Cardiovascular Risk in Diabetes: A story of missed opportunities?

doi:10.2337/diacare.24.11.2015

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Letters: Comments and Responses
Letter

Cardiovascular Risk in Diabetes

A story of missed opportunities?

Anne Fagot-Campagna, MD, PHD , Tiffany L. Gary, PHD and Stephanie M. Benjamin, PHD

Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, Georgia

We commend the Veterans Administration for implementing a clinicaltrial of the impact of glucose control on cardiovascular complicationsin patients with type 2 diabetes (1). Among people with diabetes,cardiovascular disease (CVD) is the leading cause of death (2);27% have CVD, and an additional 71% have CVD risk factors (3).However, the burden of CVD can be substantially reduced by improvingmetabolic control, including that of glucose, lipids, bloodpressure, and coagulation parameters (4). Published data fromnational surveys enable us to evaluate the current level andcontrol of CVD risk factors among people with diabetes in theU.S.

In regard to glucose control, 37% of people with diabetes hadHbA_1c >8.0% according to the Third National Health and NutritionExamination Survey (NHANES III) (5). Although the majority (73%)were taking either insulin or oral agents, 51% of those on insulin,42% of those on oral agents only, and 15% of those on diet onlyhad HbA_1c >8%.

Among individuals with diabetes, 97% had at least one lipidabnormality (NHANES III) (6). Overall, 33% had LDL between 100and 130 mg/dl, and 56% had LDL $>=$ 130 mg/dl. Of diabetic individuals,32% followed some type of treatment for high cholesterol, butonly 9% were taking a lipid-lowering medication. Among thosetreated, only 1% had LDL <100 mg/dl, and 61% had LDL $>=$ 130mg/dl.

The prevalence of elevated blood pressure ( $>=$ 130/85 mmHg or onantihypertensive medication) was 71% among U.S. people withdiabetes (NHANES III) (7). Among those with elevated blood pressure,only 57% were on prescription medication.

Although nearly every U.S. adult with diabetes is eligible foraspirin treatment (3,4), aspirin was used by only 20% of diabeticindividuals overall, 37% of whom had CVD, and 13% of whom hadCVD risk factors (NHANES III) (3). Other risk factors in peoplewith diabetes were also inadequate. Of people with diabetes,26–34% had microalbuminuria ( $>=$ 30 µg/ml) (NHANES III)(3,8), 34–54% were obese (BMI $>=$ 30 kg/m²) (NHANES III) (8),31% were sedentary, 35% were somewhat active, only 34% wereregularly active according to the National Health InterviewSurvey (NHIS) (9), and 18–27% were smokers (NHIS and NHANESIII) (8,10).

In conclusion, national data in the U.S. point to suboptimalcontrol of CVD risk factors and substantial missed opportunitiesfor awareness, treatment, and control of these risk factorsin the diabetic population. Although the prevalence of CVD riskfactors is higher among people with diabetes, the use of treatmentsfor many CVD risk factors is not more prevalent among the diabeticpopulation. In fact, CVD mortality for the U.S. diabetic populationhas not declined as much as it has for the nondiabetic population(2). Reduction in CVD mortality in the general population isa major achievement in recent decades, but people with diabetesdeserve similar improvement. We look forward to seeing the resultsof the Veterans Affairs Diabetes Trial. We hope this trial willencourage future trials that will examine how control of otherCVD risk factors (such as lipid levels, blood pressure, andcoagulation parameters) may reduce morbidity and mortality associatedwith CVD among people with diabetes.

Footnotes

Address correspondence to Stephanie Benjamin, Division of DiabetesTranslation, Centers for Disease Control and Prevention, 4770Buford Highway, NE (MS-K68), Atlanta, GA 30341. E-mail: sbenjamin{at}cdc.gov.

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