The Practical Aspects

These FAQs on cardiovascular diabetes

What is CV Risk?

The likelihood that a person will have a cardiovascular event (angina, heart attack, stroke or transient ischaemic attack) over 5 years. This can be estimated and forms the basis for all decisions and discussions about the treatment options for people who have cardiovascular risk factors or cardiovascular disease.

What are the major risk factors?

A personal history of cardiovascular disease, age, sex, smoking, lipids (cholesterol), blood pressure, diabetes, atrial fibrillation, obesity and physical inactivity.

Who should have their CVD risk assessed?

• Risk assessment for men without symptoms or risk factors is recommended from the age of 45.
• Risk assessment for women without symptoms or risk factors is recommended from the age of 55.
• People with risk factors should be assessed 10 years earlier - particularly people who are smokers or who have raised BP, raised cholesterol, diabetes or raised blood glucose.
• People with diabetes should have assessments every year.
• Mäori should be assessed 10 years earlier than non-Mäori. There is an urgent need to focus intervention programmes on Mäori, who bear the greatest burden of cardiovascular disease in New Zealand. The 'outcome gap' between Mäori and non-Mäori is widening.

What should be measured?

• A comprehensive cardiovascular risk assessment includes measurement and recording of the following:
• Age • gender • ethnicity • smoking history • a fasting lipid profile
• A fasting plasma glucose • the average of two sitting blood pressures
• Family history • waist circumference • body mass index.
• People with diabetes will require additional tests
• HbA1c • albumin:creatinine ratio • creatinine • date of diagnosis.

What lifestyle advice is recommended?

Lifestyle change and drug intervention should be considered together. A life free from cigarette smoke, eating a heart healthy diet and taking every opportunity to be physically active is recommended for people at less than 10% 5-year CV risk. More intensive lifestyle change can be recommended for people at more than 10% 5-year CV risk and advice should be individualised and specific usually given by the primary carer team, relating to smoking cessation if relevant, a cardio protective diet and regular physical activity.

Lifestyle change and drug therapy (aspirin, blood pressure lowering medication and lipid modifying therapy, statins) are advised for people at greater than 15% 5-year CV risk. More intense advice and treatment is suggested for higher risk people (more than 20 – 30%)

What is recommended for people after stroke?

• Organised stroke units save lifes, reduce morbidity, reduce length of stay in hospital and improve quality of life in people living with stroke.
• All District Health Boards should provide organised stroke services.
• Services must be responsive to the needs of Maori and Pacific peoples.
• All patients with stroke should receive information.
• Most people after stroke will be on low dose aspirin within 48 hours if CT rules out intracerebral haemorrhage and no contraindications exist.
• Most people after ischaemic stroke should be receiving additional blood-pressure lowering medication and statin treatment even when blood pressure or cholesterol are within previously accepted or borderline ranges.
• Follow-up should be by community based rehabilitation services, stroke clinics or family doctors according to continuing needs.

What is recommended for people with angina or after a heart attack?

After myocardial infarction (a heart attack), comprehensive programmes that promote lifestyle change for people are best delivered by a cardiac rehabilitation team. Most people with angina or after myocardial infarction will be taking at least four standard drugs, low-dose aspirin (75 – 150 mg), a beta-blocker, a statin and an ACE-inhibitor.

What is recommended for people with diabetes?

• Involving families in diabetes management planning is of particular importance to Maori and pacific people with diabetes.
• Regular screening for renal, retinal and foot complications should occur from diagnosis of type 2 diabetes.
• Tight glycaemic control reduces the risk of and slows the progression of complications. A stepped approach is recommended to lower and maintain HbA1c to as close to physiological levels as possible, preferably less than 7%, without hypoglycaemia.
• Optimum blood pressure control, below 130/80 mm Hg, reduces the risk of and slows the progression of complications.
• Intensive blood pressure management is recommended in people with diabetes and overt nephropathy, microalbuminuria or other renal disease, with most requiring more than one blood pressure lowering agent and an ACE-inhibitor.
• Any sustained reduction in both HbA1c is worthwhile.