Vascular Risk Reduction

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    Topics: 

    Recommendations for vascular protection 

    Related: 

    Recommendations for Vascular Protection 

    A1c 

    Usually ≤ 7.0%. See Targets and Priorities page for exceptions. Optimal glycemic control has been shown to significantly reduce major vascular events. See the A1c page for more information. 

     

    Blood Pressure 

    BP target < 130/80 mmHg (threshhold for both treatment and target)

    • Diabetes Canada 2018 guidelines are now harmonized with Hypertension Canada guidelines.
    • Advise patient to have blood pressure checked at least once a year and more often if elevated. 
    • Patients are encouraged to check their blood pressure at home. See Topics Catalogue: Vascular Risk for patient resources. 
    • ACE (angiotensin converting enzyme) inhibitors and ARBs (angiotensin receptor blockers) are first line treatment for hypertension in those patients who have diabetes, known cardiovascular disease (CVD) and/or renal disease (including increased urinary albumin excretion). 
    • ACE inhibitors, ARBs, dihydropyridine CCBs (calcium channel blockers) or thiazide/thiazide-like diuretic medications may be used as first line treatment for hypertention in those patients who have diabetes without known CVD or renal complications. 
    • Multiple antihypertensive medications may be required to achieve target. 

     

    Cholesterol 

     The lipid panel consists of TC (Total Cholesterol), LDL-C, HDL-C, Triglycerides and non-HDL-C. Apo-B requires a separate order. Diabetes Canada Clinical Practice Guidelines suggest that people with diabetes have lipids tested every 1-3 years or more often based on cardiovascular risk. Lipids can be checked at the lab in a non-fasting state if no known TG abnormalities. 

    Cholesterol is essential to body function as it forms membranes for cell walls, is used to make horomones and forms bile acids. A small amount of cholesterol moves through the body through lipoproteins (LDL, HDL, VLDL). Lipoproteins are comprised of cholesterol, triglycerides, protein and phospholipid molecules. 

     

      Definition Target for Diabetes Treatment

    Cholesterol or TC 

     

     Cholesterol or Total Cholesterol: The sum of all cholesterol

     

    No set target

     

     

                                                                                                                                    

    LDL-C

     

     Low Density Lipoprotein

     Sometimes called 'bad' or 'lousy' cholesterol

    Contributes to atherosclerosis at high levels

     < 2.0 mmol/L or > 50% reduction from baseline

    (Some physicians are not using LDL targets alone and are assigning medications based on CV risk factors present) 

    • Medications:
      • Statin medications are first line treatment for elevated LDL-C. 
      • If LDL-C not at target despite statin, combination therapy with second line medication such as ezetimibe (cholesterol absorption inhibitor), may be needed. See Diabetes Canada, Dyslipidemia (Chapter 25) for list of second line medications. 
    • Nutrition:
      • Diet low in saturated fat and high in soluble fibre such as psyllium has been shown to lower LDL-C. See Nutrition page for more details. 

    apo-B

     

     Apolipoprotein-B is the main protein component of the atherogenic lipids -LDL, VLDL (Very Low Density Lipoprotein) and IDL (Intermediate Density Lipoprotein)

    Useful to measure when TG is elevated (>4.5 mmol/L) as LDL cannot be calculated 

     < 0.8 g/L

     

    •  See LDL-C 

     

    HDL-C

     

     High Density Lipoprotein 

    Somtimes called 'good' or 'healthy' cholesterol 

    Carries excess cholesterol to the liver for disposal

    Considered when looking at overall CV risk but not a target of therapy

     No specified target (Generally >1.0mmol/L considered optimial but not a target of therapy)

     

     

    non-HDL 

     

     Measures cholesterol in all atherogenic lipoproteins

     Useful to measure when TG is elevated (>4.5 mmol/L) as LDL cannot be calculated

     < 2.6 mmol/L

     

    •  See LDL-C

     

    TC/HDL-C Ratio

     

     Total cholesterol divided by HDL-C. A traditional risk marker that  is often high when HDL-C is low and TG are high (typical in diabetes population)

    Considered when looking at overall CV risk but not a target of therapy.

     

     No specified target (Generally >4 is considered elevated but not a target of therapy) 

     

    •  Lifestyle measures that raise HDL-C and lower TG will reduce overall TC/HDL-C ratio (exercise, healthy eating, weight loss) 

     

    TG

     

     Triglycerides

    A form of fat that is an important energy source for the body. Usually stored in adipose tissue, TG's will be found in the blood as they move from storage to replenish cells in the body. 

     

     Not a target for CV risk reduction but <1.5 mmol/L considered optimal

     

    • Glycemic control 
    • Weight loss 
    • Healthy nutrition (see Nutrition page)
    • Avoid or reduce alcohol 
    • Medications:
      • Fibrate medication should be initiated for TG > 10mmol/L
    • TG > 6 mmol/L - recommend dietitian assessment as can rise rapidly 
    • TG > 10 mmol/L - counsel on signs and symptoms of panreatitis (abdominal pain, nausea, fever) and to seek emergency medical care if present

     

    Drugs to Protect 

    Diabetes Canada's Reducing Vascular Risk tool (link available on our Topics Catalogue) helps the clinician decide if vascular protective medication is required. 

    The interactive tool is based on the following algorithm: 

     vascular algorithm

    Image Courtesy  :  Diabetes Canada Clinical Practice Guidelines Expert Committee. Diabetes Canada 2018 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada. Can J Diabetes. 2018;42(Suppl 1):S1-S325. Accessed July 2018.

     Exercise and Healthy Eating 

    Physical activity and healthy nutrition have both been shown to reduce risk for major adverse cardiovascular events. See our Physical Activity page and Nutrition page for more details. 

     

     Smoking Cessation 

     Smoking cessation is very important for overall health and reducing risk of cardiovascular disease. See the Topics Catalogue: Smoking Cessation for list of resources along with our Smoking Cessation page for more details. 

     

    References: 

    Diabetes Canada Clinical Practice Guidelines Expert Committee. Diabetes Canada 2018 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada. Can J Diabetes. 2018;42(Suppl 1):S1-S325. Accessed July 2018.

    2016 Canadian Cardiovascular Society Guidelines for the Management of Dyslipidemia for the Prevention of Cardiovascular Disease in the Adult. Can J Cardiology. 2016; 32 (11) : 1263-1282.