Type 2 diabetes: 13 tips for preventing cardiovascular disease

In recent decades, the number of patients with type 2 diabetes has increased dramatically, of which 60% are from Asia.

The prevalence of cardiovascular disease among patients with type 2 diabetes in the Asia-Pacific region is higher than that in Western countries.

On April 19, the Asia-Pacific Society of Cardiology issued a consensus statement on optimizing the cardiovascular outcome of patients with type 2 diabetes, and put forward 13 management recommendations.

Key points: • The statement emphasizes that patients with prediabetes must emphasize life>
• For patients with eligible renal function of chronic kidney disease and heart failure (HFrEF) with reduced ejection fraction (HFrEF), SGLT2 inhibitors are recommended; for patients at high risk of cardiovascular events, in addition to SGLT2 inhibitors, GLP-1 receptor agonism is also recommended Agent.

• It is generally recommended that patients with type 2 diabetes have a blood pressure goal of <140/90 mmHg.

• It is recommended to use antiplatelet drugs for secondary prevention of atherosclerotic cardiovascular disease.

Pre-diabetes recommendations 1.
Patients with pre-diabetes should be closely monitored and provided with life>
The results of large randomized controlled trials showed that compared with the control group, pre-diabetic patients can reduce the risk of diabetes, cardiovascular disease and all-cause death through life>
For high-risk groups, life>
Recommendations for hypoglycemic goals 2.
Where possible, the best blood glucose goal is HbA1c <7%.

Recommendation 3.
Hypoglycemia increases the risk of death and cardiovascular events and should be avoided.

Recommendation 4.
For patients with advanced age, limited life expectancy, or specific comorbidities, a looser blood glucose target (<8%) may be appropriate.

Recommendation 5.
Patients with complicated blood glucose management may need to be referred to the endocrinology department.

A meta-analysis of 5 prospective randomized controlled trials showed that, compared with standard treatment, intensive hypoglycemia reduced HbA1c to <7%, which was associated with a significant reduction in the risk of non-fatal myocardial infarction and coronary heart disease.

A follow-up study by UKPDS found that after 10 years of follow-up, the risk of microvascular and macrovascular complications in the intensive hypoglycemic group continued to decrease.

Recommendations for patients at high risk of cardiovascular events 6.
For patients with type 2 diabetes with adequate renal function and high risk of cardiovascular events, it is recommended to use SGLT2 inhibitors and GLP-1 receptor agonists with cardiovascular benefits.

A meta-analysis of multiple cardiovascular prognosis trials showed that compared with placebo, GLP-1 receptor agonists can reduce MACE risk by 10%, cardiovascular mortality by 13%, and all-cause mortality by 12%.

A meta-analysis of the CANVAS, CREDENCE, DECLARE-TIMI 58 and EMPA-REG trials showed that SGLT2 inhibitors can reduce the risk of MACE by 12% (HR 0.
88, 95% CI 0.
82-0.
94).

When used for secondary prevention, SGLT2 inhibitor treatment can reduce the risk of MACE by 14% (HR 0.
86, 95% CI 0.
80-0.
93) and the risk of cardiovascular death by 20% (HR 0.
80, 95% CI 0.
71–0.
90), All-cause mortality was reduced by 17% (HR 0.
83, 95% CI 0.
75-0.
91).

Recommendations for patients with chronic kidney disease 7.
SGLT2 inhibitors and GLP-1 receptor agonists are recommended for patients with eGFR> 30 ml/min/1.
73 m² because of the cardiovascular and renal benefits.

Recommendation 8.
Insulin, short-acting sulfonylureas and DPP4 inhibitors are the first choice for patients with end-stage renal disease (ESRD) on dialysis.

Recommendation 9.
Patients with eGFR <30 ml/min/1.
73 m² should avoid the use of metformin.

Recommendation 10.
For patients with type 2 diabetes who have received optimal blood pressure management and RAAS inhibitor treatment, eGFR <30 ml/min/1.
73 m², or proteinuria> 1 g/d, referral to the nephrology department should be considered.

Both the 2020ADA guidelines and 2020KDIGO guidelines recommend that patients with type 2 diabetes and diabetic nephropathy with eGFR> 30 ml/min/1.
73 m² use SGLT2 inhibitors to reduce the risk of chronic kidney disease deterioration and cardiovascular events.

In addition to SGLT2 inhibitors, the 2020 KDIGO guidelines also recommend the use of GLP-1 receptor agonists.

For patients with chronic kidney disease, including end-stage renal disease and patients undergoing dialysis treatment, DPP4 inhibitors can be used.

DPP4 inhibitors can exert renal protection by reducing albuminuria.

Because metformin is excreted from the kidneys, patients with eGFR <30 ml/min/1.
73 m² are contraindicated.

Table 1 Type 2 diabetes drug treatment options stratified by eGFR.
Recommendations for patients with heart failure 11.
For patients with heart failure with reduced ejection fraction (EF≤40%), SGLT2 inhibitors are recommended to reduce the risk of heart failure hospitalization and cardiovascular death .

The benefits of drugs such as dapagliflozin (DAPA-HF) and empagliflozin (EMPEROR-Reduced) in reducing the risk of heart failure hospitalization and cardiovascular death have been verified by large randomized controlled trials.

In addition, patients with HFrEF and type 2 diabetes should avoid the use of thiazolidinediones.

Recommendations for blood pressure reduction goals 12.
For patients with type 2 diabetes, the blood pressure reduction target is usually recommended to be <140/90 mmHg; patients with type 2 diabetes and hypertension, if they are at high cardiovascular risk or have a 10-year ASCVD risk of ≥15% or other organ involvement, The pressure reduction target should be set to <130/80 mmHg.

Recommendations for antiplatelet therapy 13.
Patients with cardiovascular disease should use antiplatelet drugs for secondary prevention.

The use of P2Y12 inhibitors in patients with type 2 diabetes needs to be individualized according to the patient's risk of ischemia and bleeding.

For patients without a high risk of bleeding and a high risk of ASCVD, low-dose aspirin can be considered for primary prevention.

Literature index: Jack Wei Chieh Tan, David Sim, Junya Ako, et al.
Consensus Recommendations by the Asian Pacific Society of Cardiology: Optimising Cardiovascular Outcomes in Patients with Type 2 Diabetes.
Eur Cardiol.
2021 Apr 19; 16: e14.