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Sunday, October 07, 2012

Division of Diabetes Treatment and Prevention - Leading the effort to treat and prevent diabetes in American Indians and Alaska Natives

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standards of care and clinical practice recommendations : cardiovascular care

Standards of Care and Clinical Practice
Recommendations: Type 2 Diabetes

Last updated: August 2012

Cardiovascular Care

Cardiovascular disease (CVD) is the major cause of mortality and a significant cause of morbidity for individuals with diabetes, and is the leading cause of death in AI/ANs. To reduce patients’ risk for CVD, it is essential to target both the specific clinical risk factors (i.e., hypertension, dyslipidemia) as well as the underlying CVD lifestyle risk factors (i.e., smoking, nutrition, and physical activity). While glucose control early in the course of diabetes appears to confer some long-term benefit in CVD risk reduction, research has shown that achieving hypertension and dyslipidemia targets confers the most benefit.

Clinical Practice Recommendations

Antiplatelet Therapy

recommendations iconRecommendations for Antiplatelet Therapy

  • Primary Prevention (see Table below):
    • Consider aspirin therapy at 75-162 mg/day in diabetes patients at increased risk for CVD (10-year risk > 10%), including most men > 50 years of age and women > 60 years of age with ≥ 1 other risk factor (i.e., family history of CVD, hypertension, smoking, dyslipidemia, albuminuria).
    • Use clinical judgment on whether to use aspirin in patients with 10-year CVD risk of 5-10%.
    • Aspirin prophylaxis is not recommended in patients with diabetes who are otherwise at low risk for CVD (10-year CVD risk < 5%) because the potential risks associated with bleeding are likely to outweigh potential benefits.
  • Secondary Prevention:
    • Aspirin therapy at 75-162 mg/day is recommended for adults with diabetes and CVD:
      • Clopidogrel may be substituted in aspirin-allergic patients and can be used in combination therapy with aspirin for up to a year after an acute coronary event.

Antiplatelet therapy, including aspirin and clopidogrel, may be used as a primary and a secondary prevention strategy to reduce the risk of CVD events. For primary prevention, the decision as to whether to prescribe aspirin is based on an estimation of the patient’s 10-year CVD risk (Framingham Heart Study Risk Score Profile Exit Disclaimer – You Are Leaving www.ihs.gov ). No specific data support an exact dose of aspirin; however, using lower doses decreases the risk of side effects.

Aspirin Therapy in CVD Primary Prevention

Action 10-year CVD Risk Examples of Patient Groups
Consider aspirin therapy at 75-162 mg/day > 10% Most men > 50 y. and women > 60 y. with ≥ 1 risk factor: family history of CVD, hypertension, smoking, dyslipidemia, albuminuria
Use clinical judgment on whether to use aspirin 5-10% Men < 50 y. and women < 60 y. with multiple other risk factors
Aspirin NOT recommended < 5% Men < 50 y. and women < 60 y. with no additional risk factors

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Assessing CVD Risk

recommendations iconRecommendations for Assessing CVD Risk

  • Assess each patient’s CVD risk at diabetes diagnosis and routinely thereafter until CVD is diagnosed.
  • Tailor treatment and education interventions to each patient’s CVD risk and life context.

In diabetes patients without known CVD, it is important to calculate each patient’s CVD risk to determine appropriate risk reduction treatment goals and strategies. The Framingham Heart Study Risk Score Profile Exit Disclaimer – You Are Leaving www.ihs.gov for 10-year risk of coronary heart disease is used most often for this purpose.

Another option for calculating coronary heart disease risk in AI/AN patients is the Strong Heart Study risk calculator. Exit Disclaimer – You Are Leaving www.ihs.gov Based on data collected among adults in thirteen American Indian Tribes in Arizona, North Dakota, South Dakota, and Oklahoma over the study’s 10-year period, the Strong Heart Study risk calculator is an appropriate tool to help determine treatment goals to reduce CVD risk in AI (and AN) patients.

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Blood Pressure (BP) Management

recommendations iconRecommendations for Blood Pressure

  • Measure BP at diabetes diagnosis and at every diabetes visit:
    • Ambulatory/home monitoring may be considered to assist providers in assessing hypertension diagnosis and control.
  • Set and achieve individualized BP targets (e.g., < 130/80 mmHg, < 140/90 mmHg, etc.) for all patients with diabetes:
    • Blood pressure targets in youth vary by gender, age, and height. See section on youth for separate BP recommendations.
  • Prescribe an angiotensin-converting enzyme (ACE) inhibitor or angiotensin II receptor (ARB) for all patients with diabetes and hypertension, unless contraindicated.

BP control reduces the risk for diabetic microvascular and macrovascular complications, and is essential in diabetes care. The 2011 IHS Diabetes Care and Outcomes Audit shows that, on average, AI/AN patients with diabetes are achieving excellent BP control, with a mean of 131/75 mmHg. Use of ACE inhibitors or ARB blockers has benefits not only for controlling BP but also for reducing albuminuria, a CVD risk marker.

BP treatment requires diligent efforts to achieve targets. For those patients who can achieve a BP of < 130/80 mmHg without adverse symptoms, this target may be selected. For other patients, a target of < 140/90 mmHg (or higher if symptoms and comorbidities dictate) should be selected. Ensuring that patients with diabetes achieve and maintain individualized BP targets over the long term will improve outcomes for AI/AN patients.

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Lipids Management

recommendations iconRecommendations for Lipids

  • Obtain a complete lipid profile (total cholesterol, LDL, HDL, triglycerides) at diabetes diagnosis and annually thereafter:
    • More frequent testing may be required to assess therapeutic responses from therapies such as medical nutrition therapy and pharmacotherapy;
    • A fasting lipid profile is preferred. Until one can be obtained, reasonable assessments of lipid status can be made based on either a non-fasting lipid profile or a direct LDL cholesterol measurement.
  • Implement a treatment plan to achieve lipid goals:
    • Prescribe statin therapy, unless contraindicated, regardless of baseline lipid levels for:
      • diabetes patients with CVD, or
      • diabetes patients without overt CVD who are > 40 years of age and have ≥ 1 other CVD risk factor, or
    • Consider statin therapy for diabetes patients without overt CVD who are < 40 years of age with multiple CVD risk factors
    • For patients with elevated lipid levels, prescribe statin treatment to achieve lipid targets (LDL cholesterol < 100 mg/dL if no CVD, < 70mg/dL if CVD).
      • If patients do not reach these targets on the highest tolerated statin dose, a reduction of 30-40% from baseline is an alternative therapeutic goal.

→ Note: Lipid-lowering medications, especially used in combination, may adversely affect the liver. Consider baseline and interval laboratory assessment of liver enzymes.

→ Note: Statins are highly unsafe in pregnancy and are classified as Category X. Consider pregnancy risk when prescribing statins for reproductive age women.

Lipid control in patients with diabetes is essential for reducing risk for macrovascular complications. The IHS Diabetes Care and Outcomes Audit data show that lipid control has been improving steadily among AI/AN patients with diabetes. LDL cholesterol levels have declined over the past decade, reaching an average level below 100 mg/dL.

Patients with type 2 diabetes have an increased prevalence of lipid abnormalities, including high triglycerides and low HDL cholesterol levels. This pattern is a marker for small atherogenic LDL cholesterol particles that increase CVD risk, even when LDL cholesterol levels are not elevated. Recent research has shown that non-HDL cholesterol (total cholesterol minus HDL cholesterol) may be an even stronger measure of atherogenic load than LDL cholesterol alone. Therefore, it is reasonable to consider non-HDL cholesterol as a secondary lipid management target (< 130 mg/dL if no CVD, < 100 mg/dL if CVD).

The most effective pharmacologic treatment to reduce risk for CVD events is statin therapy. Statins reduce CVD risk beyond LDL cholesterol reduction alone. While other classes of medications (e.g., fibrates, niacin, ezetimibe, and bile acid sequestrants) lower lipid values, research has not demonstrated that they reduce CVD risk. If the LDL cholesterol target is not achieved on a statin alone, combination therapy may be considered, however this has not been evaluated in studies for either CVD outcomes or safety. For patients who cannot tolerate one statin, it is reasonable to try using a different statin. If no statin is tolerated, a non-statin medication to lower LDL cholesterol may be considered, however, research has not demonstrated efficacy in reducing CVD risk in people with diabetes.

Lifestyle therapy, including MNT addressing fat and cholesterol intake, increased physical activity, weight loss, and smoking cessation, is indicated for any patient with type 2 diabetes, even those with “normal” lipid levels.

Goals for Lipid Control in Patients with Type 2 Diabetes

Target Lipid Goal

* Non-HDL = Total Cholesterol minus HDL
Primary target LDL < 100 mg/dL, if no CVD
< 70 mg/dL, if CVD
Secondary target Non-HDL* < 130 mg/dL, if no CVD;
< 100 mg/dL, if CVD
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Peripheral Arterial Disease (PAD)

recommendations iconRecommendations for Peripheral Arterial Disease

  • Assist patients who smoke to quit. See the section on tobacco use.
  • Obtain a history of claudication symptoms and assess pedal pulses as part of routine diabetes care.
  • Obtain an Ankle-Brachial Index (ABI) in patients with diabetes:
    • Screen all patients with diabetes > 50 years of age.
    • In addition, consider a screening ABI in patients < 50 years of age who have ≥ 1 additional PAD risk factor, including smoking, hypertension, hyperlipidemia, or duration of diabetes > 10 years.
    • Obtain a diagnostic ABI in any patient with suspected lower extremity (LE) PAD, including those with abnormal pulses, symptoms of claudication, or non-healing LE wounds.
    • ABI results are defined as follows: abnormal < 0.9; normal range is 0.9-1.4.
  • Refer patients with either significant symptoms or an abnormal ABI for vascular evaluation.
  • Order one-time ultrasound screening for abdominal aortic aneurysm (AAA) in men aged 65 to 75 years who have ever smoked and in patients ≥ 65 years of age with a family history of AAA.

PAD is atherosclerosis of arteries to the head, organs, and limbs. PAD manifests most commonly in patients with diabetes as symptoms of leg claudication. If left untreated, PAD can progress to critical leg ischemia that can threaten limb viability. Moreover, PAD is a marker of systemic atherosclerosis, indicating patients are at increased risk for myocardial infarction (MI), stroke, and death. Risk factors associated with PAD include older age, cigarette smoking, diabetes, hypercholesterolemia, hypertension, and possibly genetic factors.

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Resources

Tools for Clinicians and Educators

tools and resources iconKey Tools and Resources

Antiplatelet Therapy

Aspirin for Primary Prevention of Cardiovascular Events in People with Diabetes: A Position Statement of the American Diabetes Association, a Scientific Statement of the American Heart Association, and an Expert Consensus Document of the American College of Cardiology Foundation Exit Disclaimer – You Are Leaving www.ihs.gov [PDF]. 2010.

Assessing CVD Risk

IHS Division of Diabetes Treatment and Prevention.

2010 ACCF/AHA Guideline for Assessment of Cardiovascular Risk in Asymptomatic Adults: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Exit Disclaimer – You Are Leaving www.ihs.gov [PDF] Circulation. 2010;122:e584-636.

AHA/ADA Scientific Statement. Primary Prevention of Cardiovascular Diseases in People with Diabetes Mellitus: A Scientific Statement from the American Heart Association and the American Diabetes Association. Exit Disclaimer – You Are Leaving www.ihs.gov [PDF] Circulation. 2007;115:114-26.

Blood Pressure (BP) Management

IHS Division of Diabetes Treatment and Prevention.
Diabetes Treatment Algorithm - Type 2 Diabetes and Hypertension [PDF - 93KB]

National High Blood Pressure Education Program. National Heart, Lung, and Blood Institute. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Exit Disclaimer – You Are Leaving www.ihs.gov NIH Publication No. 04-5230. 2004.

Lipids Management

IHS Division of Diabetes Treatment and Prevention.
Diabetes Treatment Algorithm - Type 2 Diabetes - Lipid and Aspirin Therapy [PDF - 515KB]

National Heart, Lung, and Blood Institute. National Institutes of Health.

Peripheral Arterial Disease

2011 ACCF/AHA Focused Update of the Guideline for the Management of Patients with Peripheral Artery Disease Exit Disclaimer – You Are Leaving www.ihs.gov (Updating the 2005 Guideline). A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2011;58:2020-45, doi:10.1016/j.jacc.2011.08.023 (Published online 29 Sep 2011).

PAD Coalition. Exit Disclaimer – You Are Leaving www.ihs.gov Web-based resources for health professionals include Webcasts on PAD topics, online CME, and conference proceedings.

additional resources iconAdditional Resources

National Heart, Lung, and Blood Institute and Indian Health Service. Honoring the Gift of Heart Health: A Heart Health Educator’s Manual for American Indians. Exit Disclaimer – You Are Leaving www.ihs.gov [PDF] NIH Publication No. 06-5218. 2006. 303 p.

  • A culturally appropriate, user-friendly, ten-lesson course on heart health education for the American Indian community. The manual is filled with skill-building activities, reproducible handouts, and idea starters.

National Heart, Lung, and Blood Institute and Indian Health Service. Honoring the Gift of Heart Health: A Heart Health Educator’s Manual for Alaska Natives. Exit Disclaimer – You Are Leaving www.ihs.gov [PDF] NIH Publication No. 06-5219. 2006. 309 p.

  • A culturally appropriate, user-friendly, ten-lesson course on heart health education for the Alaska Native community. A comprehensive culturally appropriate, user-friendly 10 lesson course on heart-health education for the Alaska Native community. Filled with skill-building activities, reproducible handouts, and idea starters.

Patient Education Materials

Cardiovascular Care

National Diabetes Education Program. Take Care of Your Heart. Manage Your Diabetes. Exit Disclaimer – You Are Leaving www.ihs.gov [PDF] 2005.

  • One-page flyer features AI/AN people and talks about the link between diabetes and heart disease, questions to ask your provider, self-care actions to take, and goals for A1C, blood pressure, and cholesterol.

National Heart, Lung, and Blood Institute. Dietary Approaches to Stop Hypertension (DASH) Eating Plan. Exit Disclaimer – You Are Leaving www.ihs.gov [PDF] NIH Publication No. 06-4082. 2006. 58 p.

  • Based on the DASH research findings, this booklet describes how to follow the DASH eating plan, reduce saturated fat and cholesterol, and offers tips on healthy eating and meal planning, including recipes and menus.

National Heart, Lung, and Blood Institute. Your Guide to Lowering Cholesterol with Therapeutic Lifestyle Changes (TLC). Exit Disclaimer – You Are Leaving www.ihs.gov [PDF] NIH Publication No. 06–5235. 2005. 82 p.

  • This booklet explains how to follow the TLC diet (low in saturated fat, trans fat, and dietary cholesterol), increase physical activity, and manage weight for people whose cholesterol level is above their goal.

National Institute of Diabetes and Digestive and Kidney Diseases. Prevent Diabetes Problems: Keep Your Heart and Blood Vessels Healthy. Exit Disclaimer – You Are Leaving www.ihs.gov [PDF] NIH Publication No. 09–4283. 2009.

  • Easy-to-read illustrated booklet describing diabetes self-care to reduce risk for cardiovascular problems caused by diabetes (available in large or standard format).

Lipid Management

Jellinger PS, Smith DA, Mehta AE, Ganda O, Handelsman Y, Rodbard HW, et al. American Association of Clinical Endocrinologists’ (AACE) guidelines for management of dyslipidemia and prevention of atherosclerosis. Exit Disclaimer – You Are Leaving www.ihs.gov [PDF] Endocr Pract. 2012 Mar/Apr;18(Suppl 1):1-78.

Peripheral Arterial Disease (PAD)

PAD Coalition. Exit Disclaimer – You Are Leaving www.ihs.gov

  • Web-based reproducible patient education tip sheets for controlling PAD and related risk factors.
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Bibliography

Antiplatelet Therapy

Belch J, MacCuish A, Campbell I, Cobbe S, Taylor R, Prescott R, et al. The prevention of progression of arterial disease and diabetes (POPADAD) trial: factorial randomised placebo controlled trial of aspirin and antioxidants in patients with diabetes and asymptomatic peripheral arterial disease. BMJ. 2008;337:a1840. http://www.bmj.com/content/337/bmj.a1840.pdf%2Bhtml Exit Disclaimer – You Are Leaving www.ihs.gov [PDF]

Pignone M, Alberts MJ, Colwell JA, Cushman M, Inzucchi SE, Mukherjee D, et al.; American Diabetes Association; American Heart Association; American College of Cardiology Foundation. Aspirin for primary prevention of cardiovascular events in people with diabetes: a position statement of the American Diabetes Association, a scientific statement of the American Heart Association, and an expert consensus document of the American College of Cardiology Foundation. Diabetes Care. 2010;33:1395-1402. http://care.diabetesjournals.org/content/33/6/1395.full.pdf+html Exit Disclaimer – You Are Leaving www.ihs.gov [PDF]

Blood Pressure Management

Action to Control Cardiovascular Risk in Diabetes (ACCORD) Study Group. Effects of intensive blood-pressure control in type 2 diabetes. N Eng J Med. 2010 Apr 29;362:1575-85.

Cushman WC, Evans GW, Byington RP, Goff DC, Grimm RH, Cutler JA, et al.; ACCORD Study Group. Effects of intensive lifestyle blood-pressure control in type 2 diabetes mellitus. N Engl J Med. 2010 Apr 29;362:918-29. http://www.nejm.org/doi/pdf/10.1056/NEJMoa1001286 Exit Disclaimer – You Are Leaving www.ihs.gov [PDF]

Friedman E. Optimizing care in diabetes: a quixotic challenge. Diabetes Care. 2012 Jun;35(6):1204-5.

Holman RR, Paul SK, Bethel MA, Neil AW, Matthews DR. Long-term follow-up after tight control of blood pressure in type 2 diabetes. N Eng J Med. 2008;359(15):1565-76.

Indian Health Service diabetes care and outcomes audit, unpublished data. Albuquerque (NM): Department of Health and Human Services (US), Indian Health Service, Office of Clinical and Preventive Services, Division of Diabetes Treatment and Prevention; 2011.

Mancia G, Schumacher H, Redon J, Verdecchia P, Schmieder R, Jennings G, et al.  Blood pressure targets recommended by guidelines and incidence of cardiovascular and renal events in the ONgoing Telmisartan Alone and in combination with Ramipril Global Endpoint Trial (ONTARGET). Circulation.2011 Oct 18; 124: 1727-36. http://circ.ahajournals.org/content/124/16/1727.full.pdf+html Exit Disclaimer – You Are Leaving www.ihs.gov [PDF]

National High Blood Pressure Education Program. The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Bethesda (MD): Department of Health and Human Services (US), National Institutes of Health, National Heart, Lung, and Blood Institute; 2004 Aug. 88 p. (NIH Publication No. 04-5230).

Redon J, Mancia G, Sleight P, Schumacher H, Gao P, Pogue J, ONTARGET Investigators, et al. Safety and efficacy of low blood pressures among patients with diabetes: subgroup analyses from the ONTARGET (ONgoing Telmisartan Alone and in combination with Ramipril Global Endpoint Trial). J Am Coll Cardiol. 2012 Jan 3;59(1):74-83. http://circ.ahajournals.org/content/124/16/1727.full Exit Disclaimer – You Are Leaving www.ihs.gov

Sacks FM, Svetkey LP, Vollmer WM, Appel LJ, Bray GA, Harsha D, et al.; the DASH-Sodium Collaborative Research Group. Effects on blood pressure of reduced dietary sodium and the dietary approaches to stop hypertension (DASH) diet. N Engl J Med. 2001 Jan 4;344(1):3-10.

United Kingdom Prospective Diabetes Study (UKPDS) Group. Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS. BMJ. 1998;317:703-13.

World Health Organization, International Society of Hypertension Writing Group. 2003 World Health Organisation (WHO) International Society of Hypertension (ISH) statement on management of hypertension. J Hypertens. 2003;21:1983–1992. http://www.who.int/cardiovascular_diseases/guidelines/hypertension_guidelines.pdf Exit Disclaimer – You Are Leaving www.ihs.gov [PDF]

Zhang Y, Galloway JM, Welty TK, Wiebers DO, Whisnant JP, Devereaux RB, et al. Incidence and risk factors for stroke in American Indians: the Strong Heart Study. Circulation. 2008;118:1577-84.

Cardiovascular Care

Action to Control Cardiovascular Risk in Diabetes (ACCORD) Study Group. Effects of intensive glucose lowering in type 2 diabetes. N Engl J Med. 2008;358(24):2545-59. http://www.nejm.org/doi/pdf/10.1056/NEJMoa0802743 Exit Disclaimer – You Are Leaving www.ihs.gov [PDF]

ADVANCE Collaborative Group. Intensive blood glucose control and vascular outcomes in patients with type 2 diabetes. N Engl J Med. 2008;358(24):2560-72. http://www.nejm.org/doi/pdf/10.1056/NEJMoa0802987 Exit Disclaimer – You Are Leaving www.ihs.gov [PDF]

Buse JB, Ginsberg HN, Bakris GL, Clark NG, Costa F, Eckel R, et al. AHA/ADA scientific statement: primary prevention of cardiovascular diseases in people with diabetes mellitus: a scientific statement from the American Heart Association and the American Diabetes Association. Circulation. 2007;115:114-26. http://circ.ahajournals.org/content/115/1/114.full.pdf+html Exit Disclaimer – You Are Leaving www.ihs.gov [PDF]

Duckworth W, Abraira C, Moritz T, Reda D, Emanuele N, Reaven PD, et al. Glucose control and vascular complications in veterans with type 2 diabetes. N Engl J Med. 2009 Jan 8;360:129-39. http://www.nejm.org/doi/pdf/10.1056/NEJMoa0808431 Exit Disclaimer – You Are Leaving www.ihs.gov [PDF]

Greenland P, Alpert JS, Beller GA, Benjamin EJ, Budoff MJ, Fayad ZA, et al. 2010 ACCF/AHA guideline for assessment of cardiovascular risk in asymptomatic adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, 2010. Circulation. 2010 Nov 12;122:e584-e636. http://circ.ahajournals.org/content/122/25/2748.full.pdf+html Exit Disclaimer – You Are Leaving www.ihs.gov [PDF]

Lee ET, Howard BV, Wang W, Welty TK, Galloway JM, Best LG, et al. Prediction of coronary heart disease in a population with high prevalence of diabetes and albuminuria: the Strong Heart Study. Circulation. 2006;113(25):2897-2905. http://circ.ahajournals.org/content/113/25/2897.full.pdf+html Exit Disclaimer – You Are Leaving www.ihs.gov [PDF]

Skyler JS, Bergenstal R, Bonow RO, Buse J, Deedwania P, Gale EAM, et al. Intensive glycemic control and the prevention of cardiovascular events: implications of the ACCORD, ADVANCE, and VA Diabetes Trials: a position statement of the American Diabetes Association and a scientific statement of the American College of Cardiology Foundation and the American Heart Association. J Am Coll Cardiol. 2009; 53:298-304. http://content.onlinejacc.org/article.aspx?articleid=1139360 Exit Disclaimer – You Are Leaving www.ihs.gov

Wilson PWF, Meigs JB, Sullivan L, Fox CS, Nathan DM, D’Agostino RB. Prediction of incipient diabetes mellitus in middle-aged adults: the Framingham Offspring Study. Arch Intern Med. 2007;167:1068-74. http://archinte.jamanetwork.com/article.aspx?articleid=486842 Exit Disclaimer – You Are Leaving www.ihs.gov

Lipid Management

ACCORD Study Group. Effects of combination lipid therapy in type 2 diabetes mellitus. N Engl J Med. 2010 Apr 29;362:1563-74. http://www.nejm.org/doi/pdf/10.1056/NEJMoa1001282 Exit Disclaimer – You Are Leaving www.ihs.gov [PDF]

Brunzell JD, Davidson M, Furberg CD, Goldberg RB, Howard BV, Stein JH. Lipoprotein management in patients with cardiometabolic risk: consensus statement from the American Diabetes Association and the American College of Cardiology Foundation. Diabetes Care. 2008 Apr;31(4): 811-22. http://care.diabetesjournals.org/content/31/4/811.full.pdf+html Exit Disclaimer – You Are Leaving www.ihs.gov [PDF]

Heart Protection Study Collaborative Group. MRC/BHF heart protection study of cholesterol lowering with simvastatin in 5963 people with diabetes: a randomized placebo-controlled trial. Lancet. 2003;361:2005-16. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2802%2909327-3/abstract Exit Disclaimer – You Are Leaving www.ihs.gov

Indian Health Service diabetes care and outcomes audit, unpublished data. Albuquerque (NM): Department of Health and Human Services (US), Indian Health Service, Office of Clinical and Preventive Services, Division of Diabetes Treatment and Prevention; 2011.

Liu J, Sempos C, Donahue RP, Dorn J, Trevisan M, Grundy SM. Joint distribution of non-HDL and LDL cholesterol and coronary heart disease risk prediction among individuals with and without diabetes. Diabetes Care. 2005;28(8):1916-21. http://care.diabetesjournals.org/content/28/8/1916.full.pdf+html Exit Disclaimer – You Are Leaving www.ihs.gov [PDF]

Lu W, Resnick HE, Jablonski KA, Jones KL, Jain AK, Howard WJ, et al. Non-HDL cholesterol as a predictor of cardiovascular disease in type 2 diabetes: the Strong Heart Study. Diabetes Care. 2003;26(1):16-23. http://care.diabetesjournals.org/content/26/1/16.full.pdf+html Exit Disclaimer – You Are Leaving www.ihs.gov [PDF]

National Cholesterol Education Program. Third report of the expert panel on detection, evaluation, and treatment of high blood cholesterol in adults (ATP III final report). Bethesda (MD): National Heart, Lung, and Blood Institute (US); 2002 Sep. 280 p. (NIH Publication No. 02-5215). http://www.nhlbi.nih.gov/guidelines/cholesterol/atp3full.pdf Exit Disclaimer – You Are Leaving www.ihs.gov [PDF]

Wing RR, Lang W, Wadden TA, Safford M, Knowler WC, Bertoni AG, et al.; Look AHEAD Research Group. Benefits of weight loss in improving cardiovascular risk factors in overweight and obese individuals with type 2 diabetes. Diabetes Care. 2011;34(7):1481-6. http://care.diabetesjournals.org/content/34/7/1481.full.pdf+html Exit Disclaimer – You Are Leaving www.ihs.gov [PDF]

Peripheral Arterial Disease

Lamar Welch VL, Casper M, Greenlund K, Zheng ZJ, Giles W, Rith-Najarian S. Prevalence of lower extremity arterial disease defined by the ankle-brachial index among American Indians: the Inter-Tribal Heart Project. Ethn Dis. 2002;12(1):S1-63-7. http://www.ncbi.nlm.nih.gov/pubmed/11915849 Exit Disclaimer – You Are Leaving www.ihs.gov

Mehler PS, Coll JR, Estacio R, Esler A, Schrier RW, Hiatt WR. Intensive blood pressure control reduces the risk of cardiovascular events in patients with peripheral arterial disease and type 2 diabetes. Circulation. 2003;107(5):753-6. http://circ.ahajournals.org/content/107/5/753.full.pdf+html Exit Disclaimer – You Are Leaving www.ihs.gov [PDF]

Resnick HE, Lindsay RS, McDermott MM, Devereux RB, Jones KL, Fabsitz RR, et al. Relationship of high and low ankle brachial index to all-cause and cardiovascular disease mortality: the Strong Heart Study. Circulation. 2004;109(6):733-9. http://circ.ahajournals.org/content/109/6/733 Exit Disclaimer – You Are Leaving www.ihs.gov

Rooke TW, Hirsch AT, Misra S, Sidawy AN, Beckman JA, Findeiss LK, et al. 2011 ACCF/AHA focused update of the guideline for the management of patients with peripheral artery disease (updating the 2005 guideline); a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2011;58:2020-45. Epub 2011 Sep 29. http://content.onlinejacc.org/cgi/content/full/j.jacc.2011.08.023 Exit Disclaimer – You Are Leaving www.ihs.gov

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Division of Diabetes Treatment and Prevention | Phone: (505) 248-4182 | Fax: (505) 248-4188 | diabetesprogram@ihs.gov