in Communities (ARIC) study, the Jackson Heart Study and the Multi-Ethnic Study of Atherosclerosis (MESA), 30% to 40% of participants were reaching target goals for individual risk factors; 7% were at target for combined composite risk factors, according to Wong.
“Importantly, if all three targets were reached, there were multivariable-adjusted risks of CV events that were 62% lower, and for CHD that were 60% lower,” Wong said. “It really points to the need that, given the tremendous gap we see in composite risk factor control in diabetes, there is a lot of potential to reduce these residual risks if we can get all these major risk factors well controlled.”
Going forward, Wong said it will be important to look at real-world patient data from large-scale databases such as the Diabetes Collaborative Registry, an interdisciplinary effort led by the American College of Cardiology in partnership with the American Diabetes Association, the American College of Physicians, the American Association of Clinical Endocrinologists and the Joslin Diabetes Center. The registry already has more than 1 million patients with more than 2 million patient encounters, and is providing feedback to all participating centers, Wong said.
“If your center is not involved, this is a perfect opportunity to improve the quality of care related to diabetes,” Wong said. – by Regina Schaffer
Reference:
Wong ND. Epidemiology of CVD in Diabetes and Metabolic Syndrome. Presented at: Heart in Diabetes Medical Conference; July 14-16, 2017; Philadelphia.
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