Diabetes mellitus and stroke: A clinical update

Table 6 Recommendations for cardiovascular risk factor management in patients with diabetes

Condition	Supporting literature
Hyperglycaemia
Targeting HbA1c < 6.5% to reduce cardiovascular events is not beneficial and is harmful when compared with a target of 7.0%	ACCORD[56], ADVANCE[57]
Hypertension
BP < 140/90 mmHg improves risk of cardiovascular and cerebrovascular outcomes (33)	UKPDS[55]
Targeting sBP < 120 does not improve cardiovascular outcomes and is associated with increased risk of adverse side effects	ACCORD-BP[69]
Antagonist of renin-angiotensin system is associated with cardiovascular benefits	HOPE[71]
Dyslipidaemia
All patients age > 40 yr, with or without history of atherosclerotic vascular disease, should receive statin therapy	HPSC[89], CARDS[90]
Use of ezetimibe with statin therapy can improve cardiovascular outcome in patients with a recent acute coronary syndrome and LDL > 50 mg/dL (1.3 mmol/L)	IMPROVE-IT[100]
Use of fibrates may be effective in selected patients with HDL < 34 mg/dL (0.9 mmol/L) and triglycerides > 204 mg/dL (2.3 mmol/L)	FIELD[101]
Obesity
Intensive lifestyle intervention with diet, physical activity, and medical therapy improves quality of life and physical function	Look AHEAD[81]
Metabolic surgery has been shown to improve long- term cardiovascular outcomes	SOS[82]
Antiplatelet therapy
Aspirin use in acute coronary syndrome treatment and in secondary prevention has been established	ISIS-2[127]
Clopidogrel use in secondary prevention reduces more cardiovascular outcomes and causes fewer bleeding complications compared to aspirin in diabetic patients	CAPRIE[116]
In patients with acute TIA or minor stroke, combination of clopidogrel and aspirin is superior to aspirin alone for reducing risk of stroke in the first 90 d without increasing risk of haemorrhage	CHANCE[117]
Use of aspirin in primary prevention has not been shown to improve cardiovascular outcomes	JPAD[128]
Low-dose aspirin use for primary prevention of cardiovascular disease in adults who have a 10% or greater 10-yr cardiovascular risk, are not at increased risk of bleeding, and are willing to take daily aspirin for at least 10 yr	USPSTF[129]

ACCORD: Action to Control Cardiovascular Risk in Diabetes; UKPDS: United Kingdom Prospective Diabetes Study; ACCORD-BP: Action to Control Cardiovascular Risk in Diabetes-Blood Pressure; HOPE: Heart Outcomes Prevention Evaluation; CARDS: Collaborative AtoRvastatin Diabetes Study; FIELD: Fenofibrate Intervention and Event Lowering in Diabetes; Look AHEAD: Look Action for HEAlth in Diabetes; CAPRIE: Clopidogrel vs Aspirin in Patients at Risk of Ischemic Events; CHANCE: Clopidogrel in High-risk patients with Acute Nondisabling Cerebrovascular Events; JPAD: Japanese Primary Prevention of Atherosclerosis with Aspirin for Diabetes; USPSTF: United States Preventive Services Task Force;; sBP: Systolic blood pressure; LDL: Low-density lipoprotein; HDL: high density lipoprotein.