1.0.0.0 In­tro­duc­tion

The Amer­i­can Di­a­betes As­so­ci­a­tion (ADA) “Stan­dards of Med­i­cal Care in Di­a­betes” in­cludes ADA’s cur­rent clin­i­cal prac­tice rec­om­men­da­tions and is in­tend­ed to pro­vide the com­po­nents of di­a­betes care, gen­er­al treat­ment goals and guide­lines, and tools to eval­u­ate qual­i­ty of care. Mem­bers of the ADA Pro­fes­sion­al Prac­tice Com­mit­tee, a mul­ti­dis­ci­plinary ex­pert com­mit­tee, are re­spon­si­ble for up­dat­ing the Stan­dards of Care an­nu­al­ly, or more fre­quent­ly as war­rant­ed. For a de­tailed de­scrip­tion of ADA stan­dards, state­ments, and re­ports, as well as the ev­i­dence-‍grad­ing sys­tem for ADA’s clin­i­cal prac­tice rec­om­men­da­tions, please refer to the Stan­dards of Care In­tro­duc­tion. Read­ers who wish to com­ment on the Stan­dards of Care are in­vit­ed to do so at pro­fes­sion­al.di­a­betes.org/‍SOC.

For pre­ven­tion and man­age­ment of di­a­betes com­pli­ca­tions in chil­dren and ado­les­cents, please refer to Sec­tion 13 “Chil­dren and Ado­les­cents.”

Atheroscle­rot­ic car­dio­vas­cu­lar dis­ease (ASCVD)-defined as coro­nary heart dis­ease, cere­brovas­cu­lar dis­ease, or pe­riph­er­al ar­te­ri­al dis­ease pre­sumed to be of atheroscle­rot­ic origin-is the lead­ing cause of mor­bid­i­ty and mor­tal­i­ty for in­di­vid­u­als with di­a­betes and re­sults in an es­ti­mat­ed $37.3 bil­lion in car­dio­vas­cu­lar-re­lat­ed spend­ing per year as­so­ci­at­ed with di­a­betes (1). Com­mon con­di­tions co­ex­ist­ing with type 2 di­a­betes (e.g., hy­per­ten­sion and dys­lipi­demia) are clear risk fac­tors for ASCVD, and di­a­betes it­self con­fers in­de­pen­dent risk. Nu­mer­ous stud­ies have shown the efficacy of con­trol­ling in­di­vid­u­al car­dio­vas­cu­lar risk fac­tors in pre­vent­ing or slow­ing ASCVD in peo­ple with di­a­betes. Fur­ther­more, large benefits are seen when mul­ti­ple car­dio­vas­cu­lar risk fac­tors are ad­dressed si­mul­ta­ne­ous­ly. Under the cur­rent paradigm of ag­gres­sive risk fac­tor modification in pa­tients with di­a­betes, there is ev­i­dence that mea­sures of 10-year coro­nary heart dis­ease (CHD) risk among U.S. adults with di­a­betes have im­proved significant­ly over the past decade (2) and that ASCVD mor­bid­i­ty and mor­tal­i­ty have de­creased (3,4).

Heart fail­ure is an­oth­er major cause of mor­bid­i­ty and mor­tal­i­ty from car­dio­vas­cu­lar dis­ease. Re­cent stud­ies have found that rates of in­ci­dent heart fail­ure hos­pi­tal­iza­tion (ad­just­ed for age and sex) were twofold high­er in pa­tients with di­a­betes com­pared with those with­out (5,6). Peo­ple with di­a­betes may have heart fail­ure with pre­served ejec­tion frac­tion (HFpEF) or with re­duced ejec­tion frac­tion (HFrEF). Hy­per­ten­sion is often a pre­cur­sor of heart fail­ure of ei­ther type, and ASCVD can co­ex­ist with ei­ther type (7), where­as prior my­ocar­dial in­farc­tion (MI) is often a major fac­tor in HFrEF. Rates of heart fail­ure hos­pi­tal­iza­tion have been im­proved in re­cent tri­als in­clud­ing pa­tients with type 2 di­a­betes, most of whom also had ASCVD, with sodi­um–glu­cose co­trans­porter 2 (SGLT2) in­hibitors (8-10).

For pre­ven­tion and man­age­ment of both ASCVD and heart fail­ure, car­dio­vas­cu­lar risk fac­tors should be sys­tematically as­sessed at least an­nu­al­ly in all pa­tients with di­a­betes. These risk fac­tors in­clude obe­si­ty/‍over­weight, hy­per­ten­sion, dys­lipi­demia, smok­ing, a fam­i­ly his­to­ry of pre­ma­ture coro­nary dis­ease, chron­ic kid­ney dis­ease, and the pres­ence of al­bu­min­uria. Modifiable ab­nor­mal risk fac­tors should be treat­ed as de­scribed in these guide­lines.

The Risk Cal­cu­la­tor

The Amer­i­can Col­lege of Car­di­ol­o­gy/ Amer­i­can Heart As­so­ci­a­tion ASCVD risk cal­cu­la­tor (Risk Es­ti­ma­tor Plus) is gen­er­ally a use­ful tool to es­ti­mate 10-year ASCVD risk (http:/‍/‍tools.acc.org/ASCVD-Risk-Es­ti­ma­tor-Plus). These cal­cu­la­tors have di­a­betes as a risk fac­tor, since di­a­betes it­self con­fers in­creased risk for ASCVD, al­though it should be ac­knowl­edged that these risk cal­cu­la­tors do not ac­count for the du­ra­tion of di­a­betes or the pres­ence of di­a­betes com­pli­ca­tions, such as al­bu­minuria. Al­though some vari­abil­i­ty in cal­i­bra­tion ex­ists in var­i­ous sub­groups, in­clud­ing by sex, race, and di­a­betes, the over­all risk pre­dic­tion does not dif­fer in those with or with­out di­a­betes (11-14), val­i­dat­ing the use of risk cal­cu­la­tors in peo­ple with di­a­betes. The 10-year risk of a first ASCVD event should be as­sessed to bet­ter strat­i­fy ASCVD risk and help guide ther­a­py, as de­scribed below.

Re­cently, risk scores and other car­dio­vas­cu­lar biomark­ers have been de­vel­oped for risk stratification of sec­ondary pre­ven­tion pa­tients (i.e., those who are al­ready high risk be­cause they have ASCVD) but are not yet in widespread use (15,16). With newer, more ex­pen­sive lipid-‍low­er­ing ther­a­pies now avail­able, use of these risk as­sess­ments may help tar­get these new ther­a­pies to “high­er risk” ASCVD pa­tients in the fu­ture.