SCREENING FOR CVD IN DIABETES: EVIDENCE AND RECOMMENDATIONS
Nathan D. Wong, Ph.D., University of California, Irvine, CA, USA
The ACC/AHA released evidence-based guidelines on cardiovascular disease (CVD) risk assessment, lifestyle, obesity, and cholesterol management. The risk assessment guideline recommended a new “Pooled Cohort Equations” calculator to estimate 10-year and lifetime risk of atherosclerotic CVD (ASCVD), and other measures-- premature family history of CVD, C-reactive protein, ankle brachial index, and coronary calcium scores to further stratify risk and inform the treatment decision. The lifestyle guideline focused on dietary patterns and physical activity for blood pressure and LDL-cholesterol reduction and the obesity guideline highlighted the importance of multiple intensive personalized sessions with lifestyle interventionalists and the value of moderate weight loss in control of risk factors. The cholesterol guideline focused on the identification of four statin eligible groups: ASCVD, diabetes, LDL-cholesterol >=190 mg/dl, and >=7.5% 10-year risk of ASCVD, but emphasizing the importance of the clinician-patient risk discussion when considering initiation or intensification of therapy. While the guideline does not support specific initiation or target LDL-C levels, emphasis is on therapeutic response, still requiring regular monitoring of LDL-C, and non-statin agents can be considered if needed response is not achieved. The IMPROVE-IT results as well as emerging data on newer agents provide promising opportunities to address lipid residual risk in persons not adequately tolerating or responding to statins. Other criteria to address residual risk such as consideration of non-HDL-C levels have been recommended by the recent National Lipid Association guideline. Finally, recent blood pressure guidelines have recommended revised cutpoints for blood pressure control where benefit has been shown. Coordinated efforts for composite risk factor control, electronic medical record adoption of risk assessment tools, identification of providers’ patients not adhering to recommended therapies, and e-health-based personalized CVD management strategies will be important steps to implement these guidelines and achieve further progress in CVD prevention efforts.