Cardiometabolic Corner:
Your Go-To Resource For All Things Prevention

Cardiovascular Protection in Diabetes

Type 2 Diabetes

Diagnosis Criteria:

  1. Fasting BG ≥ 7mmol/L

  2. A1C>6.5%

  3. 2 Hour Plasma Glucose 75g challenge BG>11mmol/L

  4. Random BG>11mmol/L

If hyperglycemic symptoms are present, one test is sufficient for diagnosis; otherwise, a repeat test is needed to confirm. If asymptomatic and high random BG, do an alternate test. 

Prediabetes

  1. Fasting BG 6.1-6.9 mmol/L

  2. A1C 6%-6.4%

  3. 2 Hour Plasma Glucose 75g challenge BG 7.8-11mmol/L

Source: Diabetes Canada

Approach To Reducing Cardiovascular Risk/Major Adverse Cardiovascular Events (MACE)

ABCES Approach

A: A1c

Glucose control - HbA1c<7%

B: BP 

Blood pressure control - BP < 130/80 mmHg

C: Cholesterol

LDL<2

D: Drugs

ACE/ARB: Rx if a) Clinical CVD, b) Age ≥55 + 1 other cardiovascular risk factor, or c) microvascular complications 

Statins: Rx if a) Clinical CVD,  b) Age≥40 c) >15y duration of DM and age>30y d) microvascular complications or e) Presence of other cardiovascular risk factors. 

Cardioprotective Antiglycemics: SGLT2i (Empagloflozin, Canagliflozin) & GLP-1 Agonist (Liraglutide)

E: Exercise and Eating

S: Smoking and Stress Management

Cardiovascular Protection in Hypertension

Definition: BP>130/80 mmHg in validated measurement conditions in adults. Must be consistent between home and office readings. 

BP at home high, in office normal → Masked HTN

BP at home normal, in office high → White coat HTN

Who to treat with medication: 

1- BP >140/90 mmHg → always treat

2- SBP range 130-139 mmHg when Cardiovascular risk factors present(CAD/CVA/PAD, DM, CKD GFR<60, Age>75, 10 year Framingham risk score >20%)

How to Treat?

Lifestyle Changes

Regular Exercise, emphasis on dynamic aerobic exercise

Diet: 

  • Restricting Sodium <2g/day (Quick Trick: Tell patients when they shop at the supermarket is to avoid food labels where sodium>number of calories. Assuming they eat around 2000 Kcal per day, they would be effectively following the <2g sodium)

  • Increased Potassium Intake (in the absence of CKD or meds such as ACE/ARB/MRA)

  • Weight loss 

Alcohol and Smoking Cessation 

Pharmacotherapy

  • Treatment target: SBP<130mmHg

  • Medication Classes: 

  • ACE/ARB

  • Thiazide/Thiazide-like diuretics

  • Dihydropyridine Calcium Channel Blockers

  • MRA

  • Beta Blockers

  • Other meds: Alpha blockers, central agents, non-DHP CCBs

  • Prefer early use of combination therapy for better BP control and adherence (e.g. irbesartan/HCTZ)

  • Select agents also based on patient comorbidities (e.g., CKD, diabetes, coronary disease), contraindications (e.g., pregnancy) and cost/access.

Cardiovascular Protection in Dyslipidemia

Who to screen: Age>40 or younger if risk factors (HTN, CKD, obesity, family history of premature CVD, smoking, or inflammatory conditions) 

Who to Treat with Medication

Primary prevention (no known Atherosclerotic cardiovascular disease):

  1. LDL-C ≥ 5.0 mmol/L → treat (likely familial hypercholesterolemia)

  2. Intermediate or high cardiovascular risk (Framingham ≥10–20%) → treat if:

  • LDL-C ≥ 3.5 mmol/L

  • non-HDL-C ≥ 4.2 mmol/L

  • ApoB ≥ 1.05 g/L

  1. Statin-indicated conditions (treat regardless of LDL):

  • Diabetes (age ≥40 yrs or >15 yrs duration)

  • CKD (eGFR <60)

  • AAA

  • Clinical evidence of atherosclerosis (CAD, stroke, PAD)

Secondary prevention (known ASCVD): Always treat to lower LDL-C / non-HDL-C / ApoB as much as tolerated.

Source: CCS Guidelines

How To Treat?

Lifestyle Modifications

  • Diet: Mediterranean or DASH-style diet. Reduce saturated fats, processed foods, and trans fats. Increase fruits, vegetables, fibre, whole grains, fish, and plant oils

  • Exercise: At least 150 min/week, favoring moderate-intensity aerobic activity

  • Weight management: Aim for BMI <25 kg/m² or ≥5% weight loss

  • Smoking cessation and limiting alcohol

Pharmacotherapy

First-line Statins

Add-on / Intensification (if LDL not at goal):

  • Ezetimibe: add if LDL remains high despite maximally tolerated statin

  • PCSK9 inhibitors for very high-risk patients or statin-intolerant patients

  • Icosapent ethyl for patients with TG 1.5–5.6 mmol/L and existing CVD or diabetes + risk factors

Impress your attendings by knowing these studies:

  • PROVE IT: Intensive lipid lowering with high-dose atorvastatin (high-intensity statin) > moderate-dose pravastatin

  • IMPROVE IT: Further LDL-C lowering beyond standard statin therapy using non-statin agents like ezetimibe provides incremental CV benefits

  • FOURIER: PCSK9 inhibitors improved CV outcomes in patients with established ASCVD who were already receiving statin therapy

  • ODYSSEY OUTCOMES: PCSK9 inhibitors reduced the time to first occurrence of MACE in patients with recent ACS who were already receiving high-intensity or maximum-tolerated statins