Welcome to the Clinical Review/Specialty Care. It consists of five unique case studies. After reading through each, you will have the opportunity to answer several questions about your treatment of each patient.
Read the Introduction below, then click on “Case Study 1” either from the link at the bottom of the page or from the menu above to get started.
Atherosclerotic cardiovascular disease (ASCVD) remains the leading cause of morbidity and mortality worldwide1. ASCVD is also the leading cause of morbidity and mortality for individuals with diabetes. ASCVD alone results in an estimated $37.3 billion in cardiovascular-related spending per year associated with diabetes in the United States alone2.
Type 2 diabetes common comorbidities that are concomitant with Type 2 diabetes mellitus (T2DM) such as hypertension and dyslipidemia are clear risk factors for ASCVD. At the same time, diabetes itself carries independent risk for ASCVD2. A significant number of patients under care for cardiovascular conditions have diagnosed T2DM, undiagnosed diabetes or pre-diabetes3.
About 12% of U.S. adults have diabetes, 90% to 95% of them have T2DM. More than one-third of U.S. adults, about 80 million individuals, have prediabetes and are at risk of developing T2DM1. On a global scale, about 60 million Europeans are thought to have T2DM, half of them undiagnosed, as does about 10% of the population of countries such as India and China, which are embracing increasingly Westernized lifestyles.
The cumulative result is an estimate of more than 600 million individuals with T2DM worldwide by 2045 and another 600 million developing pre-diabetes4.
Multiple randomized controlled clinical trials have shown that lowering individual CVD risk factors can slow or prevent ASCVD in individuals with diabetes. Addressing multiple risk factors simultaneously confers even larger benefits2.
For patients with T2DM, comprehensive risk factor management reduces events and improves survival. Useful approaches include encouraging healthy eating, regular physical activity, weight loss if needed, blood pressure management, reduction of blood lipids when necessary and guideline-based use of antiplatelet agents3.
There is substantial evidence that the current approach of aggressive risk factor modification in patients with diabetes has significantly improved measures of 10-year coronary heart disease risk among U.S. adults with diabetes over the past decade and that ASCVD morbidity and mortality have decreased in this population2.
Heart failure (HF) is another major cause of morbidity and mortality from CVD, particularly for individuals with diabetes. Rates of incident heart failure hospitalization are twofold higher in patients with diabetes compared to those without diabetes after adjustment for age and sexx. Those with diabetes may have heart failure with preserved ejection fraction (HFpEF) or with reduced ejection fraction (HFrEF)2.
Hypertension is often a precursor of heart failure of both types, and ASCVD can coexist with either HFpEF or HFrEF. Myocardial infarction (MI), by contrast, is often a major factor in HFrEF22.
Major trials have shown treatment with sodium-glucose cotransporter 2 (SGLT2) inhibitors can significantly decrease rates of heart failure hospitalization in patients with T2DM, most of whom also had ASCVD2. These same trials have also shown that the SGLT-2 inhibitors are renoprotective.
Cardiovascular risk factors should be systematically assessed at least annually in all patients with diabetes for the prevention and management of both ASCVD and heart failure. The most common risk factors include obesity or overweight/obesity, hypertension, dyslipidemia, smoking, a family history of premature coronary disease, chronic kidney disease and the presence of albuminuria2.
Hypertension, defined as sustained blood pressure ≥130/90 mmHg, is commonly seen in patients with any type of diabetes and is a major risk factor for both ASCVD and microvascular complications of diabetes. Blood pressure targets can be adjusted for individual factors.
In general, individuals at higher cardiovascular risk, a blood pressure target of <130/80 mmHg may be appropriate if it can be attained safely. For individuals at lower risk for CVD, a target of <140/80 mmHg may be appropriate2.
For individuals with blood pressure >120/80 mmHg, lifestyle management is an important component of treatment. If overweight/obese, weight loss through calorie restriction is appropriate. A diet emphasizing intake of vegetables, fruits, legumes, nuts, whole grains and fish, and minimizing the intake of processed meats, refined carbohydrates and sweetened beverages is recommended to decrease ASCVD risk factors.
Between 20%-40% of individuals with diabetes will progress to diabetic kidney disease. Chronic kidney disease (CKD) typically takes about 10 years to develop in Type 1 diabetes but may be present at diagnosis for T2DM. Having CKD increases cardiovascular risk and health care costs for all types of diabetes6. Most people with advanced CKD die from CVD, not from CKD. CKD is also the leading cause of end-stage renal disease in the United States, which requires dialysis or kidney transplantation6.
CKD is diagnosed by the continuing presence of albuminuria, low estimated glomerular filtration rate (eGFR) or other evidence of kidney damage. SGLT2 inhibitors and glucagon-like peptide 1 receptor agonists (GLP1-RAs) have been shown to reduce the risk of CKD progression, cardiovascular events or both6.
Best practices for the treatment of diabetes and associated comorbidities includes building relationships between the patient and the care team. A patient-centered approach that uses active listening, focuses on patient preferences and beliefs and assesses potential barriers to care can improve patient outcomes and quality of life related to health. Individuals with diabetes should be encouraged to take an active role in their care with shared decision-making7.
The patient, care partner and an interdisciplinary health care team should formulate a diabetes management and care plan designed to prevent or delay comorbidities and maintain quality of life. The care team can include primary care providers, specialists such as cardiology, nephrology or endocrinology as appropriate, nurses, diabetes educators, dietitians, exercise specialists, pharmacists, dentists, podiatrists, mental health specialists and other providers as needed7.
Health care providers should provide a referral to a Diabetes Self-Management Education and Support (DSME/S) program for newly diagnosed diabetes patients, annual assessment, new complication factors (physicial, health status, emotional or basic living) and when transitions in care occur. These programs with the support of a Certified Diabetes Educator provide the foundation to help people with diabetes to navigate these decisions and activities and has been shown to improve health outcomes8.
DSME/S has been shown to be cost-effective by reducing hospital admissions and readmissions as well as estimated lifetime health care costs related to a lower risk for complications8. Medicare and most insurance plans cover the cost of DSME/S.
The risks of ASCVD and heart failure, CKD and other complications together with assessment of other acute and chronic complications can be used to individualize targets for glycemic management as well as blood pressure and lipids. Those same factors can be used to select the most appropriate lifestyle modifications and, as needed, pharmacologic interventions7. Aggressive risk factor modification using strategies that affect multiple risks simultaneously is more effective than managing individual risk factors2.