Reference: 2018 ADA guideline. Topics: hypertension management(drug choice and combination), indications for hyperlipidemia treatment, atherosclerosis disease prevention with antiplatelet agents and issues about coronary artery diseases.

1. Cardiovascular Disease Management
in Diabetes Mellitus
Reference:
9. Cardiovascular Disease and Risk Management: Standards of Medical Care in Diabetes—2018. American Diabetes
Association. Diabetes Care 2018 Jan; 41(Supplement 1): S86-S104
Summarized by Yung-Tsai Chu

2. Outline
Blood Pressure Control
Lipid Control
Antiplatelet Agent
Coronary Heart Disease

3. Blood Pressure Management

4. 1.BP 2.Albuminuria 3.Response
3 Questions for Blood Pressure Control in DM

5. 1.BP
140/90
mmHg
160/100
mmHg
2 Agents
1 Agent
Reference:9. Cardiovascular Disease and Risk Management: Standards of Medical Care in Diabetes—2018.
American Diabetes Association. Diabetes Care 2018 Jan; 41(Supplement 1): S86-S104

6. 1.BP
140/90
mmHg
160/100
mmHg
1 Agent
2.Albuminuria
Yes
No
ACEi
ARB
CCB
Diuretics
ACEi
ARB
Reference:9. Cardiovascular Disease and Risk Management: Standards of Medical Care in Diabetes—2018.
American Diabetes Association. Diabetes Care 2018 Jan; 41(Supplement 1): S86-S104

7. 1.BP
160/100
mmHg
2 Agents
2.Albuminuria
ACEi or ARB
CCB or Diuretics
Yes
ACEi or ARB
CCB
Diuretics
No 2 of 3
options
Reference:9. Cardiovascular Disease and Risk Management: Standards of Medical Care in Diabetes—2018.
American Diabetes Association. Diabetes Care 2018 Jan; 41(Supplement 1): S86-S104

8. If Poor Response...
ACEi or ARB
CCB
Diuretics
Combination of 3 Classes
Still Poor Response or
Adverse Effects
Add Mineralocorticoid
Receptor Antagonist
Refer to Specialist
Reference:9. Cardiovascular Disease and Risk Management: Standards of Medical Care in Diabetes—2018.
American Diabetes Association. Diabetes Care 2018 Jan; 41(Supplement 1): S86-S104

9. Lipid Management

10. Lifestyle Intervention
Lifestyle modification focusing on weight loss (if indicated)
Reduction of saturated fat, trans fat, and cholesterol intake
Increase of dietary n-3 fatty acids, viscous fiber,and plant stanols/sterols intake
Increase physical activity
Intensify lifestyle therapy and optimize glycemic control for patients with
elevated triglyceride levels (>150 mg/dL)
and/or
low HDL cholesterol (< 40 mg/dL for men, <50 mg/dL for women)
Reference:9. Cardiovascular Disease and Risk Management: Standards of Medical Care in Diabetes—2018.
American Diabetes Association. Diabetes Care 2018 Jan; 41(Supplement 1): S86-S104

11. 1. Age
2. ASCVD
(Atherosclerotic CV Disease)
Reference:9. Cardiovascular Disease and Risk Management: Standards of Medical Care in Diabetes—2018.
American Diabetes Association. Diabetes Care 2018 Jan; 41(Supplement 1): S86-S104

12. 1. Age
40
2. ASCVD
Yes
High-
Intensity
Statin
Add ezetimibe or
PCSK9 inhibitor
If LDL ≥70 mg/dL
despite max. dose
Reference:9. Cardiovascular Disease and Risk Management: Standards of Medical Care in Diabetes—2018.
American Diabetes Association. Diabetes Care 2018 Jan; 41(Supplement 1): S86-S104
No
Moderate,
High if
ASCVD risk(+)
No,
Moderate if
ASCVD risk(+)

13. Intensity of Statin Therapy
Reference:9. Cardiovascular Disease and Risk Management: Standards of Medical Care in Diabetes—2018.
American Diabetes Association. Diabetes Care 2018 Jan; 41(Supplement 1): S86-S104

14. Lipid Profile Monitoring
If no medication given: Every 5 Years
If starting or changing dose/regimen: 4-12 weeks
If fasting triglyceride levels ≥500 mg/dL, evaluate for secondary causes of
hypertriglyceridemia and consider medical therapy to reduce the risk of
pancreatitis.
Reference:9. Cardiovascular Disease and Risk Management: Standards of Medical Care in Diabetes—2018.
American Diabetes Association. Diabetes Care 2018 Jan; 41(Supplement 1): S86-S104

15. Other Drug Combination with Statin?
Statin + Fibrate = No additional Benefit
Statin + Niacin = No additional Benefit
Reference:9. Cardiovascular Disease and Risk Management: Standards of Medical Care in Diabetes—2018.
American Diabetes Association. Diabetes Care 2018 Jan; 41(Supplement 1): S86-S104

16. Antiplatelet Agents

17. 3 Groups
Risk (+)
Primary
Prevention
Age >50 years and
● Family history
● Hypertension
● Dyslipidemia
● Smoking
● Albuminuria
Not at increased
risk of bleeding
Reference:9. Cardiovascular Disease and Risk Management: Standards of Medical Care in Diabetes—2018.
American Diabetes Association. Diabetes Care 2018 Jan; 41(Supplement 1): S86-S104
ASCVD (+)
Secondary
Prevention
Aspirin 75–
162 mg/d
If allergy...
Clopidogrel 75 mg/d
Acute
Coronary
Syndrome
Low dose Aspirin +
P2Y12 inhibitor
for 1 year

18. Coronary Heart Disease

19. Coronary Heart Disease
Q1: Routine screening for asymptomatic patients?
A: Not recommended.
It does not improve outcomes as long as ASCVD risk factors are treated.
Q2: When to consider investigations for coronary artery disease?
A:
● Atypical cardiac symptoms (e.g., unexplained dyspnea, chest discomfort)
● Cerebrovascular Disease: TIA, stroke, or carotid bruits,
● Peripheral arterial disease or claudication
● EKG abnormalities (e.g., Q waves).
Reference:9. Cardiovascular Disease and Risk Management: Standards of Medical Care in Diabetes—2018.
American Diabetes Association. Diabetes Care 2018 Jan; 41(Supplement 1): S86-S104

20. 3 Groups
ASCVD (+)
ACEi or ARB (B)
Empagliflozin (A)
Liraglutide (A)
Canagliflozin (C)
(evidence level)
Reference:9. Cardiovascular Disease and Risk Management: Standards of Medical Care in Diabetes—2018.
American Diabetes Association. Diabetes Care 2018 Jan; 41(Supplement 1): S86-S104
Prior
Myocardial
Infarction
Beta-blocker
for 2 years
Congestive
Heart Failure
Continue metformin
if stable and eGFR
>30 mL/min
Avoid metformin
if unstable or
hospitalized