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CMHC PULSE

Cardio Metabolic Health Congress – Official Blog

Finding Common Ground for Glycated Haemoglobin Test Targets

In March of this year, the American College of Physicians (ACP) issued a guidance statement on HbA1c targets for adults with type 2 diabetes (T2D), which have been the subject of debates and discussions in the medical community. At the center of this debate is ACP’s recommendation for a target HbA1c goal between 7-8% to maintain optimal glucose control, which is higher than what’s recommended by the American Diabetes Association (ADA) or the American Association of Clinical Endocrinologists (AACE) and American College of Endocrinology (ACE).

ADA recommends a goal of <7% for HbA1c, even advocating more stringent goals (such as <6.5%) for certain patients with a low risk of hypoglycemia. The AACE/ACE guidelines recommend keeping glycated hemoglobin levels at ≤ 6.5% for most patients with low-risk of side effects.

The statement from ACP also recommends the individualization of T2D therapy, deintensification of therapy for patients that achieve HbA1c levels of less than 6.5%, and controlling symptoms rather than focusing on specific HbA1c goals in patients with a life expectancy of less than 10 years (such as patients aged 80 or older, that reside in a nursing home, or with chronic conditions – including dementia, cancer, end-stage kidney disease, severe COPD, or congestive heart failure). One of the main ideas behind this statement is to balance the benefits of lowering blood glucose with potential risks, such as important side effects (like hypoglycemia and weight gain), costs, and overall patient burden.

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Coronary Artery Calcium as a Predictor of ASCVD Risk

Atherosclerotic cardiovascular disease (ASCVD) is the leading cause of death in the US, and prevention of ASCVD is a public health priority in order to minimize its impacts on morbidity and mortality. Global CVD risk assessment is an integrated approach to evaluate the total risk of developing CVD over a given period (usually 10 years) based on several risk factors, including age, male sex, hypertension, diabetes mellitus, dyslipidemia, smoking, family history, overweight and obesity. These risk factors have been incorporated in several algorithms for the primary prevention of CVD, including the Pooled Cohort Equation (PCE) developed by American College of Cardiology (ACC) and American Heart Association (AHA). However, despite the development of several algorithms for risk assessments aimed to prevent CVD events, the overall disease burden has increased. CVD events can occur even in individuals that do not have risk factors, and the dependence of CVD risk assessment on the presence or absence of conventional risk factors may not allow for accurate risk prediction, given the fact that CVD is multi-factorial and progresses in a continuum.

As a result, novel risk assessment methods, including coronary artery calcium (CAC) score, may be necessary to improve ASCVD risk prediction and to better guide treatment options. The utility of the CAC score in preventing CVD risk in asymptomatic individuals has been demonstrated in several results from the Multi-Ethnic Study of Atherosclerosis (MESA), a study designed to evaluate the characteristics of subclinical atherosclerosis and risk factors for ASCVD progression. However, most of the outcomes of these studies have evaluated coronary heart disease (CHD) with short to intermediate follow-ups.

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