What does the abbreviation ASCVD stand for?
This term refers to Atherosclerotic cardiovascular disease, which is considered the primary contributor to the death of diabetes patients
What is the definition of ASCVD?
ASCVD can be defined as “ acute coronary syndromes (ACSs), a history of myocardial infarction (MI), stable/unstable angina, coronary or other arterial revascularization, stroke, transient ischemic attack, or peripheral arterial disease presumed to be of atherosclerotic origin”
The relation between ASCVD and diabetes:
ASCVD is the primary contributor to the sickness and death of diabetes patients, meantime type2 diabetes itself along with certain conditions associated with it like dyslipidemia and hypertension represents risk factors for ASCVD. A broad range of studies indicated that controlling cardiovascular risk factors can protect diabetes patients against ASCVD, therefore, they have to undergo regular evaluation of cardiovascular risk factors (i.e smoking, hypertension, dyslipidemia..) every year
ASCVD Risk Calculator/Score:
Among the widely used ASCVD risk calculators in the USA are: the Framingham Risk Score (FRS), the Reynolds Risk Score (RRS), the American College of Cardiology/American Heart Association arteriosclerotic cardiovascular disease risk estimator (AC/AHA-ASCVD), while the Systematic Coronary Risk Evaluation (SCORE) and the QRisk2 are the most approved for European patients
The Framingham Risk Score (FRS) was released in 1998 with the aim to evaluate the 10-year risk of coronary heart disease for patients who are susceptible to a variety of risk factors, based on the data of the Framingham Heart Study. Since that time onward (RRS) undergoes constant updating
The Reynolds Risk Score (RRS) was released in 2007 based on data from a study carried out on 24,558 US of female diabetes patients 10 years ago. It is designed to calculate both the conventional risk factors and the risk factor of increased C-reactive protein (CRP)
The American College of Cardiology (ACC)/American Heart Association(AHA) Arteriosclerotic Cardiovascular Disease (ASCVD) Risk calculator, released in 2013 with a view to evaluating the risk at the early stage of cardiovascular diseases among a group of patients from different races and geographic regions
between 40-79 years old. Yet it was not proven to be particularly useful for diabetes patients, as diabetes represents a risk factor for ASCVD.
However, doubts were soon to arise about the accuracy of the 2013 ACC/AHA-ASCVD when the studies which were conducted on three large groups found that it exaggerated the risk by 75-150% than it really is in the three groups. Other studies assumed that using this ASCVD risk calculator would lead to raising the number of patients treated by statin to 12.8 million patients, and include people who do not suffer from cardiovascular disease
The Systematic Coronary Risk Evaluation (SCORE) was first developed in 2003 based on combined data of more than 250,000 patients from 12 European studies. It is designed to evaluate the 10 years of deadly cardiovascular risk, apart from calculating the mortality factors of coronary heart disease and stroke
The QRISK (2007) and the updated QRISK2 (2008) are released for the United Kingdom patients in order to calculate 10-year coronary heart disease risk
What are the ASCVD risk factors?
The main risk factors include the following:
It represents a primary risk factor which leads to microvascular and ASCVD diseases
Controlling blood pressure: diabetic patients who also suffer from hypertension have to aim for a systolic blood pressure of <140 mmHg and diastolic blood pressure of <90 mmHg.(the systolic blood pressure as low as <130 mmHg and diastolic blood pressure as low as <80 mmHg are still normal in some cases)
Controlling blood pressure depends on adopting a healthy lifestyle and the use of medications. A healthy lifestyle involves following a healthy eating pattern i.e. consuming more vegetables, fruits, and dairy products which are low in fats while decreasing sodium consumption, alcoholic beverage intake in addition to maintaining healthy body weight. A healthy lifestyle may also enhance glycemia and lipid control.in the event that blood pressure exceeded 140/90 mmHg, following a healthy lifestyle should be accompanied by pharmacological treatment
The pharmacological treatment is based on the patients’ consumption of antihypertensive agents such as ACE inhibitors and ARBs i.e (angiotensin receptor blockers. Some studies indicated that treatment with ACE inhibitors had better results on lowering the possibility of the occurrence of cardiovascular diseases, while other studies indicated no remarkable effect of ACE inhibitors alone but rather in combination with a small dosage of thiazide diuretics. On the other hand, renin-angiotensin system (RAS) inhibitors were proved to be effective in the treatment of hypertension in diabetic people as an initial approach, it was suggested that ACE inhibitors and ARBs are also effective in mitigating the consequences of ASCVD. It is essential to note that ACE inhibitors and ARBs should not be taken together.
Diabetic patients who also have hypertension, consume more than one type of medicine along with their treatment course, thereby it is very important to handle any problem that may interrupt their course of treatment such as costly medicines or drug adverse effects. In case of pregnancy, women who suffer from both diabetes and hypertension may not be treated with ACE inhibitors and ARBs, they are not advised either to use diuretic for a long time during pregnancy, they may only use safe medicines
Lipid management (useful tips ):
Patients prescribed a statin should undergo lipid panel test at the beginning of medication then carry the same test regularly hereinafter, while patients who are not under statin treatment should carry out a lipid panel test upon the detection of diabetes and on the first medical examination then every 5 years after that.
All patients who suffer from both diabetes and atherosclerotic cardiovascular disease should consume a high dosage of statin
Healthcare providers can modify the statin dosage on a case by case basis given the different patients’ responses to the drug
Enhancing the lipid profile of diabetic patients entails adopting a healthier lifestyle that gives heed to decreasing saturated fat, trans fat, and cholesterol intake, maintaining weight within the desirable range, exercising, consuming more omega-3 fatty acids, viscous fiber, and plant stanols/sterols.
Enhancing glycemic control for patients with high triglyceride levels (≥150 mg/dL [1.7 mmol/L]) and HDL cholesterol (<40 mg/dL for men and <50 mg/dL] for women).
The combination of moderate statin dosage and ezetimibe was proved to be more effective for cardiovascular patients than treatment with a moderate dose of statin by itself
The combination of statin and niacin is not advised as it was not proven to have a significant effect on cardiovascular diseases treatment when compared to the treatment with a statin alone, furthermore, such combination may increase the probability of strokes
The combination of statin and fibrate is not advised either as it was not established that it reduces the complications of atherosclerotic cardiovascular diseases
Finally, statin must not be used during pregnancy
Patients who are 40 years old or older:
Patients of 40 years old and above are recommended to receive an average dose of Statin along with lifestyle modification. While a high-intensity dose of the drug is usually prescribed for patients who are more susceptible to ASCVD, such as in cases of Acute Coronary Syndrome (ACS) or patients who have already experienced a cardiovascular disease, clinical trials suggested that intensive treatment with statins contributed to decreasing the possibility of future incidents, hence it is recommended for patients in danger of cardiovascular diseases i.e whose LDL cholesterol is 100 mg/dL [2.6 mmol/L or above, who already have ASCVD / a family history of premature ASCVD, who are smokers or suffer from hypertension
Patients who are above the age of 75:
There is not much data about the effect of statins on diabetic patients of this age group. However, high statin doses can be a good choice for diabetic patients over the age of 75 who are also susceptible to ASCVD. Nevertheless, patients of this age group should have regular risks against benefits calculations, along with decreasing the dosage intensity as the case may require
Patients who are below the age of 40 with type 1 diabetes:
Although very limited evidence is available concerning the influence of statin on patients with type 2 diabetes under 40 years old and patients with type 1 diabetes, the Heart Protection Study conducted on 600 type 1 diabetic patient with a minimum age of 40 years old, indicated that the recorded risk in this group was as low as that of type 2 patients, which suggests that patients of both diabetes types should receive the same statin dosage, this is precisely true if other cardiovascular risk factors were associated with diabetes. It is worth mentioning here that patients who suffer from diabetes and ASCVD together are advised to take high statin doses, while patients who suffer from diabetes only accompanied by ASCVD risk factors are advised to receive average statin dosage.