American Diabetes Association Standards for CVD Risk Reduction: Key Points

The following are key points to remember from sections of a 2023 American Diabetes Association (ADA) Standards of Care in Diabetes document on risk management for cardiovascular disease (CVD) and chronic kidney disease:

1. The ADA recommends using the American College of Cardiology/American Heart Association (ACC/AHA) atherosclerotic CVD (ASCVD) Risk Estimator Plus tool (https://tools.acc.org/ASCVD-Risk-Estimator-Plus/#!/calculate/estimate/) to estimate the patient’s 10-year risk of a first ASCVD event.
2. The ADA defines hypertension (HTN) in accords with the ACC/AHA as a blood pressure ≥130/80 mm Hg with a target goal of <130/80 mm Hg.
3. For patients with HTN and coronary artery disease (CAD) needing single antihypertensive therapy, an angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker is recommended, and if two-drug therapy is needed, the second drug recommended is a dihydropyridine calcium channel blocker or thiazide diuretic.
4. For primary prevention of ASCVD in patients at high risk and a low-density lipoprotein (LDL) cholesterol ≥70 mg/dL, the addition of either ezetimibe or a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor is recommended.
5. For secondary prevention of ASCVD, if an LDL goal of 55 mg/dL is not achieved with maximally tolerated statin, the addition of either ezetimibe or a PCSK9 inhibitor is recommended.
6. While the use of a fibric acid derivative or fish oils could be used to reduce pancreatitis risk in patients with triglycerides of ≥500 mg/dL, icosapent ethyl can be considered in addition to statin for those with triglycerides 135-499 mg/dL. Use of niacin or fibric acid derivation with a statin should be avoided.
7. Aspirin therapy (75-162 mg/day) can be considered for primary prevention for patients at intermediate or high risk of ASCVD with patient-shared decision-making, but is not recommended in patients <50 years of age without at least one ASCVD risk factor.
8. For patients with established ASCVD or multiple other risk factors for ASCVD, either a sodium–glucose cotransporter 2 (SGLT2) inhibitor (in patients with estimated glomerular filtration rate [eGFR] ≥20 mL/min/1.73 m2) or a glucagon-like peptide-1 receptor agonist (GLP-1 RA) (in patients with estimated eGFR ≥20 mL/min/1.73 m2) with demonstrated benefit is recommended for reduction in major CV events or kidney events, and combined therapy may be considered for additive benefits.
9. In patients with heart failure with either reduced or preserved left ventricular ejection fraction, an SGLT2 inhibitor with proven benefit in reducing worsening heart failure or CV death is recommended.
10. Diabetic kidney disease is defined as either reduced eGFR or albuminuria or both without other apparent causes. The eGFR should be estimated with the 2021 Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) creatinine equation (without specification of race). In patients with diabetic kidney disease, either an SGLT2 inhibitor (in patients with estimated eGFR ≥20 mL/min/1.73 m), GLP-1 RA (in patients with eGFR ≥25 mL/min/1.73 m2), or a nonsteroidal mineralocorticoid receptor antagonist (e.g., finerenone) (in patients with estimated eGFR ≥25 mL/min/1.73 m2) is recommended for CV risk reduction.