Farzad Hadaegh , MD, Professor of Internal Medicine & Endocrinology

2. Update on Prevention of Cardiovascular Disease in Adults With Type 2 Diabetes Mellitus in Light of Recent Evidence FarzadHadaegh, MD, Professor of Internal Medicine & Endocrinology Prevention of Metabolic Disorders Research Center, Research Institute for Endocrine Sciences ShahidBeheshti University of Medical Sciences Tehran Jan 2018

3. Agenda ــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ • Dyslipidemia in T2DM • Hypertension in T2DM • Antithrombotic therapy • Smoking &T2DM • Glucose-Lowering Agent Selection for CVD Risk Reduction • Screening of cardiovascular disease in diabetes

4. Cardiometabolic Risk Factors ــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ • Non-modifiable • Age • Race/ethnicity • Gender • Family history • Modifiable • Overweight • Abnormal lipid metabolism • Inflammation, hypercoagulation • Hypertension • Smoking • Physical inactivity • Unhealthy diet • Insulin resistance

5. Benefit of different interventions per 200 individuals with diabetes treated for 5 years ــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ 5 Per 0.9% lower HbA1c Per 1 mmol/L lower LDL-C Per 4 mmHg lower SBP 0 –2.9 –5 CV events –8.2 –10 –12.5 –15 –20 Ray KK, et al. Lancet. 2009;373:1765–72

6. Dyslipidemia in Diabetes

7. Efficacy of statins in diabetic patients

8. CARDS: Effect of Statin for PRIMARY Prevention in DM ــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ • n = 2838 • Age 40-75, no history of CVD • T2DM plus one or more: • Retinopathy • Albuminuria • Hypertension • Smoking • Intervention: Atorvastatin 10 mg vs. Placebo • Outcome: ACS, revascularization, stroke Colhoun HM, et al. Lancet 2004;364:685.

9. CARDS: Statins Reduced CVD in Patients with DM ــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ Colhoun HM, et al. Lancet 2004;364:685.

10. Efficacy of cholesterol-lowering therapy in diabetic patients in 14 RCT of statins : meta analysis ــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ Lancet 2008, Jan 12;371(9607):117-25 • Aim of study: • Although statin therapy reduces the risk of occlusive vascular events in people with DM • There is uncertainty about the effects on particular outcomes and whether such effects depend on the type of diabetes, lipid profile, or other factors. • Methods: • Data from 18686 individuals with diabetes (1466 type 1 and 17,220 type 2) in the context of a further 71,370 without diabetes in 14 randomised trials of statin therapy. • Estimates effectson clinical outcomes per 1.0 mmol/L reduction in LDL cholesterol.

11. Meta Analyses (cont’d) ــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ Lancet 2008, Jan 12;371(9607):117-25 • Result in Diabetic patients:

12. Results ــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ • After 5 years, 42 (95% CI 30–55) fewer people with diabetes had major vascular events per 1000 allocated statin therapy.

15. Meta Analyses (cont’d) ــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ Lancet 2008, Jan 12;371(9607):117-25 • Among diabetic patients the proportional effects of statin therapy were similar irrespective of whether there was a : • Prior history of vascular disease • Other baseline characteristics • Conclusion: Statin therapy should be considered for all diabetic individuals who are at sufficiently high risk of vascular events.

16. Atorvastatin 10 mg Atorvastatin 80 mg High intensity statins are better than moderate intensity in diabetes (TNT study) ــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ 0.20 HR = 0.75 (95% CI: 0.58, 0.97) P = 0.026 0.15 Cumulative incidence of major cardiovascular events* 0.10 0.05 Relative risk reduction = 25% 0 0 1 2 3 4 5 6 Years 1501 patients with diabetes and CHD, primary end point: time to first major cardiovascular event* *CHD death, nonfatal non–procedure-related MI, resuscitated cardiac arrest, fatal or nonfatal stroke TNT: Treating to New Target study Shepherd J, et al. Diabetes Care 2006;29:1220–6

17. ADA 2018 ــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ • In adults with diabetes, it is reasonable to obtain a lipid profile (total cholesterol, LDL cholesterol, HDL cholesterol, and triglycerides) at the time of diagnosis, at the initial medical evaluation, and at least every 5 years thereafter in patients under the age of 40 years. • Once a patient is taking a statin, LDL cholesterol levels should be assessed 4–12 weeks after initiation of statin therapy, after any change in dose, and on an individual basis (e.g., to monitor for medication adherence and efficacy). • There is evidence for benefit from even extremely low, less than daily statin doses

19. The Risk Calculator. • The American College of Cardiology/American Heart Association • ASCVD risk calculator may be a useful tool to estimate 10-year ASCVD (http://my .americanheart.org).

23. ADA 2018 ــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ • However, as diabetes itself confers increased risk for ASCVD and risk calculators in general do not account for the duration of diabetes or the presence of other complications such as albuminuria, the risk calculator has limited use for assessing cardiovascular risk in individuals with diabetes.

24. ADA 2018 Recommendations: ــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ

25. ADA 2018 ــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ • For patients under the age of 40 years and/or who have type 1 diabetes with other ASCVD risk factors, we recommend that the patient and health care provider discuss the relative benefits and risks and consider the use of moderate-intensity statin therapy.

27. Statins ــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ • Reduce LDL-C 18–55% & TG 7–30% • Raise HDL-C 5–15% • Major side effects • Myopathy • Increased liver enzymes • Contraindications • Absolute: liver disease • Relative: use with certain drugs

28. Concomitant Medications increasing Risk of Statin-associated Myopathy ــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ • HIV protease inhibitors • Nefazodone • Verapamil and diltiazem • Amiodarone • Grapefruit juice, >1 qt/d • Fibric acid derivatives, especially Gemfibrozil • Niacin • Cyclosporine • Azole antifungals • Macrolide antibiotics

29. Statin and incident Diabetes ــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ • A meta-analysis of 13 randomized statin trials with 91,140 participants showed an odds ratio of 1.09 (9%) for a new diagnosis of diabetes, • On average ,treatment of 255patients with statins for 4years resulted in 1additional case of diabetes, • while simultaneously preventing 5.4vascular events among those255patients

31. Treatment of Other Lipoprotein fractions ــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ • Hypertriglyceridemia should be addressed with dietary and lifestyle changes including abstinence from alcohol; check for secondary causes!! • Severe hypertriglyceridemia (>1,000 mg/dL) may warrant pharmacologic therapy (fibric acid derivatives and/or fish oil) to reduce the risk of acute pancreatitis. In a large trial in patients with diabetes, fenofibratefailed to reduce overall cardiovascular outcomes. • Low levels of HDL cholesterol, often associated with elevated triglyceride levels, are the most prevalent pattern of dyslipidemia in individuals with type 2 diabetes.

32. Fibric Acids ــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ DrugDose • Gemfibrozil 600 mg BID • Fenofibrate 200 mg QD • Clofibrate 1000 mg BID

33. Fibric Acids ــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ • Major actions • Lower LDL-C 5–20% (with normal TG) • May raise LDL-C (with high TG) • Lower TG 20–50% • Raise HDL-C 10–20% • Side effects: dyspepsia, gallstones, myopathy • Contraindications: Severe renal or hepatic disease

34. If combination therapy necessary? • Combination therapy (statin/fibrate) has not been shown to improve atherosclerotic cardiovascular disease outcomes and is generally not recommended. However, therapy with statin and fenofibratemay be considered for men with both triglyceride level ≥204 mg/dL (2.3 mmol/L) and HDL cholesterol level ≤ 34 mg/dL (0.9 mmol/L). • Combination therapy (statin/niacin) has not been shown to provide additional cardiovascular benefit above statin therapy alone and may increase the risk of stroke and is not generally recommended.

35. If combination therapy necessary? • Combination therapy (statin/fibrate) has not been shown to improve atherosclerotic cardiovascular disease outcomes and is generally not recommended. A • Combination therapy (statin and fibrate) is associated with an increased risk for abnormal transaminase levels, myositis, and rhabdomyolysis. • The risk of rhabdomyolysis is more common with higher doses of statins and renal insufficiency and appears to be higher when statins are combined with Gemfibrozil(compared with fenofibrate)

36. If combination therapy necessary? • Clinicians should attempt to find a dose or alternative statin that is tolerable, if side effects occur. • There is evidence for benefit from even extremely low, less than daily, statin doses . • The addition of Ezetimibeto moderate-intensity statin therapy has been shown to provide additionalcardiovascular benefit compared with moderate-intensity statin therapy aloneand may be considered for patients : • with a Recent ACS with LDL –C >50 mg/dL or for those patients who cannot tolerate high intensitystatin therapy. A

37. The IMProved Reduction of Outcomes:(IMPROVE-IT) ــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ • Individuals were 50 years of age who experienced an ACS within the preceding 10days and had an LDL –C level> 50 mg/dL. • In those with diabetes (27%), the combination of moderate intensity Simvastatin (40mg) and Ezetimibe(10 mg) showed a significant reduction of major adverse cardiovascular events with an absolute risk reduction of5%(40% vs. 45%) and RR reduction of 14%(RR 0.86 [95% CI 0.78–0.94]) over moderate-intensity simvastatin (40 mg) alone.

38. Statins and PCSK9 Inhibitors (adjunctive therapy) ــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ • The addition of the novel PCSK9 inhibitors, Evolocumab and Alirocumab, • To maximally tolerated doses of statin therapy in participants who were at high risk for ASCVD • Decresethe LDL cholesterol ranging from 36% to 59%.

39. Hypertensive Disorders in Type 2 Diabetic Patients

40. ADA 2018 ــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ • Recommendations: • Blood pressure should be measured at every routine clinical visit. Patients found to have elevated blood pressure (≥140/90 mmHg) should have blood pressure confirmed using multiple readings, including measurements on a separate day, to diagnose hypertension. B • All hypertensive patients with diabetes should monitor their blood pressure at home. B • Check BP in a correct way and control for orthostatic hypotension

41. Treatment Goals , ADA 2018 ــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ • Most patients with diabetes and hypertension should be treated to a SBP < 140 mmHg and a DBP <90 mmHg. A • Lower systolic and diastolic blood pressure targets, such as 130/80 mmHg, may be appropriate for individuals at high risk of cardiovascular disease, if they can be achieved without undue treatment burden. C • In pregnant patients with diabetes and preexisting hypertension who are treated with antihypertensive therapy, blood pressure targets of 120–160/80–105 mmHg are suggested in the interest of optimizing long-term maternal health and minimizing impaired fetal growth. E

42. In type 1 diabetes, hypertension is often the result of underlying nephropathy, while in type 2 diabetes it usually coexists with other cardiometabolic risk factors.

43. JAMA. 2015 Feb 10;313(6):603-15. Blood pressure lowering in type 2 diabetes: a systematic review and meta-analysis. ــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ • OBJECTIVE: To determine the associations between BP-lowering treatment and vascular disease in type 2 diabetes. • DATA SOURCES AND STUDY SELECTION: We searched MEDLINE for large-scale randomized controlled trials of BP-lowering treatment including patients with diabetes, published between January 1966 and October 2014. • MAIN OUTCOMES AND MEASURES: All-cause mortality, cardiovascular events, coronary heart disease events, stroke, heart failure, retinopathy, new or worsening albuminuria, and renal failure.

44. JAMA. 2015 Feb 10;313(6):603-15. Blood pressure lowering in type 2 diabetes: a systematic review and meta-analysis. ــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ • RESULTS: 100,354 participants were included. Each 10-mm Hg lower systolic BP was associated with a significantly lower risk of : • Mortality (relative risk [RR], 0.87; 95% CI, 0.78-0.96); 13%  • CVD(RR, 0.89 [95% CI, 0.83-0.95]; 11%  • CHD(RR, 0.88 [95% CI, 0.80-0.98]; 12% • Stroke (RR, 0.73 [95% CI, 0.64-0.83]; 27%  • Albuminuria (RR, 0.83 [95% CI, 0.79-0.87]; 17% • Retinopathy (RR, 0.87 [95% CI, 0.76-0.99]; 13% • When trials were stratified by mean baseline ,lower RRs observed among those with baseline BP of ≥ 140 mm Hg

45. Tight BP Control : Large RCTs

48. Systolic Pressures (mean + 95% CI) ــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ Mean # Meds Intensive: 3.2 3.4 3.5 3.4 Standard: 1.9 2.1 2.2 2.3 Average after 1st year: 133.5 Standard vs. 119.3 Intensive, Delta = 14.2

49. Primary & Secondary Outcomes ــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ Also examined Fatal/Nonfatal HF (HR=0.94, p=0.67), a composite of fatal coronary events, nonfatal MI and unstable angina (HR=0.94, p=0.50) and a composite of the primary outcome, revascularization and unstable angina (HR=0.95, p=0.40)

50. Primary Outcome Nonfatal MI, Nonfatal Stroke or CVD Death HR = 0.88 95% CI (0.73-1.06)