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Heart Disease

• HbA1c
• Blood Pressure
• Microalbuminuria
• Smoking Status
• Body Weight
• Activity Level
• Current or previous Cardiovascular Risk History
• Fasting lipid profile (total cholesterol, LDL, HDL, triglyceride)
• Use of coronary risk prediction charts is not recommended for patients with diabetes as they are already at increased risk

• Cardiovascular disease is a major cause of illness and death in people with type 1 and type 2 diabetes

• Patients with diabetes have a 2 to 4 fold increased risk of developing cardiovascular disease compared with those without diabetes

• Patients with diabetes are more likely to have other risk factors for cardiovascular disease, including hypertension (high blood pressure) and abnormal lipids (cholesterol) with high LDL ('bad') cholesterol, high triglycerides and low HDL ('good') cholesterol

• 15-20% of people with type 2 diabetes will have evidence of cardiovascular disease at diagnosis

• Recent evidence suggests that people with type 2 diabetes have the same cardiovascular risk as non-diabetic people with previous cardiovascular disease

• Patients over 40 with type 1 diabetes and even microscopic traces of protein in the urine, or a family history of early heart trouble have an even higher risk of cardiovascular disease

• Therefore assessment, identification and treatment of these modifiable risk factors is essential to prevent cardiovascular disease in patients with diabetes

Cardiovascular Risk Rationale for Treatment

• Many studies have shown that reducing LDL cholesterol, raising HDL cholesterol and lowering triglycerides reduces the risk of cardiovascular disease in patients with Diabetes
• Patients with Type 2 Diabetes aged >18 and with Type 1 Diabetes >40years, or with microalbuminuria should be treated with a statin (and Aspirin), unless contemplating pregnancy.
• Patients aged 18-40 with Type 1 diabetes should have statin (and aspirin) if they have any increase from background risk ( a family history of early CVD,smoking) , or diabetes > 10 years.
• Statins (Simvastatin) are first line treatment for dyslipidaemia in patient with Diabetes
• Fibrates, nicotinic acid and/or Omega-3 fish oils (Omacor) should be considered to raise HDL and lower triglyceride
• To view the algorithm related to Lipid please click on the following link (lipid pathway)
• See British National Formulary and BCAPJoint Formulary for specific guidance on prescribing

Blood Pressure Control

• Up to 70% of people with type 2 diabetes have hypertension (high blood pressure)
• Each 10mmHg rise in systolic blood pressure increases the risk of myocardial infarction (heart attack) by 11%
• Tight blood pressure control In type 1 and type 2 diabetes is associated with a decreased risk of cardiovascular disease
• A reduction in systolic blood pressure of 5–10 mmHg can reduce the risk of cardiovascular events by 20-30%

Type 1 Diabetes

• Target BP < 130/80
• Type 1 diabetes with microalbuminuria or established nephropathy
• Target BP < 120/70

Type 2 Diabetes

• Target BP < 130/80

Treatment of Hypertension (High Blood Pressure)

• An angiotensin-converting enzyme (ACE) inhibitor or angiotensin-receptor blocker (ARB) should be the first choice anti-hypertensive in a patient with diabetes
• Then add a Calium channel blocker
• Thereafter other anti-hypertensives to consider include diurectics including spironolactone, doxazocin, moxonidine
• Titrate monthly to achieve target blood pressure
• Most people will require at least two anti-hypertensive drugs to achieve recommended BP targets
• See British National Formulary and BCAP Joint Formulary for specific guidance on prescribing

Targets for lipid treatment:

• Total cholesterol < 4mmol/l
• LDL cholesterol < 2 mmol/l
• HDL cholesterol > 1.0 (male) and > 1.3 (female)
• Fasting triglyceride < 1.7 mmol/l

Aspirin

• Aspirin reduces the risk of cardiovascular events especially in patients with known ischaemic heart disease by25 %.In  patients without proven ischaemic heart disease the reduction is about 12%. 
• Recent studies (small numbers of patients and short duration) have suggested less benefit in patients without proven cardiovascular disease.The  ASCEND study is presently looking at tthe effect of low dose aspirinin this group of patients, as well as omega oils. It has already recruited and a result is expected in 2011. For further details, please  go to the ASCEND website : www.ctsu.ox.ac.uk/ascend/index.htm 
• There can be no consensus at the present time, so each patient should be considered individually. Those patients with the most to gain also have the highest risk of GI bleeds. The Diabetes team suggest the following approach :
•  Primary prevention: over 50, smoker, treated for hypertension and high cholesterol: yes if no mild counterindications
• Under 50 with all factors and FH: yes from age 40 if no mild counterindications
• Under 50: no
• Over 50 non-smoker only DM: no
• Over 50 treated for hypertension, and high cholesterol: probably yes if no mild counterindications.

 Smoking

• All patients should be advised to stop smoking  
• For help go to life style issues  

Lifestyle Advice

Patients who are overweight should be encouraged to lose weight

• Patients should be encouraged to increase physical activity to 30 mins daily

Referral to Diabetes Service

Consider referral for further management:

• Poor glycaemic control with cardiovascular risk factors
• Uncontrolled hypertension
• Abnormal lipid profile despite statin therapy
• New or known coronary artery disease:
  • Angina
  • Coronary Artery By Pass
  • Balloon angioplasty or coronary artery stent
• Stroke or TIA
• PVD:
  • Intermittent claudication
  • Absence of foot pulses

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This work has been completed with the support of Lilly UK through an educational grant, which includes permission to use the basic IT structure and design of the website and the provision of Project Management training to the project team.