Journal of Cardiovascular Nursing
Vol. 31, No. 3, pp 198Y200 x Copyright B 2016 Wolters Kluwer Health, Inc. All rights reserved.
Progress in Prevention
Preventing Cardiovascular Disease in Patients
With Diabetes
New Evidence Informs Changes in Standards of Care
Jane Nelson Worel, MS, RN, ANP-BC, FAHA, FPCNA; Laura L. Hayman, PhD, RN, FAAN, FAHA
C ardiovascular disease (CVD)
is the leading cause of morbid-
ity and mortality for individuals
with diabetes. At least 68% of
adults 65 years or older with diabe-
tes die of some form of CVD,
whereas 16% die of stroke. Adults
with diabetes are 2 to 4 times more
likely to have heart disease or stroke
than adults without diabetes.1 Hy-
pertension and dyslipidemia are
major risk factors for CVD, and
they commonly coexist in people
with diabetes.2 An added concern is
that diabetes itself is independently
associated with increased CVD
risk.3 A number of large clinical
trials have demonstrated the ben-
efits of controlling hypertension or
dyslipidemia in preventing and
slowing CVD in adults with dia-
Jane Nelson Worel, MS, RN, ANP-BC,
FAHA, FPCNA
Nurse Practitioner, Phases Primary Care for
Women, Madison, Wisconsin.
Laura L. Hayman, PhD, RN, FAAN,
FAHA
Associate Vice-Provost for Research and
Professor of Nursing, College of Nursing
and Health Sciences, University of
Massachusetts Boston.
The authors have no funding or conflicts of
interest to disclose.
Correspondence
Jane Nelson Worel, MS, RN, ANP-BC,
FAHA, FPCNA, Phases Primary Care for
Women, 2955 Triverton Pike Dr,
Madison, WI 53711
(jnworel@mscwomenshealth.com).
DOI: 10.1097/JCN.0000000000000333
198
Copyright 2016 Wolters Kluwer Health, Inc. All rights reserved.
betes. The global management of
multiple CVD risk factors yields
even greater results.2
An estimated 70% to 80% of
people with diabetes are also hy-
pertensive. The presence of hyper-
tension in this population increases
the risk of myocardial infarction
(MI), stroke, heart failure, nephrop-
athy, and all-cause mortality.3 Ep-
idemiological studies show that
blood pressure (BP) readings greater
than 115/75 mm Hg are associated
with increased CVD events and
mortality. Given the relationship
between lower BP and better long-
term clinical outcomes, 2 landmark
trials, Action to Control Cardiovas-
cular Risk in Diabetes (ACCORD)4
and Action in Diabetes and Vascular
Disease: Preterax and Diamicron
MR Controlled EvaluationVBlood
Pressure,5 were conducted to evalu-
ate the clinical benefit of achieving
tight BP control in those with type
2 diabetes mellitus (DM2).
The ACCORD trial assessed
whether a systolic BP of less than
120 mm Hg provided greater CVD
risk reduction compared with the
accepted systolic BP goal of 130 to
140 mm Hg. The findings showed
no additional benefit in achieving
the more aggressive target; yet, there
were increased costs and more
adverse events associated with the
use of more medications at higher
doses.4 In the Action in Diabetes
and Vascular Disease: Preterax
and Diamicron MR Controlled
EvaluationVBlood Pressure trial,
there was a significant CVD pre-
vention benefitVfewer major CVD
events and fewer deaths attrib-
uted to CVD as well as all cause
mortalityVin those who were ran-
domized to the treatment arm and
given a fixed-dose combination of
angiotensin converting enzyme in-
hibitor (perindopril) and thiazide
diuretic (indapamide). The base-
line BP among study subjects was
145/81 mm Hg. The treatment
arm achieved an average BP of
136/73 mm Hg, not nearly as low
or aggressive as those achieved in
the ACCORD trial, but with fewer
side effects and less cost.5
These trials, taken together with
previous epidemiologic observa-
tional studies, have resulted in
slightly higher thresholds for treat-
ment in patients with diabetes. The
2015 American Diabetes Associa-
tion (ADA) Standards for Medical
Care in Diabetes amended their
recommended BP threshold to
140/90 mm Hg, up from previous
recommendation of 130/80 mm Hg.
They do state, however, that lower
treatment targets may be appropri-
ate for individuals who are at high
risk for stroke or chronic kidney
disease or younger patients who can

easily achieve lower BP levels with-
out undue treatment burden.2
Patients with DM2 have an in-
creased prevalence of lipid abnor-
malities, contributing to their high
risk of CVD. Subgroup analysis of
diabetic patients within large clin-
ical trials and trials in patients with
diabetes showed significant reduc-
tions in incident and recurrent
cardiovascular events and CVD-
related mortality. Meta-analyses
including data from over 18 000
patients with diabetes from 14 ran-
domized trials of statin therapy
demonstrate a 9% proportional re-
duction in all-cause mortality and
13% reduction in vascular mortal-
ity for each mmol/L reduction in
low-density lipoprotein cholesterol
(LDL-C). Statins are the drug of
choice for LDL-C lowering and
cardio-protection.2
Most trials of statins and CVD
outcomes tested specific doses of
statins against placebo or other
statins rather than aiming for spe-
cific LDL-C targets. With consid-
eration of the conduct and
outcomes of these trials, the 2015
ADA Standards of Care were re-
vised to recommend when to initi-
ate and intensify statin therapy
based on a patients risk level
(Table 1).2 The standards recom-
mend screening lipid panels at the
time of diagnosis of diabetes and
at least annually thereafter mainly
to evaluate for adherence to med-
ication therapy.
Hypertriglyceridemia and low
cardio-protective high-density li-
TABLE 1
Recommendations for Statin Therapy in Adults With
Diabetes (Type 2 Diabetes Mellitus)
Age Risk Factor Profile
G40 y None
CVD risk factor(s)
Known CVD
40Y75 y None
CVD risk factors
Overt CVD
975 y None
CVD risk factors
Overt CVD
Abbreviation: CVD, cardiovascular disease.
Copyright 2016 Wolters Kluwer Health, Inc. All rights reserved.
Preventing CVD in Patients With Diabetes 199
poprotein cholesterol (HDL-C) are
the most prevalent pattern of dys-
lipidemia in persons with DM2.
The evidence base for medications
that target these lipid particles is
much less robust than that for statin
therapy. The ADA standards recom-
mend dietary and lifestyle modifica-
tions as first line of management of
hypertriglyceridemia, unless the
triglyceride level is greater than
1000 mg/dL, in which case imme-
diate pharmacologic therapy with
omega-3 fatty acids or fibric acid
derivatives may reduce the risk of
acute pancreatitis.2 In a large clini-
cal trial specific to diabetic patients,
fenofibrate showed no benefit for
CVD risk reduction. In the AC-
CORD study, combination therapy
with simvastatin and fenofibrate
showed no added CVD risk reduc-
tion benefit when compared with
simvastatin alone.6
The Atherothrombosis Interven-
tion in Metabolic Syndrome With
Low HDL/High Triglycerides: Im-
pact on Global Health Outcomes
trial evaluated the benefit of statin
plus extended-release niacin in pa-
tients with established CVD, low
LDL-C and HDL-C levels, and high
triglyceride levels; about a third of
the study population were also
diabetic. The trial was halted early
because of lack of efficacy in rela-
tion to the primary CVD outcome
(death from coronary heart disease,
nonfatal MI, ischemic stroke, hos-
pitalization for acute coronary syn-
drome, or revascularization) and a
possible increase in ischemic stroke
Statin Dose
None
Moderate or high
High
Moderate
High
High
Moderate
Moderate or high
High
risk in those on combination ther-
apy.7 Combination therapy with
niacin is therefore not recommended.
The ADA standards suggest that the
use of niacin and fibric acid deriva-
tives may be limited to patients with
hypertriglyceridemia and low HDL-C
levels who are intolerant of statins.2
Lifestyle intervention including
dietary changes, increased physical
activity, weight loss, and smoking
cessation, together with medica-
tion management, is helpful in
managing many CVD risk factors,
including hypertension and dyslip-
idemia. Nutrition intervention
should be individualized with a gen-
eral focus on reducing saturated fat,
cholesterol, and trans-fat intake
while increasing omega-3 fatty
acids and viscous fiber. Glycemic
control can also help to improve
plasma lipid levels, particularly in
patients with very high triglyceride
levels and poor glycemic control.2
Lifestyle interventions targeting
weight loss through decreased ca-
loric intake and increased physical
activity as implemented in the Ac-
tion for Health in Diabetes (Look
AHEAD) trial may be considered
for improving glucose control, fit-
ness, and some CVD risk factors.
However, the trial was stopped early
on the basis of a futility analysis that
demonstrated no reduction in the
rate of CVD events in overweight
or obese adults with DM2 as a res-
ult of intensive lifestyle intervention.8
One explanation of these findings
is that those with improved CVD
risk factor profiles stopped taking
known cardioprotective therapies
such as statins for dyslipidemia.3
Thus, it is reassuring to know that
there was no increase in CVD events
in those who were able to control
risk factors with accepted lifestyle
changes.
Antiplatelet therapy with aspi-
rin has been shown to be effective
in reducing CVD morbidity and
mortality in high-risk patients with
previous MI or stroke (secondary
prevention). It is less clear whether
aspirin is helpful in people without
200 Journal of Cardiovascular Nursing x May/June 2016
CVD, including those with diabetes
(primary prevention). Two random-
ized controlled trials that specifi-
cally looked at aspirin use in adults
with diabetes, failed to show a sig-
nificant reduction in CVD end
points. The Antithrombotic Trialists
collaborators published a meta-
analysis of 6 large trials of aspirin
for primary prevention in the gen-
eral population. Of the 95 000 par-
ticipants included in this analysis,
approximately 4000 were diabetic.
The effects of aspirin on major vas-
cular events (MI and stroke) were
similar for patients with or without
diabetes: relative risk of 0.88 (95%
confidence interval, 0.67Y1.15)
and 0.87 (95% confidence interval,
0.79Y0.96), respectively.9 Aspirin
seems to have a modest effect on
CVD event reduction, with the
greatest benefit for those with the
highest CVD risk. The benefit of
aspirin use must be evaluated in
context with the risk of gastroin-
testinal bleeding. The ADA there-
fore suggests that aspirin therapy
(75Y162 mg/d) may be considered
as a primary prevention strategy in
those with type 1 diabetes or DM2
at increased CVD risk (10-year risk
of CVD events 910%). This includes
most men older than 50 years and
women older than 60 years who
have at least 1 additional major
CVD risk factor (hypertension, dys-
lipidemia, smoking).2
In 2011 to 2012, the estimated
prevalence of diabetes was 12% to
14% among US adults. Between
1988Y1994 and 2011Y2012, the
Copyright 2016 Wolters Kluwer Health, Inc. All rights reserved.
prevalence of diabetes increased in
the overall population and in all
subgroups evaluated.10 Given these
growing numbers and the strong
association between diabetes and
CVD risk, it is imperative that we
adopt an all hands on deck men-
tality when it comes to management
of diabetes and its coexisting meta-
bolic CVD risk factors. Nurse-led
diabetes self-management programs
have demonstrated benefit with re-
gard to improved glycemic control
and reduction in CVD risk factors.11
These programs should be used
and expanded to meet the growing
demand. Healthcare providers in
all community, primary and cardio-
vascular care settings must be em-
powered to screen and treat CVD
risk factors in people with diabetes
with current, evidenced-based life-
style and pharmacologic interventions
to reduce risk and prevent disease.
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