Discussion points. The cardiometabolic connection. Cardiometabolic Risk Management in the Primary Care Setting

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1 Session #5 Cardiometabolic Risk Management in the Primary Care Setting Sonja Reichert, MD MSc FCFP FACPM Betty Harvey, RNEC BScN MScN Amanda Mikalachki, RN BScN CDE S Discussion points Whom should we be targeting? Why should we bother? Delay or prevent progression on to T2DM Reduce or minimize CV risk The cardiometabolic connection UK: Two-thirds of patients had abnormal glucose tolerance on an OGTT (IGT 39%). 1 Sweden: AMI patients: 35% had undiagnosed IGT. Europe: Patients with acute CAD and no previous dysglycemia, 36% had IGT. 1. Onyebuchi E, et al. Diabetes Care. 2008;31(10): ; 2. Norhammar A, et al. Lancet 2002;359: ; 3. Bartnik M, et al. Eur Heart J 2004;25:

2 Whom should we be targeting? Cardiometabolic risk (CMR) refers to the likelihood of developing vascular events or diabetes. Includes traditional risk factors included such as: Hypertension Dyslipidemia Smoking IGT Also includes emerging risk factors, such as: Abdominal obesity Ethnicity Lifestyle factors Adapted from: Leiter LA, et al. CJC. 2011;27 e1 e33 Why primary care? Most patients who at risk for DM and CVD are in need of targeted prevention interventions and will present at an early stage with no symptoms. Primary care settings are ideally suited to: Systematically screen patients Identify those at high risk Intervene to prevent cardiovascular disease and type 2 diabetes Meet Aakar. 49-year-old South Asian man In Canada since 1997 Presents at clinic with concerns about prostate FPG of 6.8 mmol/l 6/12 lost req for 75-g OGTT Family history of diabetes Non-smoker Presents with questions about prostate cancer screening B

3 Cardiometabolic risk assessment Examination and clinical review: WC, BMI, BP, family history, smoking status, activity level, diet If any of these risk factors are present: Known CV risk factor (e.g. elevated BP, dysglycemia, dyslipidemia) Overweight/obese Reached guideline screening threshold Order laboratory tests as appropriate: Glucose screening Fasting lipid profile (TC, HDL-C, LDL-C, TGs) Other investigations if indicated (e.g. renal function, A1C, ECG, exercise stress test, apob, hs- CRP) Leiter LA, et al. Can J Cardiol. 2011;27:e1-e33. Assessment and plan for Aakar Discuss his concerns about prostate Have not seen Aakar in a while, so assess the following: BMI 23.5 kg/m2 Waist circumference 94 cm BP 132/87 mm Hg Ask about his lifestyle Diet: High fat, high salt, high sugar-sweetened beverages intake Physical activity: <30 minutes per day Order PSA and suggest it s a good time to do some routine blood work. Order lipid profile and 75-g OGTT. Ask him to return to discuss lab results Aakar s lab results PSA =1.8 ng/ml Lipids Total cholesterol 4.09 mmol/l LDL-cholesterol 2.32 mmol/l HDL-cholesterol 1.14 mmol/l Triglycerides 1.71 mmol/l 75-g OGTT FPG 5.6 mmol/l 2-h 9.8 mmol/l

4 Follow-up with Aakar The good news You don t need to worry about your prostate right now The bad news You may have prediabetes meaning you are at high risk for developing diabetes. Going to order another test to confirm. You have other risk factors for CVD Calculating Aakar s cardiometabolic risk Absolute CV Risk Calculation Use validated CV risk prediction tool eg. Framingham Risk Score Reynolds Risk Score Adapted from: Leiter LA, et al. CJC. 2011;27 e1 e33 What do we miss in Aakar by using only Framingham? Ethnicity: Aakar is from a high-risk population Family history: Diabetes in the family BMI: Ethnicity may mean he is at higher risk at lower BMI Waist circumference: At the cut-point for this population Dysglycemia: Linear relationship between increasing glucose levels and CVD with no apparent threshold LDL-cholesterol: Linear relationship between LDL levels and outcomes Triglycerides High-risk lifestyle: Low activity levels, poor diet Accounting for metabolic syndrome provides a more accurate estimation of Aakar s cardiometabolic risk Absolute CV Risk Calculation Use validated CV risk prediction tool eg. Framingham Risk Score Reynolds Risk Score Metabolic Syndrome Factor Metabolic syndrome increases absolute risk by a factor of 1.5 to 2 Adapted from: Leiter LA, et al. CJC. 2011;27 e1 e33. Total Cardiometabolic Risk = Absolute CV Risk x 1.5 to 2.0

5 Aakar has metabolic syndrome? Diagnostic criteria BG BP Harmonized definition of metabolic syndrome 3 risk determinants are present FPG 5.6 mmol/l (or receiving treatment of elevated glucose) 130/85 mm Hg (or receiving treatment of previously diagnosed hypertension) TGs 1.7 mmol/l (or receiving treatment) HDL-C <1.0 mmol/l (men) <1.3 mmol/l (women) (or receiving treatment) Abdominal obesity Europids, whites, Sub-Saharan Africans, Mediterranean, and Middle East (Arab) populations: WC 94 cm (men) WC 80 cm (women) Asian (including Japanese), Asian, Chinese, Japanese, ethnic South and Central American populations: WC 90 cm (men) WC 80 cm (women) Canada, US, European populations: WC 102 cm (men) WC 88 cm (women) Alberti KG, et al. Circulation. 2009;120: Absolute CV Risk Calculation Use validated CV risk prediction tool eg. Framingham Risk Score Reynolds Risk Score Metabolic Syndrome Factor Metabolic syndrome increases absolute risk by a factor of 1.5 to 2 Adapted from: Leiter LA, et al. CJC. 2011;27 e1 e33 Total Cardiometabolic Risk = Absolute CV Risk x 1.5 to 2.0 Absolute CV Risk Calculation Use validated CV risk prediction tool eg. Framingham Risk Score Reynolds Risk Score Metabolic Syndrome Factor Metabolic Syndrome increases absolute risk by a factor of 1.5 to 2 Total Cardiometabolic Risk = Absolute CV Risk x 1.5 to 2.0 = Aakar is at moderate risk Adapted from: Leiter LA, et al. CJC. 2011;27 e1 e33

6 Lifestyle Delay or prevent progression to T2DM the evidence Non-Thiazolidinediones DPS 1 Da Qing 2 DPP 3 DPP 3 IDPP 4 IDPP 4 STOP- XENDOS 6 NAVI- NIDDM 5 GATOR 7 Met Met Met + Acarbose Orlistat + NTG lifestyle lifestyle Thiazolidinediones DPP 8 DREAM 10 TRIPOD 9 CANOE Troglitazone Rosi Rosi + met Act Now 11 Pio 42%* 31% 26%* 28%* 25% 37% 36% 58%* 58% 50% 75% 1 Lindström J, et al. J Am Soc Nephrol. 2003;14:S108-S Pan XR, et al. Diabetes Care. 1997;20: Knowler WC, et al. N Engl J Med. 2002;346: Ramachandran A, et al. Diabetologia. 2006;49: Chiasson JL, et al. Lancet. 2002;359: Torgerson JS, et al. Diabetes Care. 2004;27: The NAVIGATOR Study Group. N Engl J Med. 2010;362: Knowler WC, et al. Diabetes. 2005;54: Buchanan TA, et al. Diabetes. 2002;51: DREAM Trial Investigators. Lancet. 2006;368: DeFronzo R. American Diabetes Association 68th Scientific Sessions (oral presentation). San Francisco, CA: June 9, 2008 Zinman B, Harris SB, Neuman J, et al. Lancet. 2010;368: % 66% 81% *vs. control vs. placebo The plan to mimimize cardiometabolic risk for Aakar Health behaviour modification If not achieving treatment targets Pharmacologic interventions Adapted from: Leiter LA, et al. CJC, 2011;27 e1 e33 Get below the surface

7 Delay or prevent progression of cardiometabolic risk: Lifestyle modification DM prevention trials have shown that intensive, comprehensive, structures and sustained lifestyle modification that results in the loss of approximately 5% of initial body wt can reduce the risk of progression from IGT to T2DM by approximately 60% Trial interventions Low-calorie/low-fat nutrition plan (reduce caloric intake by calories/day) 15 g fibre/1000 calories Regular physical activity (150 minutes/week) Moderate weight loss (5%/year) Tuomilehto J. N Engl J Med. 2001;344: Knowler WC. N Engl J Med. 2002;346: Rally the troops! What can you delegate? Consider your team Your literal team of allied health professionals who may work directly with you in your practice Nurse, dietitian, pharmacist Community resources DEC, dietitians, retail pharmacists, YCMA, physiotherapists, social workers etc Colleagues and other experts A Explain the problem and his treatment options remembers he likely feels fine! 150 min physical activity/wk 5% wt loss

8 Insulin resistance: Hence hyperglycemia High blood glucose can injure the inside of blood vessels Weight loss & muscle activity & medication reduce insulin resistance allowing glucose to move into cells

9 Healthy BP through weight loss and physical activity reduces risk of clots and vessel damage Healthy cholesterol through weight loss and physical activity reduces risk of clots and blood vessel damage The plan to mimimize cardiometabolic risk for Aakar Health behaviour modification If not achieving treatment targets Pharmacologic interventions Adapted from: Leiter LA, et al. CJC. 2011;27 e1 e33 B

10 Delay or prevent progression on to T2DM: Pharmacotherapy Progression from prediabetes to type 2 diabetes can be reduced by pharmacologic therapy with: metformin (~30% reduction); or acarbose (~30% reduction) 2013 CDA Clinical Practice Guidelines. Can J Diabetes. 2013;37(Suppl 1):S1-S212. Medications In addition to lifestyle changes to reduce his CVD and diabetes risk, consider: Statin Antihypertensive He asks about aspirin because he saw TV commercial about it Discuss that aspirin not recommended for primary prevention 2013 CDA Clinical Practice Guidelines. Can J Diabetes. 2013;37(Suppl 1):S1-S212. Summary Global cardiometabolic risk is an umbrella term for a comprehensive (and emerging) list of factors that predict CVD and/or type 2 diabetes. These patients may warrant more comprehensive or intensive intervention, including prompt health behaviour changes. A structured, goal-directed approach appears to be associated with the best outcomes. Consider using the three easy questions to direct your risk management.

11 Recruits take a break!