9  Diabetes Mellitus

Cardiovascular Risk Reduction in Type 2 Diabetes Mellitus Guidelines and Consensus Recommendations

9.1 Guideline Recommendations

Source: (Kelsey et al. 2022)

9.1.1 Risk assessment

ACC/AHA ADA AACE/ACE ESC/EASD USPSTF KDIGO
Risk assessment method Pooled Cohort Equation and diabetes-specific risk enhancers Pooled Cohort Equation and diabetes-specific risk enhancers Framingham Risk Assessment Tool and risk factors Moderate, high, very high risk Pooled Cohort Equation No recommendation

9.1.2 Lifestyle modifications

ACC/AHA ADA AACE/ACE ESC/EASD USPSTF KDIGO
Exercise 150 min of moderate-intensity activity per week 150 min of moderate-intensity activity per week 150 min of moderate-intensity activity per week 150 min of moderate-intensity activity per week No specific recommendation 150 min of moderate-intensity activity per week
Diet Individualized nutrition assessment; Mediterranean Diet Individualized nutrition assessment; Mediterranean Diet Individualized nutrition assessment; Mediterranean Diet Individualized nutrition assessment; Mediterranean Diet No specific recommendation Individualized nutrition assessment; Mediterranean Diet, 0.8 g protein/day if CKD
Vitamin use No recommendation No recommendation No recommendation Avoid vitamin supplementation to reduce ASCVD risk in T2DM No recommendation No recommendation

9.1.3 BP management

ACC/AHA ADA AACE/ACE ESC/EASD USPSTF KDIGO
BP target <130/80 mm Hg <130/80 mm Hg if 10-y ASCVD risk ≥15%; <140/90 if 10-y ASCVD risk <15% <130/80 mm Hg <130/80 mm Hg, (but not <120/70 mm Hg), and 130-139 mm Hg in those older than 65 y <120/80 mm Hg only for stroke risk reduction <120/80 mm Hg if concurrent CKD
First-line treatment of hypertension ACE/ARB if albuminuria ACE/ARB if albuminuria ACE/ARB ACE/ARB if albuminuria or LVH No recommendation ACE/ARB if albuminuria
Indication for combination therapy If BP >140/90 mm Hg Dual therapy first line regardless of BP If BP >150/100 mm Hg If BP >160/100 mm Hg No recommendation No recommendation

9.1.4 LDL-C management

ACC/AHA ADA AACE/ACE ESC/EASD USPSTF KDIGO
Primary prevention treatment targets 50% LDL-C lowering for those at high risk 50% LDL-C lowering for those at high risk Numeric goal (LDL-C <55, 70, or 100 mg/dL) Numeric goal (LDL-C <55, 70, or 100 mg/dL) N/A N/A
Primary prevention in young patients Treat if longstanding disease, end-organ damage, risk factors Treat if longstanding disease, end-organ damage, risk factors No recommendation Treat if LDL-C > 100 mg/dL N/A N/A
Secondary prevention treatment targets Goal 50% LDL-C reduction, start meds LDL-C <70 mg/dL Goal 50% LDL-C reduction, start meds at LDL-C <70 mg/dL LDL-C <55 mg/dL LDL-C < 55mg/dL N/A N/A
Secondary prevention second-line therapy Ezetimibe Ezetimibe or PCSK9i No recommendation Ezetimibe N/A N/A

9.1.5 Hyperglycemia Tx

ACC/AHA ADA AACE/ACE ESC/EASD USPSTF KDIGO
First line SGLT2i/GLP-1RA may be beneficial regardless of background metformin SGLT2i/GLP-1RA may be beneficial regardless of background metformin SGLT2i/GLP-1RA may be beneficial regardless of background metformin SGLT2i/GLP-1RA first line No recommendation Metformin and SGLT2i in combination for those with CKD
Relative priority of SGLT2/GLP-1RA SLGT2i >GLP-1RA for HF, renal disease, weight loss SLGT2i >GLP-1RA for HF and renal disease SLGT2i >GLP-1RA for HF and renal disease No specific recommendation No recommendation SGLT2 inhibitor first, GLP-1RA second line

9.1.6 Aspirin recs

ACC/AHA ADA AACE/ACE ESC/EASD USPSTF KDIGO
Primary prevention May be considered if elevated ASCVD risk without increased bleeding risk May be considered if elevated ASCVD risk without increased bleeding risk No recommendation Not in moderate risk, but can be considered in high or very high risk No significant risk reduction with aspirin in individuals with T2DM May be considered if elevated ASCVD risk without increased bleeding risk

9.1.7 CKD

ACC/AHA ADA AACE/ACE ESC/EASD USPSTF KDIGO
Type 2 diabetes treatment SGLT2i SGLT2i, specifically canagliflozin SGLT2i SGLT2i No recommendation SGLT2i