Page 908 - Cardiac Nursing

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and mortality and is cost-effective. The internationally agreed of coronary artery events by 25%, independent of baseline LDL
upon goals are systolic blood pressure 130 mm Hg and diastolic levels. Based on the results of this study and others which had sim-
blood pressure 80 mm Hg. 5,11,15,51 If tolerated, an even lower ilar findings, the IDF guidelines state that statin therapy should be
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blood pressure may be attempted. Blood pressure should be initiated in people over 40 years of age with diabetes or all those
measured each office visit and home blood pressure monitoring with diabetes and heart disease. The EASD state that statin ther-
devices may also be beneficial. 52 Promoting lifestyle changes in- apy should be considered in adults with type 2 diabetes and heart
cluding weight reduction, reducing sodium and alcohol intake, disease regardless of baseline LDL cholesterol with a treatment
and regular exercise can help lower blood pressure. However, they target of 70 mg/dL (1.8 mmol). For patients with diabetes
are generally insufficient by themselves to achieve blood pressure without CVD, if total cholesterol is 135 mg/dL (3.5 mmol/L)
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goals. According to the ADA, if blood pressure goals are not met statin therapy should be considered aiming to reduce LDL by
within 3 months through lifestyle intervention then pharmaco- 30% to 40%. The ADA guidelines state that statin therapy should
logic intervention is warranted. Studies have shown that the use of be added to lifestyle therapy regardless of baseline lipid levels for
antihypertensives not only provide renal protection, but can help patients with diabetes if they have overt CVD or if they are over
reduce endothelial inflammation and reduce the risk of CAD. 15,51 40 years of age and have one or more CVD risk factors. For pa-
Most people with diabetes require combination therapy to lower tients without CVD and under 40 years of age, statin therapy
blood pressure and improve outcomes. 15,51 Effective first line should be added to lifestyle in LDL is 100 mg/dL (2.6
agents include angiotensin-converting enzyme (ACE) inhibitor mmol/L). Even though these goals to initiate treatment are
and/or angiotensin receptor blocker. The IDF also includes slightly different, research has demonstrated that statin therapy is
-adrenergic blockers as a first line agent, although the AACE a powerful primary and secondary intervention that effectively
strongly argues against their use due to accumulating literature lowers LDL and prevents cardiovascular events. Triglycerides and
that questions their benefit. If one class is not tolerated, than the HDL usually improve in response to lower LDL and glucose lev-
other should be substituted. According to ADA, if blood pressure els. According to the EASD and IDF if goals are not met, a spe-
control is not achieved with one or a combination of these, a di- cific inhibitor of cholesterol absorption, ezetimibe, can be added
uretic may be added. In addition, the ADA and EASD note that in addition to lifestyle and statin therapy. All agree that if goals are
for patients with a prior myocardial infarction, the addition of still not met, a combination of fenofibrates and nicotinic acid
-blockers reduces mortality. (niacin) may be considered.
In addition to lipid lowering, there is international agreement
Cardiovascular Risk Protection regarding provision of aspirin therapy to as an antiplatelet agent.
Since CVD is the major cause of mortality and morbidity in peo- The EASD also recommends the use of ADP receptor-dependent
ple with diabetes, assessment and aggressive management of CVD platelet activation (clopidogrel) in addition to aspirin for patients
5
risk factors is a core part of care. Risk assessment of CVD should with acute coronary syndrome and the ADA recommends its ad-
be performed at diagnosis and at least annually thereafter. Areas to dition for those with severe and progressive CVD. The ADA cau-
assess include history of heart disease, BMI and abdominal adi- tions against aspirin therapy for patients under 30 years of age due
posity, presence of hypertension, smoking, dyslipidemia, family to lack of evidence of benefit and for patients under 21 years of
history of premature heart disease, and presence of microalbu- age due to associated risk of Reye’s syndrome.
minuria (a marker of heart disease). 53 Aggressive management of glucose and cardiovascular risk fac-
People with diabetes typically present with abnormal, athero- tors can improve daily quality of life and long-term complications
genic lipid profiles, including small dense LDLs, elevated triglyc- for people with diabetes. Informing patients of the goals and steps
erides, and low HDL levels. This profile increases the risk of heart to achieve these goals can dramatically improve outcomes.
disease and requires aggressive treatment. The goals for lipids are
as follows: For LDL, ADA states the level should be less than 100 Strategies to Achieve Glucose Control
mg/dL. The EASD and IDF goal is slightly lower at 95 mg/dL
(2.5 mmol/L). Both the ADA and EASD agree, that for those Lifestyle Management
with overt CVD an LDL cholesterol goal of 70 mg/dL (1.8 Since many of the risk factors associated with diabetes can be im-
mmol/L) is desirable. This more aggressive goal is in line with the proved by changes in lifestyle, it is important to encourage healthy
National Cholesterol Education Adult Treatment Program III. eating and exercise when working with patients with diabetes. All
The goal for HDL cholesterol is greater than 40 mg/dL (1.0 patients with diabetes should meet with a health care professional
mmol/L). The ADA and EASD guidelines recommend a slightly trained in the principles of nutrition at the time of diagnosis and
higher target for women of 50 g/dL (1.3 mmol/L) and 46 mg/dL on an ongoing basis to assess their current nutritional status and
(1.2 mmol/L), respectively. Triglyceride targets are less than 200 develop an individualized meal plan that works within the context
mg/dL (2.3 mmol) according to the IDF. The EASD and ADA of their life and addresses their particular risk factors. 56 Some ba-
triglyceride goals are more stringent at less than 150 mg/dL (1.7 sic initial recommendations include limiting foods with high
mmol/L). amounts of sugars and fats—especially saturated and trans fats
Lifestyle treatment to lower the risk of heart disease includes and teaching patient to monitor intake of carbohydrate-contain-
57
reduction of saturated fat, trans fat, and cholesterol intake, weight ing foods. Eating fresh fruits, vegetables, and whole grains and lim-
loss if indicated, and increased physical activity. Patients who iting alcohol should also be encouraged. Weight loss of 5% to 7% of
smoke should receive education, support, and pharmacologic in- current body weight reduces insulin resistance and other risk factors
tervention if appropriate to quit smoking. 54 In addition to these and can be accomplished gradually through calorie reduction and
lipid-lowering measures, pharmacologic therapy to achieve lipid regular physical activity. In addition to healthy eating, exercise is
goals is a priority. In the Heart Protection Study, 55 patients over also a cornerstone of diabetes self care. Besides helping with
40 years of age who were treated with a statin reduced their risk weight maintenance, exercise also reduces cardiac risk factors and