Last updated March 14, 2022

Primary Prevention of ASCVD and T2DM in Patients at Metabolic Risk

Diagnosis

Definitions and Diagnosis

1.1: In individuals aged 40–75 years in the office setting, ES suggests providers screen for all five components of metabolic risk at the clinical visit. The finding of at least three components should specifically alert the clinician to a patient at metabolic risk (at higher risk for ASCVD and T2DM). ( 2-VL )

Technical Remarks:

  • The main components of metabolic risk as defined in this guideline are 1) elevated blood pressure, 2) increased waist circumference, 3) elevated fasting triglycerides, 4) low high-density lipoprotein-cholesterol (HDL-C), and 5) elevated glycemia.
  • Elevated glycemia should be determined either by hemoglobin A1c, fasting glucose, or 2-hour glucose with a second test for confirmation using a new blood sample.
  • Testing for additional biological markers (e.g., high-sensitivity C-reactive protein) associated with metabolic risk should be limited to subpopulations.
  • This recommendation is specifically for adults aged 40–75 years, those for whom the interventions have the greatest impact and evidence for efficacy. This does not restrict screening for appropriate individuals outside of this age range, especially those who are younger.
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1.2: In individuals aged 40–75 years in the office setting who do not yet have ASCVD or T2DM and already have at least one risk factor, we advise screening every 3 years for all five components of metabolic risk as part of the routine clinical examination. ( UGPS )
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1.3: To establish metabolic risk in the general population, ES recommends that clinicians measure waist circumference as a routine part of the clinical examination. ( 1-M )

Technical Remarks:

  • This measurement does not replace the routine measurement of weight or calculation of body mass index but can provide more focused information regarding risk for ASCVD and T2DM.
  • The writing committee agrees that the cutoffs for elevated waist circumference should be ≥102 cm for men and ≥88 cm for women in Caucasian, African, Hispanic, and Native American populations.
  • The writing committee agrees that the cutoffs for waist circumference in Asian populations (both East Asian and South Asian) should be ≥90 cm for men and ≥80 cm for women.
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1.4: In individuals previously diagnosed with prediabetes, ES suggests testing at least annually for the presence of overt T2DM. ( 2-M )

Technical Remark:

  • Prediabetes is defined in a variety of ways ( fasting plasma glucose, 2-hour plasma glucose following a 75-g oral glucose tolerance test, or hemoglobin A1c) by different organizations in different countries, and the writing committee does not endorse preferential use of one definition over another.
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1.5: ES recommends that all individuals at metabolic risk in the office setting have their blood pressure measured annually and, if elevated, at each subsequent visit. ( 1-H )

Technical Remarks:

  • Blood pressure should be measured after five minutes of rest.
  • Ambulatory and/or home blood pressure monitoring, if performed correctly, is recommended to confirm a diagnosis of hypertension after initial screening.
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1.6: For individuals with elevated blood pressure >130 mmHg systolic and/or 80 mmHg diastolic who are not documented as having a history of hypertension, ES recommends confirmation of elevated blood pressure on a separate day within a few weeks or with a home blood pressure monitor ( 1-H )
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Treatment
Lifestyle and Behavioral Therapy
2.1: In individuals at metabolic risk, ES recommends that lifestyle modification be first-line therapy. ( 1-H )

Technical Remark:

  • The writing committee believes that primary care providers, endocrinologists, geriatricians and cardiologists should initiate discussions about the importance of adopting a healthy lifestyle with all individuals at metabolic risk. These and other relevant providers should encourage individuals to join comprehensive programs led by trained health professionals which support the adoption of healthy lifestyles, including diet and physical activity, aiming for moderate but sustained weight loss.
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2.2: For individuals at metabolic risk with excess weight (defined by body mass index and/or waist circumference), ES recommends that comprehensive programs to support the adoption of a healthy lifestyle should aim to achieve a weight loss of ≥5% of initial body weight over the first year. (1-H)

Technical Remark:

  • Maintenance of weight loss by adoption of sustainable healthy behaviors should be encouraged with continuing support of primary providers and/or extended programs.
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2.3: In individuals at metabolic risk, ES recommends prescribing a cardiovascular-healthy diet. (1-M)

Technical Remarks:

  • Providers can offer dietary recommendations based on common components of healthy cardiovascular dietary patterns to all individuals at metabolic risk.
  • Specific dietary changes according to individual risk profiles could be supported with the help of a nutrition specialist in addition to the primary care provider.
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2.4: In individuals at metabolic risk, ES recommends prescribing daily physical activity, such as brisk walking, and reduction in sedentary time. (1-M)

Technical Remark:

  • Providers should encourage all individuals at metabolic risk to adopt an active lifestyle by walking and reducing the amount of time in sedentary activities. Structured activity programs may be added with the help of an exercise specialist for appropriate individuals.
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Medical and Pharmacological Therapy
Risk Assessment and Evaluation
3.1: In individuals identified as having metabolic risk, ES recommends global assessment of 10-year risk for either coronary heart disease or ASCVD to guide the use of medical or pharmacological therapy. ( 1-M )

Technical Remarks:

  • Global risk assessment includes the use of one of the established cardiovascular risk equations.
  • Elevated low-density lipoprotein (LDL) is indicative of cardiovascular risk.
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3.2: In individuals with low density lipoprotein-cholesterol (LDL-C) ≥190 mg/dL (4.9 mmol/L) or triglycerides ≥500 mg/dL (<5.6 mmol/L), ES recommends that, before considering the diagnosis of primary hyperlipidemia, practitioners should rule out secondary causes of hyperlipidemia. If a secondary cause can be excluded, primary hyperlipidemia should be suspected. ( 1-M )

Technical Remark:

  • Examples of secondary causes of hyperlipidemia include untreated hypothyroidism, nephrotic syndrome, renal failure, cholestasis, acute pancreatitis, pregnancy, polycystic ovarian disease, excess alcohol use, treatment with estrogens/oral contraceptives, antipsychotic agents, glucocorticoids, cyclosporine, protease inhibitors, retinoids, and beta blockers.
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Cholesterol Reduction
3.3: In individuals 40–75 years of age with LDL-C ≥190 mg/dL (≥5.9 mmol/L), ES recommends high-intensity statin therapy to achieve a LDL-C reduction of ≥50%. ( 1-M )
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3.4: In individuals 40–75 years of age with LDL-C 70–189 mg/dL (1.8–4.9 mmol/L) ES recommends a 10-year risk for ASCVD should be calculated. ( 1-M )
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3.4.1: In individuals 40–75 years of age without diabetes and a 10-year risk ≥7.5%, ES recommends high-intensity statin therapy either to achieve a LDL-C goal <100 mg/dL (<2.6 mmol/L) or a LDL-C reduction of ≥50%. ( 1-M )
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3.4.2: In individuals 40–75 years of age without diabetes and a 10-year risk of 5%–7.5%, ES recommends moderate statin therapy as an option after consideration of risk reduction, adverse events, drug interactions, and individual preferences to achieve either a LDL-C goal <130 mg/dL (<3.4 mmol/L) or an LDL-C reduction of 30%–50%. ( 1-M )
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3.4.3: In individuals with metabolic risk, without diabetes, on statin therapy, ES suggests monitoring glycemia at least annually to detect new-onset diabetes mellitus. ( 2-M )
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3.4.4: In individuals aged >75 years without diabetes and a 10-year risk ≥7.5%, ES recommends discussing the benefits of statin therapy with the patient based on expected benefits versus possible risks/side effects. ( 1-M )

Technical Remarks:

  • Decisions should be made on a case-by-case basis depending on estimates of likely benefits vs. risks in individual patients.
  • Statin therapy should be calibrated to reach the recommended LDL targets.
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3.5: In individuals at metabolic risk who are taking statins with adequate LDL-C reduction, elevated triglyceride levels [≥200 mg/dL (2.3 mmol/L)], and reduced HDL levels [≤50 mg/dL (1.3 mmol/L) in females, or ≤40 mg/dL (1.0 mmol/L) in males], ES suggests considering fenofibrate adjunct therapy. ( 2-M )

Technical Remark:

  • Avoid gemfibrozil in this situation.
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3.6: In individuals aged 40 years and older at metabolic risk with LDL-C at target, an estimated 10-year ASCVD risk of >7.5% and without clinical ASCVD or other ASCVD risk factors, ES suggests treatment with a moderate-intensity statin. ( 2-M )
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Blood Pressure Reduction
3.7: In individuals with blood pressure above 130/80 mmHg and a ten-year cardiovascular risk <10%, ES suggests lifestyle management to lower blood pressure to <130/80 mmHg and to reduce the risk for ASCVD. ( 2-M )

Technical Remarks:

  • Since the 10-year risk is ≤10%, lifestyle intervention is appropriate and preferable to use of medications.
  • Interventions include weight loss, healthy diet, sodium restriction, enhanced potassium intake, increased physical activity, and moderation of alcohol use.
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3.8: In individuals without a history of ASCVD with metabolic risk who have a 10-year cardiovascular risk of >10% and blood pressure of >130/80 mmHg, ES suggests the use of blood pressure-lowering medication in addition to lifestyle modifications for primary prevention of ASCVD only if lifestyle modification alone has failed. (2-M)
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Reducing Progression to Type 2 Diabetes
3.9: In individuals with prediabetes, ES recommends prescribing lifestyle modification before drug therapy to reduce plasma glucose levels. (1-H)
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3.10: In individuals with prediabetes who have limitations to physical activity or are not responding to lifestyle modifications, ES recommends metformin as a first pharmacologic approach to reduce plasma glucose levels. ( 1-M )
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Recommendation Grading

Overview

Title

Primary Prevention of ASCVD and T2DM in Patients at Metabolic Risk

Authoring Organization

Publication Month/Year

July 31, 2019

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Inclusion Criteria

Female, Male, Adult, Older adult

Health Care Settings

Ambulatory

Scope

Counseling, Assessment and screening, Prevention, Treatment

Diseases/Conditions (MeSH)

D003920 - Diabetes Mellitus, D002318 - Cardiovascular Diseases, D003924 - Diabetes Mellitus, Type 2, D050356 - Lipid Metabolism, D008660 - Metabolism

Keywords

diabetes, cardiovascular disease, primary prevention

Source Citation

James L Rosenzweig, George L Bakris, Lars F Berglund, Marie-France Hivert, Edward S Horton, Rita R Kalyani, M Hassan Murad, Bruno L Vergès, Primary Prevention of ASCVD and T2DM in Patients at Metabolic Risk: An Endocrine Society Clinical Practice Guideline, The Journal of Clinical Endocrinology & Metabolism, Volume 104, Issue 9, September 2019, Pages 3939–3985, https://doi.org/10.1210/jc.2019-01338