Box 2. Situations where up-categorisation of risk may be appropriate | ||||
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• People with a first-degree female relative aged less than 65 who has had a heart attack or stroke.
• People with a first-degree male relative aged less than 55 who has had a heart attack or stroke.
• First Nations people.
• Māori and Pacific Islander peoples.
• People of South Asian ethnicity( eg, Indian, Pakistani, Bangladeshi, Sri Lankan, Nepali, Bhutanese or Maldivian).
• People with serious mental illness.
• People with diabetes and microvascular complications in two or more areas( kidney disease, foot disease, eye disease, liver disease).
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cardiovascular emergency is important | ||||
for all those at increased CVD | ||||
risk. | ||||
Early cardiovascular events | ||||
may be transient and symptoms | ||||
short-lived, such as a TIA or angina. | ||||
Although these will fully resolve, | ||||
it remains important to educate | ||||
patients at high CVD risk to still seek | ||||
medical attention to ensure early |
|
diagnosis and treatment, as the next event may be imminent and may not be transient.
In people with T2DM, the first
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Figure 2. Use the metaphor of traffic congestion to explain the risk of CVD to patients. |
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presentation of CVD may not be as |
||||
obvious as chest pain or neurologi- |
of education, diet and lifestyle opti- |
mental health concerns( stress) fol- |
or vegan is practical and improves |
Alongside traditional CVD risk fac- |
cal deficit. MI may be silent in peo- |
misation, treatment adherence and |
lowing smoking cessation are com- |
their metabolic risks. If patients are |
tors, identifying and managing men- |
ple with T2DM, although the survival |
regular support and monitoring. |
mon barriers for patients with T2DM |
using or considering SGLT2 inhib- |
tal health issues can improve control |
of patients with a silent MI may be as |
Without these elements, even the |
who smoke, and these barriers may |
itors( as is appropriate for patients |
of CVD risks and improve adherence |
poor as those who have had a clinical event. 27 Patients may present with only shortness of breath, fatigue, |
most potent therapies can prove ineffective. But with them, there is a clear opportunity to change the |
need to be specifically addressed.
REGULAR PHYSICAL ACTIVITY
|
with T2DM at high cardiovascular risk), diets that are low in carbohydrates or intermittent fasting should |
with therapy. Without dealing with underlying mental health issues, almost nothing seems to work! |
increasing oedema, or nausea / vomiting following an MI. It may even mimic an acute viral infection, like COVID-19. However, it is important to consider any atypical acute presentation in a patient with T2DM with increased CVD risk as potentially cardiovascular in origin. |
future course of your patient’ s health and their life.
Lifestyle change to prevent CVD
Optimal nutrition and physical
activity, tailored to meet individual needs, accounting for cost,
|
AND LIMITING TIME SPENT BEING SEDENTARY Encourage and support all people with T2DM to undertake regular, sustainable physical activity to increase their cardiovascular fitness and reduce their risk of CVD events. A simple first goal is to aim for at |
be avoided because of the increased risk of ketoacidosis. 31
DIETARY MANAGEMENT OF OBESITY Most people with T2DM have overweight or obesity. Significant weight loss( greater than 10 %) is associated with improved cardiovascular out-
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PHARMACO- THERAPY FOR PATIENTS WITH T2DM AT INCREASED CVD RISK
ALL patients with T2DM at increased
|
In large follow-up studies of adults |
acceptability, accessibility, comor- |
CVD risk require multifactorial treat- |
with T2DM but without CVD, about 4 % developed symptomatic CVD every year( or more simply, approximately one in five every five years). 16 In men, the most frequent first CVD presentation was with CHD( 29 %) or peripheral arterial disease( 28 %). In |
bidity, cultural values and other factors, as appropriate, are recommended to reduce the incidence and improve outcomes for CVD in all adults with T2DM. In most cases, this will involve simply accentuating healthy lifestyle and |
Dietary change is one of the simplest ways to improve cardiovascular risk factors in patients with T2DM. |
ment that includes the use of medications proven to reduce CVD risk factors and lower the incidence of cardiovascular events( see figure 5).
Optimal glucose control
Intensive glucose lowering can
|
|
women with T2DM, the most common first presentation was with heart |
behaviours that are appropriate for all adults, and selectively eliminat- |
least 30 minutes of moderate-intensity
aerobic physical activity on
|
comes. 32 Even with GLP-1 receptor agonists( GLP-1 RAs)( see later), die- |
improve cardiovascular outcomes in people with T2DM, proportional |
failure( 40 %) or following a TIA or stroke. 16, 28 Similarly, in older adults( older than 65) with T2DM, the most frequent first presentation of CVD is heart failure( 36 %). 16 This means always considering CVD in the differential diagnosis for patients with T2DM presenting with shortness of breath, nocturnal cough, increasing fatigability or leg oedema. |
ing high-risk behaviours( eg, high calorie intake, sedentary behaviour, smoking, excessive alcohol intake). This may be less likely to work or sustain, if many changes are made all at once; instead making a progressive approach starting with‘ low-hanging fruit’ which is generally the most acceptable to patients, especially when other |
most, if not all, days of the week( ie, 150-300 minutes / week). 30 This does not have to be all at once and can be accumulated across a day( eg, in three bursts longer than 10 minutes over a day). More benefits beyond these simple goals may be accrued from additional activity.
OPTIMAL NUTRITION
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tary change is essential to achieve and sustain this kind of weight loss. However, on their own, most standard diets will achieve only 2-3 % loss of weight at best. This can improve metabolic risk factors in patients with T2DM but may not reduce CVD risk. 33 More aggressive dietary intervention( eg, very low-calorie diets) in patients with recently diagnosed |
to the degree and duration of glucose control. In large clinical trials, intensive glucose lowering has been associated with a 14 % reduction in MACE( 95 % confidence interval [ CI ] 0.77-0.98; p = 0.02) associated with an average HbA1c difference of 0.8 % when compared with standard of care in patients with T2DM. 34 Potentially, greater cardiovascular bene- |
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NON-PHARMA- COLOGICAL MANAGEMENT OF INCREASED CVD RISK
THE management of CVD begins
by informing patients of their level of risk and shared decision-making
|
targets( eg, glucose, body weight, blood pressure) are also trying to be addressed.
SMOKING CESSATION Encourage and support all people with T2DM who smoke / vape to quit. 29 After one year of not smoking, the excess risk for CHD falls to half
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Dietary change is one of the simplest ways to improve cardiovascular risk factors in patients with T2DM. Adherence is the major predictor of their success, so diets that are simple to understand, practical to institute, and enjoyable to eat every day will usually work best. Some healthy examples are the plant-based‘ Medi- |
T2DM can have more profound effects, including the induction of diabetes remission, and may be suitable for some patients keen to avoid medications.
MENTAL HEALTH Patients with T2DM have an increased risk of psychological dis-
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fits from glucose-lowering have been observed for primary prevention subgroups and for early treatment in patients with shorter duration of diabetes, when compared with outcomes in those with established CVD, possibly due to a prolonged legacy of prior glucose control. 34, 35 An HbA1c of less than 7 %( 53.0mmol / |
regarding the initiation of strate- |
that of current smokers. Plug‘ non- |
terranean-style diet’ and‘ DASH diet |
tress, anxiety and depression, espe- |
mol) is appropriate and achievable |
gies that will most effectively reduce |
smoker’ into their CVD risk calcu- |
( Dietary Approaches to Stop Hyper- |
cially in those with high CVD risk |
in most patients with T2DM. More |
their risk. The primary prevention of |
lator and let them see how big this |
tension)’. Some patients with T2DM |
in whom the looming threat of |
intensive targets( eg,‘ normalisa- |
CVD is always based on a foundation |
benefit might be. Weight gain and |
find going completely vegetarian |
CVD is another unwanted burden. |
tion’ of HbA1c) may be appropriate |