• Quality Improvement Team in Chronic Care (CCQI). Cardiometabolic risk management in primary care. Qatif (Saudi Arabia): Qatif Primary Health Care; 2008. Various p.

This is the current release of the guideline.

Note from Qatif Primary Health Care: English is the main language of the guideline. However, many pages have been written in Arabic to facilitate their implementation by the users, especially nurses. These include recommendations related to lifestyle management and information management.

Cardiometabolic risk factors (CMR) encompasses a cluster of modifiable classic and emerging risk factors and markers that identify individuals at increased risk for cardiovascular disease (CVD) and type 2 diabetes mellitus (T2DM). CMR includes factors that make up the definition of metabolic syndrome (MetSyn); in addition to four other factors: smoking, elevated low-density lipoprotein- cholesterol (LDL-C) inflammatory markers, and insulin resistance.

Clinical Highlights and Recommendations

1. Focus on cardiovascular risk reduction (blood pressure control, statin use, aspirin (ASA), and tobacco cessation).
2. Self-management support is necessary for people with CMR to manage their disease.
3. Prevent microvascular complications through annual eye exams, foot risk assessments and foot care counseling, and annual screening for renal function.
4. Screen for renal function by more sensitive tools including albumin-creatinine ratio (ACR) and estimated glomerular filtration rate (eGFR).
5. Screen every individual >45 years of age and obese individuals for CMR factors.
6. Involve other community nurses (those involved in vital signs measurement and laboratory results) in chronic care.
7. Use clinical information to identify individuals at higher need of care.
8. Use quality indicators and electronic data management for monitoring the performance.
9. Build a nurse-led chronic care.
10. Offer multiple tools for assessing lifestyle and self-management.
11. Screen for depression.

Screening

Obesity: Screening and Classification

1. Measure weight in each clinic visit
2. Calculate body mass index (BMI) at least once each year
3. Waist circumference should be measured, at least in overweight persons to better classify them (see table below). (To measure waist circumference locate the top of the hip bone. Place the tape measure evenly around the bare abdomen at the level of this bone. Read the tape measure and record the waist circumference in inches or centimeters.)

Table: Classification of Overweight and Obesity by BMI, Waist Circumference and Associated Risk

* Disease risk for type 2 diabetes, hypertension, and cardiovascular disease (CVD).

** Increased waist circumference can also be a marker for increased risk even in persons of normal weight.

Hypertension: Screening, Classification and Diagnosis

1. Blood pressure (BP) should be measured in each visit to the clinic.
2. If an elevated blood pressure reading has been obtained, the blood pressure level should be rechecked (see table below).
3. Confirmation of hypertension (persistent high BP) is based on the initial visit plus two follow-up visits with at least 2 blood pressure readings at each visit, over a period of 1 to several weeks.

Table: Definitions, Classification and Actions of Blood Pressure Levels

^AWhen a patient's systolic and diastolic blood pressures fall into different categories, the higher category should apply.

^BIsolated systolic hypertension can also be graded (grades 1, 2, 3) according to systolic blood pressure values in the ranges indicated, provided diastolic values are <90 mmHg.

Criteria for Testing for Diabetes in Asymptomatic Adult Individuals

1. Testing for diabetes should be considered in all individuals at age 45 years and above, particularly in those with a BMI ≥25 kg/m², and, if normal, should be repeated at 3-year intervals.
2. Testing should be considered at a younger age or be carried out more frequently in individuals who are overweight (BMI ≥25 kg/m²) and have additional risk factors:
   • Are habitually physically inactive
   • Have a first-degree relative with diabetes
   • Have delivered a baby weighing ≥4 kg or have been diagnosed with gestational diabetes mellitus (GDM)
   • Are hypertensive (≥140/90 mmHg)
   • Have a high-density lipoprotein (HDL) cholesterol level <35 mg/dL or a triglyceride level >250 mg/dL
   • On previous testing, had impaired glucose tolerance (IGT) or impaired fasting glucose (IFG)
   • Have other clinical conditions associated with insulin resistance (e.g., polycystic ovary syndrome [PCOS] or acanthosis nigricans)
   • Have a history of vascular disease (e.g., stroke, coronary heart disease [CHD], peripheral vascular disease [PVD])

Table: Definitions, Classification and Actions of Blood Sugar Levels (mg/dL)

^ANot appropriate for ruling out diabetes mellitus (DM).

^BTest must be confirmed by repeating on a different day.

^CThe classic symptoms of diabetes include polyuria, polydipsia, and unexplained weight loss.

Hypercholesterolemia: Screening, Classification and Diagnosis

1. Complete lipoprotein profile (total cholesterol, serum triglycerides, low-density lipoprotein [LDL] and HDL) must be obtained after 9- to 12-hour fast.
2. Keeping tourniquet in place longer than 3 minutes may cause 5% variation in lipid values.
3. If lipid measurement is high, one more measurement should be taken prior to classifying risk, initiating drug treatment or starting an intensive lifestyle treatment.
4. If the total cholesterol level varies more than 30-40 mg/dL in the two measurements, a third measurement should be taken and the average of the three measurements should be used as the baseline measure.
5. Diagnosis and reason for re-test have to be noted on the lab request.

Table: Definitions, Classification and Actions of Blood Cholesterol Levels (mg/dL)

Cardio-Metabolic Risk (CMR) Screening

Assess CMR for

1. Individuals at age of 45 years and over (preferably, at age of 35 for male)
2. All obese individuals
3. All hypertensive, diabetic and dyslipidemic individuals

Repeat CMR Assessment

• Each 10 years for low risk individuals
• Each 5 years for intermediate risk individuals
• Annually for high risk individuals, hypertensive, diabetic and dyslipidemic individuals

Use CMR1 (CMR Encounter Form no. 1, available in the original guideline document) to help you in the assessment.

Aim

To identify individuals at high risk to develop CVD. These include individuals with diabetes mellitus (DM), hypertension, hypercholesterolemia, morbid obesity and multiple risk factors for CVD.

Rationale

Early detection and intervention help to reduce morbidity, improve quality of life and lower cardiovascular (CV) mortality.

How

1. History of
   1. Sedentary lifestyle (assess level of exercise)
   2. DM, hypertension (HTN), dyslipidemia and vascular disease
   3. Smoking
2. Family history of premature cardiovascular disease
3. Measure
   1. BMI ± waist circumference
   2. BP
   3. Fasting blood sugar (FBS) and lipid profile
4. Stratify cardiovascular risk
   • Management of hypertension, hypercholesterolemia and obesity are related to the quantification of total CV risk (i.e., the chance to develop a major CV event in 10 years.) (See the original guideline document for stratification and definitions of CV risk.)

Assessment

Assessment of Hypertension

1. This assessment has to be done in the initial and the annual assessment visits. It might be repeated as needed.
2. Use CMR-2 (CMR Encounter Form no. 2, available in the original guideline document) to help you in the assessment.

Assessment Helps in Finding Answers for

1. What is the level of the BP?
2. Is it a secondary HTN?
3. What other CV risk factors does the patient have?
4. Is there any complication (target organ damage [TOD])?
5. What is the current management, if any?
6. How is the quality of life?
7. What is the risk to develop CVD?

Medical History

• Duration and previous level of high BP
• Previous admissions and visits to the emergency room (ER)
• History of target organ damage/associated clinical conditions (TOD/ACC)
• Symptoms of TOD:
  • Brain and eyes: headache, vertigo, impaired vision, transient ischaemic attacks, sensory or motor deficit
  • Heart: palpitation, chest pain, shortness of breath, swollen ankles
  • Kidney: thirst, polyuria, nocturia, hematuria
  • Peripheral arteries: cold extremities, intermittent claudication
• Risk factors for CVD
• Lifestyle (including amount of physical exercise, dietary habits and psychosocial factors that might influence the management of hypertension).
• Previous antihypertensive therapy: drugs used; efficacy and adverse effects; herbs and other traditional therapy.
• Use of other medications that might raise the BP^A
• Features of secondary hypertension^A
• History of snoring and sleep apnea. Family history of HTN, premature CVD, premature sudden death, and chronic kidney or endocrine diseases

Physical Examination

• Correct measurement of BP
• 2 or more BP measurements separated by 2 minutes with the patient seated and after standing for at least 2 minutes.
• Verification in the contralateral arm (if values are different, the higher value should be used).
• Measure BMI and waist circumference
• Look for signs of organ damage
  • Brain: murmurs over neck arteries, motor or sensory defects
  • Retina: refer to ophthalmology for fundoscopic abnormalities
  • Heart: location and characteristics of apical impulse, abnormal cardiac rhythms, ventricular gallop, pulmonary rales or bronchospasm, dependent edema
  • Peripheral arteries: diminished or absent peripheral arterial pulsations, carotid bruits, radio-femoral pulse delay and edema; cold extremities and ischaemic skin lesions
• Look for features of secondary hypertension^A

Laboratory Work Up

• Fasting blood sugar
• Lipid profile (total cholesterol, LDL, HDL and serum triglycerides)
• Serum uric acid
• Serum creatinine and eGFR
• Serum potassium and sodium
• Hemoglobin and hematocrit
• Urinalysis
• Electrocardiogram
• C-reactive protein
• Microalbuminuria

^A See the table "Secondary Hypertension: Causes and Clinical Features" in the original guideline document.

Assessment of Diabetes Mellitus (DM)

• This assessment has to be done in the initial and the annual assessment visits. It might be repeated as needed.
• Use CMR-2 (CMR Encounter Form no. 2, available in the original guideline document) to help you in the assessment.

Assessment Helps in Finding Answers for

1. What is the type of DM?
2. Is it secondary?
3. What are the other CVD risk factors the patient has?
4. What are the complications he has?
5. What is the current management, if any?
6. Is his DM controlled?
7. How is his quality of life?
8. What is the risk to develop CVD?

Medical History

1. Symptoms and results of laboratory tests
2. Current treatment of diabetes, including medications, meal plan, and results of glucose monitoring
3. Frequency, severity, and cause of acute complications such as ketoacidosis and hypoglycemia (including ER visits and admissions)
4. Prior or current infections, particularly skin, foot, dental, and genitourinary infections
5. Specific system history
6. Symptoms and treatment of chronic eye, kidney or nerve disease
7. Genitourinary (including sexual), bladder, and gastrointestinal function (including symptoms of celiac disease in type 1 diabetic patients)
8. Heart, peripheral vascular, foot, and cerebrovascular complications associated with diabetes
9. Use of medications and herbs that may affect blood glucose levels
10. Risk factors for CVD, including smoking, hypertension, obesity, dyslipidemia, and family history
11. History and treatment of other conditions, including endocrine and eating disorders
12. Assessment for mood disorder
13. Family history of diabetes and other endocrine disorders
14. Cultural, psychosocial, educational, and economic factors that might influence the management of diabetes
15. Nutritional habits, weight history and physical activity
16. Tobacco, alcohol, and/or controlled substance use
17. Contraception and reproductive and sexual history

Physical Examination

1. BMI
2. Blood pressure determination, including orthostatic measurements (sitting and standing)
3. Fundoscopic examination, by an ophthalmologist
4. Oral examination (for signs of redness, bleeding, halitosis, accumulation of debris around the teeth, gingival recession with exposed root surfaces, separation of teeth, and tooth mobility)
5. Thyroid palpation
6. Cardiac examination
7. Abdominal examination (e.g., for organomegaly)
8. Evaluation of pulses by palpation of dorsalis pedis and posterior tibial; and auscultation of carotids
9. Hand/finger examination
10. Foot examination
11. Skin examination (for acanthosis nigricans, insulin-injection sites, infections, and dyslipidemia)
12. Neurological examination
13. Signs of diseases that can cause secondary diabetes (e.g., hemochromatosis, pancreatic disease)

Laboratory Evaluation

1. Average FBS (≥3 readings in the last one week)
2. Glycated hemoglobin (A_1C)
3. Fasting lipid profile (total cholesterol, HDL, triglycerides, and LDL, liver function tests [LFT] with further evaluation for fatty liver or hepatitis if abnormal)
4. Serum creatinine and calculated GFR (eGFR) or creatinine clearance; ± albumin-creatinine ratio (ACR)
5. Thyroid-stimulating hormone (TSH), if clinically indicated
6. Electrocardiogram in adults
7. Urinalysis for ketone, protein, and sediment

Etiologic Classification of Diabetes Mellitus

1. Type 1 diabetes (beta-cell destruction, usually leading to absolute insulin deficiency)
2. Type 2 diabetes (with variable degree of insulin resistance and secretory defect)
3. Other specific types:
   1. Genetic defects of beta-cell function
   2. Genetic defects in insulin action
   3. Diseases of the exocrine pancreas
   4. Endocrinopathies
   5. Drug- or chemical-induced
   6. Infections
   7. Uncommon forms of immune-mediated diabetes
   8. Other genetic syndromes sometimes associated with diabetes
   9. Gestational diabetes mellitus (GDM)

   Complications of DM

   1. CVD
   2. Nephropathy
   3. Retinopathy
   4. Neuropathy
   5. Diabetic foot complications

Assessment of Hypercholesterolemia

• This assessment has to be done in the initial and the annual assessment visits. It might be repeated as needed.
• Use CMR-2 (CMR Encounter Form no. 2, available in the original guideline document) to help you in the assessment.

Measurement

• Two fasting lipoprotein measurements should be taken to classify the patient's CV risk, prior to initiating drug treatment or intensive lifestyle treatment (see table below). This ensures that true values are within 10% of the mean of the measurements. If the total cholesterol level varies more than 30-40 mg/dL (>16%) in the two samples a third sample should be taken and the average of the three samples should be used as the baseline measure.
• Abnormal lipid test results should always be confirmed with a new specimen, within 1–8 weeks later, before beginning or changing therapy.
• The sample should not be performed during stress or acute illness (e.g., recent myocardial infarction [MI], stroke, pregnancy, trauma, weight loss, use of certain drugs; should not be performed on hospitalized patients until 2-3 months after illness).

Secondary Dyslipidemia

It must be ruled out through medical, dietary, family history and physical evaluation to determine additional risk factors and any genetic factors (see the table "Selected Causes of Secondary Dyslipidemia" in the original guideline document). Laboratory testing including FBS, LFT, renal function tests (RFT), TSH (other endocrine function tests if indicated), erythrocyte volume and urinalysis must be done in addition to clinical evaluation.

Genetic Disorders

Consider the possibility of a genetic disorder if total cholesterol (TC) is 300 mg/dL or higher or if there is a family history of premature CHD.

Table. LDL Cholesterol Goals and Cut Points for Therapeutic Lifestyle Changes (TLC) and Drug Therapy in Different Risk Categories

Screening for Depression

Why Screen for Depression?

1. Depression is the most frequently cited psychological disorder associated with diabetes. It is roughly three times more prevalent in those with diabetes (15-20% of people) than in those without diabetes.
2. Screening improves the accurate identification of depressed patients in primary health care (PHC).
3. Providers may mislabel lack of attention to self-care as non-compliant behavior when, in fact, it may indicate the need to screen for depression.
4. Early recognition of depression symptoms, prompt treatment, and referral lead to improved self-care and quality of life and decreases clinical morbidity.

Symptoms of Depression

The following changes characterize symptoms of depression:

• Decreased ability to cope with changes or challenges in life
• Changes in crying patterns
• Changes in sleeping and eating patterns
• Changes in ability to concentrate
• Changes in sexual desire
• Increased pessimism
• Sense of helplessness
• Thoughts of death or suicide
• Severe sadness
• Loss of interest in usual activities

How to Screen for Depression?

1. Asking two simple questions about mood and anhedonia may be as effective as using any of the longer screening instruments:
   1. "Over the past two weeks have you felt down, depressed, or hopeless?"
   2. "Over the past two weeks, have you felt little interest or pleasure in doing things?"
2. Use formal screening tools, such as the depression scale of the Patient Health Questionnaire, PHQ-9

See the original guideline document for details on the PHQ-9 test and how to interpret results.

Identify and monitor severity of depression every 2-4 weeks. Consult a specialist if there is no improvement.

Assessing Renal Function in CMR

Please see the clinical algorithm "Assessing Renal Function in CMR" in the original guideline document.

Foot Care in DM

Please see the clinical algorithm "Foot Care in DM" in the original guideline document.

Control

Blood Pressure

Please see the clinical algorithms "Initial Approach to High Blood Pressure in PHC" and "BP Control: Chronic Management" in the original guideline document.

Blood Pressure Control: Choice of a Plan

Choice of a plan for blood pressure control depends on the level of the cardiovascular risk (see the original guideline document for a table on stratifying risk and the tables below)

Table. Match CVR with Its Corresponding Plan

Table. Which Anti-hypertensive Agent to Use?

Resistant Hypertension

Hypertension may be termed resistant to treatment, or refractory, when a therapeutic plan that has included attention to lifestyle measures and the prescription of at least three drugs in adequate doses has failed to lower systolic and diastolic blood pressure sufficiently. In these situations, referral to a specialist should be considered, as resistant hypertension is known to be often associated with target organ damage.

Change of Anti-HTN Medications: General Principles

Changing therapy risks new side effects and it may take time to re-establish adequate control of blood pressure. A change of therapy is unlikely to be appropriate in patients on three or more antihypertensive drugs.

Once a hypertensive drug therapy is initiated, most patients should return for follow-up and medication adjustments at least at monthly intervals until BP goal is reached.

If blood pressure goals are not met the clinician has three options for subsequent therapy:

1. Increase the dose of the initial drug toward maximal levels
2. Substitute an agent from another class
3. Add a second drug from another class

Individualized Drug Selection Is Based on Several Principles

1. If the initial response to one drug is:
   • Adequate: continue the same drug
   • Partial: increase the dose or add a second drug of a different class
   • Little: substitute another single drug from a different class
2. Consider low-dose diuretic use early or as a first addition
   • Consider loop diuretic agents instead of thiazide or thiazide-like diuretics when creatinine is >2.0 mg/dL or eGFR <30
3. Do not combine two drugs of the same class
4. Combine agents at medium doses. It can be more effective than a high-dose single agent. In addition, it can result in fewer side effects
5. Combination is more effective if a medicine from column 1 is combined with another from column 2

Hyperglycemia

Please see the clinical algorithms "Initial Management of Symptomatic Hyperglycemia" and "Glycemic Control: Chronic Management" in the original guideline document.

Use of Oral Hypoglycemic (OHG) Agents

• Once an OHG drug therapy is initiated, most patients should return for follow-up and medication every 1-2 weeks until glycemic goal is reached.
• If glycemic goals are not met the clinician has three options for subsequent therapy:
  1. Increase the dose of the initial drug toward maximal levels
  2. Substitute an agent from another class
  3. Add a second drug from another class
• Start metformin use early or as a first addition, unless contraindicated. Begin with low dose and titrate gradually, to avoid gastrointestinal intolerance
• Do not combine two drugs of the same class
• Combine agents at medium doses. It can be more effective than a high-dose single agent. In addition, it can result in fewer side effects

Notes on Use of Insulin in Type 2 Diabetes Mellitus (T2DM)

• Early initiation of insulin would be a safer approach for individuals presenting with weight loss, severe symptoms and random blood sugar (RBS) >250-300 mg/dL.
• Insulin might be added to the oral regimen if glycemic control is not achieved, after the use of two different classes. This has to be done by an expert physician.

Target Glycemic Control

• A_1C <7%
• If A_1C is not available
  • Average fasting blood sugar (FBS) 90–130
  • Average post-prandial blood sugar (PPBS) <180

Assessment of Glycemic Control

Glycemic control is best assessed by A_1C. Please note that:

1. Hemoglobinopathies, hemolysis and blood loss interfere with its accuracy.
2. Fructosamine (reflects glycemic control in the last 1-2 weeks) might be used instead, if available.
3. Average of multiple readings of FBS is a useful tool in achieving glycemic control (done daily or alternately). However, it reflects control over the measurement period only.

Hyperlipidemia

Please see the clinical algorithm "LDL Control: Initiation of Drug Treatment" in the original guideline document.

Notes on the Use of Statins

1. Bedtime or evening dose of statin is more effective (higher cholesterol synthesis).
2. Dosage adjustments should not be made more often than every 4 weeks after a fasting lipid profile.
3. If patients are intolerant to a statin, clinicians are encouraged to have the patient try the other statins in reduced doses before ruling out all statins.
4. If patients are unable to take a statin, then fibric acids and other lipid lowering agents may be used.

Safety Considerations

5. DO
   • Check baseline renal function and TSH prior to initiating statin therapy.
   • Check alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels prior to prescribing a statin and prior to any planned increase in statin dose.
   • Consider the potential for drug-drug interactions when prescribing statins. Vitamin E intake may reduce the benefit of statins.
   • Counsel patients to discontinue statin therapy during a short course of a macrolide antibiotic (erythromycin, azithromycin, and clarithromycin).
   • Be alert for patient characteristics that may increase the risk for myopathy during statin therapy, such as advanced age, renal or liver impairment, diabetes with evidence of hepatic fatty changes, hypothyroidism, surgery, trauma, ischemia-reperfusion, debilitated status, heavy exercise.
   • Provide patient education regarding recognition and reporting of symptoms of myopathy during statin therapy.
   • Suspect myopathy when a statin-treated patient complains of unexplained, generalized muscle pain, tenderness, or weakness. Joint pain, nocturnal leg cramps, or localized pain are not symptoms of myopathy.
   • Assess for signs of dehydration or renal compromise in patients with myopathy.
   • Check creatine kinase (CK) levels when a patient reports symptoms of myopathy.
     • If CK levels are less than 5 times upper limit of normal, repeat measurement in 1 week.
     • If CK levels are elevated to 5 times upper limit of normal or greater, discontinue statin therapy and monitor serum CK levels.
   • Consider referral for patients requiring combination lipid-lowering therapy.

6. DON'T
   • Prescribe high-dose statin therapy for elderly patients and patients with renal insufficiency, or in combination with fibrates.

Note on Starting Long-Term Aspirin Therapy

• Aspirin (ASA) reduces the risk of a cardiovascular event by about 25% over 5 years, in both sexes.
• The decision to use aspirin should be based on a balance of the risks and benefits for each person, taking into account their absolute risk of an event.

ASA Indications

• Very High CV Risk:
  • Commence low-dose ASA (75-150 mg)
• High CV Risk:
  • Commence low-dose ASA (75-150 mg) unless contraindicated. Low-dose ASA is as effective as higher daily doses and may be associated with less side effects.
• Low-Medium CV Risk:
  • The risk of significant adverse effect (bleeding) outweighs the benefits of ASA for the prevention of CVD.

ASA Contraindications

• ASA allergy
• ASA intolerance
• Uncontrolled blood pressure
• Active peptic ulceration
• Any major bleeding risk

The original guideline document contains clinical algorithms for:

• Cardiometabolic Risk (CMR) Screening
• Chronic Management of CMR
• Assessing Renal Function in CMR
• Foot Care in Diabetes Mellitus (DM)
• Initial Approach to High Blood Pressure (BP) in Primary Health Care (PHC)
• BP Control: Chronic Management
• Initial Management of Symptomatic Hyperglycemia
• Glycemic Control: Chronic Management
• Low-Density Lipoprotein (LDL) Control: Initiation of Drug Treatment
• Lifestyle Management (in Arabic only)
• CMR Patient Recall

The type of supporting evidence is not specifically stated for each recommendation. In general, published evidence-based guidelines were used as the basis for the recommendations.

• Quality Improvement Team in Chronic Care (CCQI). Cardiometabolic risk management in primary care. Qatif (Saudi Arabia): Qatif Primary Health Care; 2008. Various p.

Not applicable: The guideline was not adapted from another source.

2008

Qatif Primary Health Care - National Government Agency [Non-U.S.]

Qatif Primary Health Care

Practice Guidelines Writing Committee

Committee Members: Bader Almustafa, MD; Nada Alfaraj, MBBS; Aamal Almobarak, BSc; Nawal Al-Eid, BSc, RN; Farha Almarhoon, RN, RE

Not stated

This is the current release of the guideline.

Several Arabic-language patient educational tools and pamphlets are available in the original guideline document.

Please note: This patient information is intended to provide health professionals with information to share with their patients to help them better understand their health and their diagnosed disorders. By providing access to this patient information, it is not the intention of NGC to provide specific medical advice for particular patients. Rather we urge patients and their representatives to review this material and then to consult with a licensed health professional for evaluation of treatment options suitable for them as well as for diagnosis and answers to their personal medical questions. This patient information has been derived and prepared from a guideline for health care professionals included on NGC by the authors or publishers of that original guideline. The patient information is not reviewed by NGC to establish whether or not it accurately reflects the original guideline's content.

This NGC summary was completed by ECRI Institute on February 12, 2009. The information was verified by the guideline developer on February 14, 2009.

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.