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Bertoluci MC, Silva Júnior WS, Valente F, Araujo LR, Lyra R, de Castro JJ, Raposo JF, Miranda PAC, Boguszewski CL, Hohl A, Duarte R, Salles JEN, Silva-Nunes J, Dores J, Melo M, de Sá JR, Neves JS, Moreira RO, Malachias MVB, Lamounier RN, Malerbi DA, Calliari LE, Cardoso LM, Carvalho MR, Ferreira HJ, Nortadas R, Trujilho FR, Leitão CB, Simões JAR, Dos Reis MIN, Melo P, Marcelino M, Carvalho D. 2023 UPDATE: Luso-Brazilian evidence-based guideline for the management of antidiabetic therapy in type 2 diabetes. Diabetol Metab Syndr 2023; 15:160. [PMID: 37468901 PMCID: PMC10354939 DOI: 10.1186/s13098-023-01121-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Accepted: 06/23/2023] [Indexed: 07/21/2023] Open
Abstract
BACKGROUND The management of antidiabetic therapy in people with type 2 diabetes (T2D) has evolved beyond glycemic control. In this context, Brazil and Portugal defined a joint panel of four leading diabetes societies to update the guideline published in 2020. METHODS The panelists searched MEDLINE (via PubMed) for the best evidence from clinical studies on treating T2D and its cardiorenal complications. The panel searched for evidence on antidiabetic therapy in people with T2D without cardiorenal disease and in patients with T2D and atherosclerotic cardiovascular disease (ASCVD), heart failure (HF), or diabetic kidney disease (DKD). The degree of recommendation and the level of evidence were determined using predefined criteria. RESULTS AND CONCLUSIONS All people with T2D need to have their cardiovascular (CV) risk status stratified and HbA1c, BMI, and eGFR assessed before defining therapy. An HbA1c target of less than 7% is adequate for most adults, and a more flexible target (up to 8%) should be considered in frail older people. Non-pharmacological approaches are recommended during all phases of treatment. In treatment naïve T2D individuals without cardiorenal complications, metformin is the agent of choice when HbA1c is 7.5% or below. When HbA1c is above 7.5% to 9%, starting with dual therapy is recommended, and triple therapy may be considered. When HbA1c is above 9%, starting with dual therapyt is recommended, and triple therapy should be considered. Antidiabetic drugs with proven CV benefit (AD1) are recommended to reduce CV events if the patient is at high or very high CV risk, and antidiabetic agents with proven efficacy in weight reduction should be considered when obesity is present. If HbA1c remains above target, intensification is recommended with triple, quadruple therapy, or even insulin-based therapy. In people with T2D and established ASCVD, AD1 agents (SGLT2 inhibitors or GLP-1 RA with proven CV benefit) are initially recommended to reduce CV outcomes, and metformin or a second AD1 may be necessary to improve glycemic control if HbA1c is above the target. In T2D with HF, SGLT2 inhibitors are recommended to reduce HF hospitalizations and mortality and to improve HbA1c. In patients with DKD, SGLT2 inhibitors in combination with metformin are recommended when eGFR is above 30 mL/min/1.73 m2. SGLT2 inhibitors can be continued until end-stage kidney disease.
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Affiliation(s)
- Marcello Casaccia Bertoluci
- Faculdade de Medicina da Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil.
- Serviço de Endocrinologia do Hospital de Clínicas de Porto Alegre, Departamento de Medicina Interna da Universidade Federal do Rio Grande do Sul (UFRGS), Rua Ramiro Barcelos, 2350, 4º Andar, Porto Alegre, RS, 90035-007, Brazil.
- Sociedade Brasileira de Diabetes (SBD), São Paulo, Brazil.
| | - Wellington S Silva Júnior
- Disciplina de Endocrinologia, Departamento de Medicina I, Universidade Federal Maranhão, São Luís, Brazil
- Sociedade Brasileira de Endocrinologia e Metabologia (SBEM), Rio de Janeiro, Brazil
| | - Fernando Valente
- Faculdade de Medicina do ABC, Santo André, Brazil
- Sociedade Brasileira de Diabetes (SBD), São Paulo, Brazil
| | - Levimar Rocha Araujo
- Faculdade de Ciências Médicas de Minas Gerais, Belo Horizonte, Brazil
- Sociedade Brasileira de Diabetes (SBD), São Paulo, Brazil
| | - Ruy Lyra
- Universidade Federal de Pernambuco, Recife, Brazil
- Sociedade Brasileira de Diabetes (SBD), São Paulo, Brazil
| | - João Jácome de Castro
- Serviço de Endocrinologia do Hospital Universitário das Forças Armadas, Lisbon, Portugal
- Sociedade Portuguesa de Endocrinologia, Diabetes e Metabolismo (SPEDM), Lisbon, Portugal
| | - João Filipe Raposo
- NOVA Medical School, Universidade Nova de Lisboa, Lisbon, Portugal
- Sociedade Portuguesa de Diabetologia (SPD), Lisbon, Portugal
| | - Paulo Augusto Carvalho Miranda
- Clínica de Endocrinologia e Metabologia da Santa Casa Belo Horizonte, Belo Horizonte, Brazil
- Sociedade Brasileira de Endocrinologia e Metabologia (SBEM), Rio de Janeiro, Brazil
| | - Cesar Luiz Boguszewski
- Divisão de Endocrinologia (SEMPR), Departamento de Clínica Médica, Universidade Federal do Paraná, Curitiba, Brazil
- Sociedade Brasileira de Endocrinologia e Metabologia (SBEM), Rio de Janeiro, Brazil
| | - Alexandre Hohl
- Departamento de Clínica Médica da Universidade Federal de Santa Catarina, Florianópolis, Brazil
- Sociedade Brasileira de Endocrinologia e Metabologia (SBEM), Rio de Janeiro, Brazil
| | - Rui Duarte
- Associação Protectora dos Diabéticos de Portugal, Lisbon, Portugal
- Sociedade Portuguesa de Diabetologia (SPD), Lisbon, Portugal
| | - João Eduardo Nunes Salles
- Faculdade de Ciências Médicas da Santa Casa de São Paulo, São Paulo, Brazil
- Sociedade Brasileira de Diabetes (SBD), São Paulo, Brazil
| | - José Silva-Nunes
- NOVA Medical School, Universidade Nova de Lisboa, Lisbon, Portugal
- Sociedade Portuguesa de Diabetologia (SPD), Lisbon, Portugal
| | - Jorge Dores
- Centro Hospitalar e Universitário de Santo António, Lisbon, Portugal
- Instituto de Ciências Biomédicas Abel Salazar da Universidade do Porto, Porto, Portugal
- Sociedade Portuguesa de Endocrinologia, Diabetes e Metabolismo (SPEDM), Lisbon, Portugal
| | - Miguel Melo
- Serviço de Endocrinologia, Diabetes e Metabolismo, Centro Hospitalar e Universitário de Coimbra, Faculdade de Medicina da Universidade de Coimbra, Coimbra, Portugal
- Sociedade Portuguesa de Diabetologia (SPD), Lisbon, Portugal
| | - João Roberto de Sá
- Faculdade de Medicina do ABC, Santo André, Brazil
- Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil
- Sociedade Brasileira de Diabetes (SBD), São Paulo, Brazil
| | - João Sérgio Neves
- Cardiovascular R&D Centre (UnIC@RISE), Faculdade de Medicina da Universidade do Porto, Porto, Portugal
- Serviço de Endocrinologia, Diabetes e Metabolismo, Centro Hospitalar Universitário de São João, Porto, Portugal
- Sociedade Portuguesa de Endocrinologia, Diabetes e Metabolismo (SPEDM), Lisbon, Portugal
| | - Rodrigo Oliveira Moreira
- Instituto Estadual de Diabetes e Endocrinologia Luiz Capriglione (IEDE), Rio de Janeiro, Brazil
- Faculdade de Medicina, Centro Universitário Presidente Antônio Carlos (UNIPAC/JF), Juiz de Fora, Brazil
- Faculdade de Medicina, Centro Universitário de Valença (UNIFAA), Valença, Brazil
- Sociedade Brasileira de Endocrinologia e Metabologia (SBEM), Rio de Janeiro, Brazil
| | | | - Rodrigo Nunes Lamounier
- Departamento de Clínica Médica da Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
- Sociedade Brasileira de Diabetes (SBD), São Paulo, Brazil
| | - Domingos Augusto Malerbi
- Hospital Israelita Albert Einstein, São Paulo, Brazil
- Sociedade Brasileira de Endocrinologia e Metabologia (SBEM), Rio de Janeiro, Brazil
| | - Luis Eduardo Calliari
- Faculdade de Ciências Médicas da Santa Casa de São Paulo, São Paulo, Brazil
- Sociedade Brasileira de Diabetes (SBD), São Paulo, Brazil
| | - Luis Miguel Cardoso
- i3S, Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Porto, Portugal
- Serviço de Endocrinologia, Diabetes e Metabolismo, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
- Sociedade Portuguesa de Endocrinologia, Diabetes e Metabolismo (SPEDM), Lisbon, Portugal
| | - Maria Raquel Carvalho
- Hospital CUF, Tejo, Portugal
- Sociedade Portuguesa de Endocrinologia, Diabetes e Metabolismo (SPEDM), Lisbon, Portugal
| | - Hélder José Ferreira
- Clínica Grupo Sanfil Medicina, Coimbra, Portugal
- Sociedade Portuguesa de Diabetologia (SPD), Lisbon, Portugal
| | - Rita Nortadas
- Associação Protectora dos Diabéticos de Portugal, Lisbon, Portugal
- Sociedade Portuguesa de Diabetologia (SPD), Lisbon, Portugal
| | - Fábio Rogério Trujilho
- Faculdade de Medicina da UniFTC, Salvador, Brazil
- Centro de Diabetes e Endocrinologia da Bahia (CEDEBA), Salvador, Brazil
- Sociedade Brasileira de Endocrinologia e Metabologia (SBEM), Rio de Janeiro, Brazil
| | - Cristiane Bauermann Leitão
- Faculdade de Medicina da Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- Serviço de Endocrinologia do Hospital de Clínicas de Porto Alegre, Departamento de Medicina Interna da Universidade Federal do Rio Grande do Sul (UFRGS), Rua Ramiro Barcelos, 2350, 4º Andar, Porto Alegre, RS, 90035-007, Brazil
- Sociedade Brasileira de Endocrinologia e Metabologia (SBEM), Rio de Janeiro, Brazil
| | - José Augusto Rodrigues Simões
- Faculdade de Ciências da Saúde da Universidade da Beira Interior, Covilhã, Portugal
- Sociedade Portuguesa de Diabetologia (SPD), Lisbon, Portugal
| | - Mónica Isabel Natal Dos Reis
- Unidade Integrada de Diabetes Mellitus do Hospital de Vila Franca de Xira, Vila Franca de Xira, Portugal
- Sociedade Portuguesa de Diabetologia (SPD), Lisbon, Portugal
| | - Pedro Melo
- Serviço de Endocrinologia, Hospital Pedro Hispano, Matosinhos, Portugal
- Unidade de Endocrinologia, Instituto CUF, Porto, Portugal
- Sociedade Portuguesa de Endocrinologia, Diabetes e Metabolismo (SPEDM), Lisbon, Portugal
| | - Mafalda Marcelino
- Serviço de Endocrinologia do Hospital Universitário das Forças Armadas, Lisbon, Portugal
- Sociedade Portuguesa de Endocrinologia, Diabetes e Metabolismo (SPEDM), Lisbon, Portugal
| | - Davide Carvalho
- Faculdade de Medicina da Universidade do Porto, Porto, Portugal
- Sociedade Portuguesa de Endocrinologia, Diabetes e Metabolismo (SPEDM), Lisbon, Portugal
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Rietz M, Lehr A, Mino E, Lang A, Szczerba E, Schiemann T, Herder C, Saatmann N, Geidl W, Barbaresko J, Neuenschwander M, Schlesinger S. Physical Activity and Risk of Major Diabetes-Related Complications in Individuals With Diabetes: A Systematic Review and Meta-Analysis of Observational Studies. Diabetes Care 2022; 45:3101-3111. [PMID: 36455117 PMCID: PMC9862380 DOI: 10.2337/dc22-0886] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 09/19/2022] [Indexed: 12/02/2022]
Abstract
BACKGROUND Physical activity is a cornerstone in diabetes management; however, evidence synthesis on the association between physical activity and long-term diabetes-related complications is scarce. PURPOSE To summarize and evaluate findings on physical activity and diabetes-related complications, we conducted a systematic review and meta-analysis. DATA SOURCES We searched PubMed, Web of Science, and the Cochrane Library for articles published up to 6 July 2021. STUDY SELECTION We included prospective studies investigating the association between physical activity and incidence of and mortality from diabetes-related complications, i.e., cardiovascular disease (CVD), coronary heart disease, cerebrovascular events, heart failure, major adverse cardiovascular events, and microvascular complications such as retinopathy and nephropathy, in individuals with diabetes. DATA EXTRACTION Study characteristics and risk ratios with 95% CIs were extracted. Random-effects meta-analyses were performed, and the certainty of evidence and risk of bias were evaluated with use of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) and Risk Of Bias In Non-randomised Studies - of Interventions (ROBINS-I) tools. DATA SYNTHESIS Overall, 31 studies were included. There was moderate certainty of evidence that high versus low levels of physical activity were inversely associated with CVD incidence, CVD mortality (summary risk ratio 0.84 [95% CI 0.77, 0.92], n = 7, and 0.62 [0.55, 0.69], n = 11), and microvascular complications (0.76 [0.67, 0.86], n = 8). Dose-response meta-analyses showed that physical activity was associated with lower risk of diabetes-related complications even at lower levels. For other outcomes, similar associations were observed but certainty of evidence was low or very low. LIMITATIONS Limitations include residual confounding and misclassification of exposure. CONCLUSIONS Physical activity, even below recommended amounts, was associated with reduced incidence of diabetes-related complications.
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Affiliation(s)
- Marlene Rietz
- Institute for Biometrics and Epidemiology, German Diabetes Center, Leibniz Center for Diabetes Research, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- Research Unit for Exercise Epidemiology (ExE), Department of Sports Science and Clinical Biomechanics, Syddansk Universitet, Odense, Denmark
| | - Alexander Lehr
- Institute for Biometrics and Epidemiology, German Diabetes Center, Leibniz Center for Diabetes Research, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Eriselda Mino
- Department of Sport Science and Sport, Division Exercise and Health, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Alexander Lang
- Institute for Biometrics and Epidemiology, German Diabetes Center, Leibniz Center for Diabetes Research, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Edyta Szczerba
- Institute for Biometrics and Epidemiology, German Diabetes Center, Leibniz Center for Diabetes Research, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- German Center for Diabetes Research (DZD), Partner Düsseldorf, Düsseldorf, Germany
| | - Tim Schiemann
- Institute for Biometrics and Epidemiology, German Diabetes Center, Leibniz Center for Diabetes Research, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Christian Herder
- German Center for Diabetes Research (DZD), Partner Düsseldorf, Düsseldorf, Germany
- Institute of Clinical Diabetology, German Diabetes Center, Leibniz Center for Diabetes Research, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Nina Saatmann
- German Center for Diabetes Research (DZD), Partner Düsseldorf, Düsseldorf, Germany
- Institute of Clinical Diabetology, German Diabetes Center, Leibniz Center for Diabetes Research, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Wolfgang Geidl
- Department of Sport Science and Sport, Division Exercise and Health, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Janett Barbaresko
- Institute for Biometrics and Epidemiology, German Diabetes Center, Leibniz Center for Diabetes Research, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Manuela Neuenschwander
- Institute for Biometrics and Epidemiology, German Diabetes Center, Leibniz Center for Diabetes Research, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- German Center for Diabetes Research (DZD), Partner Düsseldorf, Düsseldorf, Germany
| | - Sabrina Schlesinger
- Institute for Biometrics and Epidemiology, German Diabetes Center, Leibniz Center for Diabetes Research, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- German Center for Diabetes Research (DZD), Partner Düsseldorf, Düsseldorf, Germany
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McCarthy MM, Wackers FJT, Davey J, Chyun DA. Physical inactivity and cardiac events: An analysis of the Detection of Ischemia in Asymptomatic Diabetics (DIAD) study. J Clin Transl Endocrinol 2017; 9:8-14. [PMID: 29067262 PMCID: PMC5651289 DOI: 10.1016/j.jcte.2017.05.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Revised: 05/01/2017] [Accepted: 05/16/2017] [Indexed: 01/02/2023] Open
Abstract
AIMS Diabetes affects 29 million adults, and the majority have type 2 diabetes (T2D). Coronary artery disease (CAD) is the leading cause of death, and physical inactivity is an important risk factor. The aims of this study were to examine the contribution of physical inactivity to CAD events, and to identify the independent predictors of CAD events in a sample of older adults with T2D. METHOD A secondary data analysis of the prospective randomized screening trial "Detection of Ischemia in Asymptomatic Diabetics (DIAD)" study. Cox proportional hazard modeling was used to examine the outcome of CAD events. RESULTS During the five years of follow-up, the CAD event rate for all subjects (n = 1119) was 8.4% (n = 94). In unadjusted analysis, physical inactivity was significantly associated with development of a CAD event. In the final model, nine baseline variables were significant predictors (p < 0.05) of a CAD: physical inactivity, race, diabetes duration, hemoglobin A1c (HbA1c), peripheral numbness, insulin use, increasing waist-to-hip ratio, family history of premature CAD, and a higher pulse pressure. In men only, there were five predictors (p < 0.05) of a CAD event: diabetes duration, peripheral numbness, HbA1c, increasing waist-to-hip ratio, and higher pulse pressure. The final model in women included three independent predictors (p < 0.05) of a CAD event: diabetes duration, a family history of premature CAD, and higher pulse pressure. CONCLUSION Several variables predicted CAD events in this sample of older adults with T2D. Understanding baseline characteristics that heighten risk may assist providers in intervening early to prevent its occurrence.
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Affiliation(s)
- Margaret M. McCarthy
- New York University Rory Meyers College of Nursing, New York, NY 10010, United States
| | | | - Janice Davey
- Yale School of Medicine, New Haven, CT 06510, United States
| | - Deborah A. Chyun
- New York University Rory Meyers College of Nursing, New York, NY 10010, United States
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Bertoluci MC, Moreira RO, Faludi A, Izar MC, Schaan BD, Valerio CM, Bertolami MC, Chacra AP, Malachias MVB, Vencio S, Saraiva JFK, Betti R, Turatti L, Fonseca FAH, Bianco HT, Sulzbach M, Bertolami A, Salles JEN, Hohl A, Trujilho F, Lima EG, Miname MH, Zanella MT, Lamounier R, Sá JR, Amodeo C, Pires AC, Santos RD. Brazilian guidelines on prevention of cardiovascular disease in patients with diabetes: a position statement from the Brazilian Diabetes Society (SBD), the Brazilian Cardiology Society (SBC) and the Brazilian Endocrinology and Metabolism Society (SBEM). Diabetol Metab Syndr 2017; 9:53. [PMID: 28725272 PMCID: PMC5512820 DOI: 10.1186/s13098-017-0251-z] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Accepted: 06/30/2017] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Since the first position statement on diabetes and cardiovascular prevention published in 2014 by the Brazilian Diabetes Society, the current view on primary and secondary prevention in diabetes has evolved as a result of new approaches on cardiovascular risk stratification, new cholesterol lowering drugs, and new anti-hyperglycemic drugs. Importantly, a pattern of risk heterogeneity has emerged, showing that not all diabetic patients are at high or very high risk. In fact, most younger patients who have no overt cardiovascular risk factors may be more adequately classified as being at intermediate or even low cardiovascular risk. Thus, there is a need for cardiovascular risk stratification in patients with diabetes. The present panel reviews the best current evidence and proposes a practical risk-based approach on treatment for patients with diabetes. MAIN BODY The Brazilian Diabetes Society, the Brazilian Society of Cardiology, and the Brazilian Endocrinology and Metabolism Society gathered to form an expert panel including 28 cardiologists and endocrinologists to review the best available evidence and to draft up-to-date an evidence-based guideline with practical recommendations for risk stratification and prevention of cardiovascular disease in diabetes. The guideline includes 59 recommendations covering: (1) the impact of new anti-hyperglycemic drugs and new lipid lowering drugs on cardiovascular risk; (2) a guide to statin use, including new definitions of LDL-cholesterol and in non-HDL-cholesterol targets; (3) evaluation of silent myocardial ischemia and subclinical atherosclerosis in patients with diabetes; (4) hypertension treatment; and (5) the use of antiplatelet therapy. CONCLUSIONS Diabetes is a heterogeneous disease. Although cardiovascular risk is increased in most patients, those without risk factors or evidence of sub-clinical atherosclerosis are at a lower risk. Optimal management must rely on an approach that will cover both cardiovascular disease prevention in individuals in the highest risk as well as protection from overtreatment in those at lower risk. Thus, cardiovascular prevention strategies should be individualized according to cardiovascular risk while intensification of treatment should focus on those at higher risk.
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Affiliation(s)
- Marcello Casaccia Bertoluci
- Departamento de Medicina Interna, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul (UFRGS), Rua Ramiro Barcelos, 2400, Porto Alegre, RS 90035-003 Brazil
- Serviço de Medicina Interna, Hospital de Clínicas de Porto Alegre (HCPA), UFRGS, Rua Ramiro Barcelos, 2350, Porto Alegre, RS 90035-903 Brazil
| | - Rodrigo Oliveira Moreira
- Instituto Estadual de Diabetes e Endocrinologia Luiz Capriglione, Rua Moncorvo Filho, 90, Rio de Janeiro, RJ 20211-340 Brazil
- Faculdade de Medicina de Valença (FMV), Rua Sebastião Dantas Moreira, 40, Valença, RJ 27600-000 Brazil
- Faculdade de Medicina da Universidade Presidente Antônio Carlos (FAME/UNIPAC), Av. Juiz de Fora, 1100, Juiz De Fora, MG 36048-000 Brazil
| | - André Faludi
- Instituto Dante Pazzanese de Cardiologia, Av. Dante Pazzanese, 500, São Paulo, SP 04012-180 Brazil
| | - Maria Cristina Izar
- Universidade Federal de São Paulo (UNIFESP), Rua Loefgren, 1350, São Paulo, SP 04040-001 Brazil
| | | | - Cynthia Melissa Valerio
- Instituto Estadual de Diabetes e Endocrinologia Luiz Capriglione, Rua Moncorvo Filho, 90, Rio de Janeiro, RJ 20211-340 Brazil
| | - Marcelo Chiara Bertolami
- Instituto Dante Pazzanese de Cardiologia, Av. Dante Pazzanese, 500, São Paulo, SP 04012-180 Brazil
| | - Ana Paula Chacra
- Universidade de São Paulo (USP), Av. Dr. Enéas de Carvalho Aguiar, 44, São Paulo, SP 05403-000 Brazil
| | | | - Sérgio Vencio
- Universidade Federal de Goiás (UFG), 1ª Avenida, s/n, Setor Leste Universitário, Goiânia, GO 74605-020 Brazil
| | - José Francisco Kerr Saraiva
- Pontifícia Universidade Católica de Campinas (PUC-Campinas), Av. John Boyd Dunlop, s/n, Campinas, SP 13059-900 Brazil
| | - Roberto Betti
- Universidade de São Paulo (USP), Av. Dr. Enéas de Carvalho Aguiar, 44, São Paulo, SP 05403-000 Brazil
| | - Luiz Turatti
- Universidade de São Paulo (USP), Av. Dr. Enéas de Carvalho Aguiar, 44, São Paulo, SP 05403-000 Brazil
| | | | - Henrique Tria Bianco
- Universidade Federal de São Paulo (UNIFESP), Rua Loefgren, 1350, São Paulo, SP 04040-001 Brazil
| | - Marta Sulzbach
- Instituto Dante Pazzanese de Cardiologia, Av. Dante Pazzanese, 500, São Paulo, SP 04012-180 Brazil
| | - Adriana Bertolami
- Instituto Dante Pazzanese de Cardiologia, Av. Dante Pazzanese, 500, São Paulo, SP 04012-180 Brazil
| | - João Eduardo Nunes Salles
- Faculdade de Ciências, Médicas da Santa Casa de São Paulo, Rua Dr. Cesário Motta Jr, 112, São Paulo, SP 01221-020 Brazil
| | - Alexandre Hohl
- Universidade Federal de Santa Catarina (UFSC), Rua Profa. Maria Flora Pausewang, s/n, Florianópolis, SC 88040-970 Brazil
| | - Fábio Trujilho
- Clínica de Endocrinologia e Metabologia, Av. Tancredo Neves, 1632/708, Salvador, BA 41820-020 Brazil
| | - Eduardo Gomes Lima
- Universidade de São Paulo (USP), Av. Dr. Enéas de Carvalho Aguiar, 44, São Paulo, SP 05403-000 Brazil
| | - Marcio Hiroshi Miname
- Universidade de São Paulo (USP), Av. Dr. Enéas de Carvalho Aguiar, 44, São Paulo, SP 05403-000 Brazil
| | | | - Rodrigo Lamounier
- Centro de Diabetes de Belo Horizonte, Rua Niquel, 31, Belo Horizonte, MG 30220-280 Brazil
| | | | - Celso Amodeo
- Instituto Dante Pazzanese de Cardiologia, Av. Dante Pazzanese, 500, São Paulo, SP 04012-180 Brazil
| | - Antonio Carlos Pires
- Faculdade de Medicina de São José do Rio Preto, Av. Brg. Faria Lima, 5416, São José do Rio Preto, SP 15090-000 Brazil
| | - Raul D. Santos
- Universidade de São Paulo (USP), Av. Dr. Enéas de Carvalho Aguiar, 44, São Paulo, SP 05403-000 Brazil
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Bertoluci MC, Rocha VZ. Cardiovascular risk assessment in patients with diabetes. Diabetol Metab Syndr 2017; 9:25. [PMID: 28435446 PMCID: PMC5397821 DOI: 10.1186/s13098-017-0225-1] [Citation(s) in RCA: 118] [Impact Index Per Article: 16.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Accepted: 04/11/2017] [Indexed: 02/08/2023] Open
Abstract
Although patients with diabetes have 2 to 4 times increased risk of cardiovascular morbidity and mortality than individuals without diabetes, recent studies indicate that a significant part of patients are in a lower cardiovascular risk category. Men younger than 35 years, women younger than 45 years, patients with diabetes duration of less than 10 years without other risk factors have a much lower risk than patients who have traditional cardiovascular risk factors, and subclinical or established coronary artery disease (CAD). These patients are not risk equivalent as stated in previous studies. On the contrary, when in the presence of traditional risk factors or evidence of subclinical coronary disease (e.g. high coronary calcium score), the coronary risk is much increased and patients may be classified at a higher-risk category. Recent guidelines do not anymore consider diabetes as a CAD risk equivalent and recommend cardiovascular risk stratification for primary prevention. Stratification of diabetic patients improves accuracy in prediction of subclinical CAD, silent ischemia and future cardiovascular events. Stratification also discriminates higher from lower risk patients who may need intensive statin or aspirin prevention, while avoiding overtreatment in lower risk cases. It may also allow the clinician to decide whether to intensify risk reduction actions through specific newer drugs for glucose control such as SGLT-2 inhibitors or GLP-1 agonists, which recently have shown additional cardiovascular protector effect. This review addresses the assessment of cardiovascular disease risk using traditional and non-traditional cardiovascular risk factors. It also reviews the use of risk calculators and new reclassification tools, focusing on the detection of subclinical atherosclerosis as well as silent ischemia in the asymptomatic patients with diabetes.
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Affiliation(s)
- Marcello Casaccia Bertoluci
- Departamento de Medicina Interna da Faculdade de Medicina da, Universidade Federal do Rio Grande do Sul, UFRGS, Rua Ramiro Barcelos 2400, Porto Alegre, ZIP 90035-003 RS Brazil
- Universidade Federal do Rio Grande do Sul, Programa de Pós-Graduação em Ciências Médicas, Rua Ramiro Barcelos 2400, Porto Alegre, 90035-003 Brazil
- Hospital de Clínicas de Porto Alegre- UFRGS, Serviço de Medicina Interna, Rua Ramiro Barcelos 2350 Sala 700, Porto Alegre, 90035-005 RS Brazil
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Kodama S, Tanaka S, Heianza Y, Fujihara K, Horikawa C, Shimano H, Saito K, Yamada N, Ohashi Y, Sone H. Association between physical activity and risk of all-cause mortality and cardiovascular disease in patients with diabetes: a meta-analysis. Diabetes Care 2013; 36:471-9. [PMID: 23349151 PMCID: PMC3554302 DOI: 10.2337/dc12-0783] [Citation(s) in RCA: 130] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The association between habitual physical activity (PA) and lowered risk of all-cause mortality (ACM) and cardiovascular disease (CVD) has been suggested in patients with diabetes. This meta-analysis summarizes the risk reduction in relation to PA, focusing on clarifying dose-response associations. RESEARCH DESIGN AND METHODS Electronic literature searches were conducted for cohort studies that examined relative risk (RR) of ACM or CVD in relation to PA in patients with diabetes. For the qualitative assessment, RR for the highest versus the lowest PA category in each study was pooled with a random-effects model. We added linear and spline regression analyses to assess the quantitative relationship between increases in PA and ACM and CVD risk. RESULTS There were 17 eligible studies. Qualitatively, the highest PA category had a lower RR [95% CI] for ACM (0.61 [0.52-0.70]) and CVD (0.71 [0.60-0.84]) than the lowest PA category. The linear regression model indicated a high goodness of fit for the risk of ACM (adjusted R(2) = 0.44, P = 0.001) and CVD (adjusted R(2) = 0.51, P = 0.001), with the result that a 1 MET-h/day incrementally higher PA was associated with 9.5% (5.0-13.8%) and 7.9% (4.3-11.4%) reductions in ACM and CVD risk, respectively. The spline regression model was not significantly different from the linear model in goodness of fit (P = 0.14 for ACM risk; P = 0.60 for CVD risk). CONCLUSIONS More PA was associated with a larger reduction in future ACM and CVD risk in patients with diabetes. Nevertheless, any amount of habitual PA was better than inactivity.
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Affiliation(s)
- Satoru Kodama
- Department of Health Management Center, Mito Kyodo General Hospital, Mito City, Japan
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