Friday, September 04, 2015

Updated AHA/ADA scientific statement on prevention of cardiovascular disease in type 2 diabetes

This document is available as free full text and a link to the citation is here.

Here are a few noteworthy points:

DM can be defined as an A1C of 6.5 or above, FBS of 126 or above OR two hour PC of 200 or above.

Prediabetes, a risk for not only DM itself but cardiovascular disease, can be defined as A1C of 5.7-6.4, FBS 100-125 OR a two hour PC of 140-199.

An A1C target of less than or equal to 7 is recommended for most patients. This recommendation is controversial. An emerging opinion in the controversy is that while 7 may be a reasonable target, levels below that may have risks that exceed benefits. Microvascular benefit may increase along a continuum of lower and lower A1C levels, even if below 7. Levels pushed below 7 by pharmacologic means, however, (at least using insulin or sulfonylureas) appear to be associated with macrovascular harm. A target of 8 is suggested for certain individuals such as older patients, those prone to hypoglycemia, and those with advanced complications.

According to the document, pharmacologic agents or bariatric surgery warrant consideration for obese patients if desired weight cannot be achieved by lifestyle changes. Weight loss drugs are controversial because any benefits appear to be counterbalanced by adverse outcomes for all agents adequately studied. The article has an extensive discussion of the data concerning bariatric surgery.

Hypoglycemia is now recognized as a driver of cardiovascular disease. The article discusses possible mechanisms which include sympathetic nervous system activation, increase in the QT interval, endothelial dysfunction, platelet activation, coagulation factor activation and activation of inflammatory mediators.

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