The goal of treatment is now less than 130/80mmHg if it can be reached safely.

In the 2012 American Diabetes Association (ADA) Standards of Care, the easing of the systolic blood pressure target to 140 mmHg for patients with diabetes caused controversy among experts. The 2023 definition of hypertension in people with diabetes is ≥130mmHg systolic or ≥80mmHg diastolic blood pressure, repeated on two measurements at different times. In individuals with established cardiovascular disease, hypertension can be diagnosed with just one measurement of ≥180/110mmHg. The goal of treatment is now less than 130/80mmHg if it can be reached safely.

For low-density lipoprotein (LDL) cholesterol levels in patients with diabetes, now the ADA recommends a target of less than 70mg/dL or no greater than 55mg/dL, depending on the individual’s cardiovascular risk. The 2023 standards also have new therapeutic lipid targets. For people with diabetes aged 40-75 years at increased cardiovascular risk, including those with one or more atherosclerotic risk factors, high-intensity statin therapy is recommended to reduce LDL cholesterol by 50% or more from baseline and to a target of less than 70mg/dL, in contrast to the previous target of 100mg/dL. To achieve that goal, it is advised to add ezetimibe or a PCSK9 inhibitor to maximally tolerated statin therapy.

FOCUS ON CARDIORENAL RISK REDUCTION

The ADA has emphasised an increased focus on cardiorenal risk reduction and weight management in the Standards of Care in Diabetes – 2023. Tools and therapies focus on weight loss and cardiorenal risk reduction in diabetes from a perspective other than simple glucose control. For people with diabetes aged 40-75 who have established cardiovascular disease, treatment with high-intensity statins is recommended with the target of a 50% or greater reduction from baseline and an LDL cholesterol level of 55mg/dL or lower, in contrast to the previous 70mg/dL. As it has for the past six years, the section on cardiovascular disease and risk management is also endorsed by the American College of Cardiology.

Another new recommendation from the ADA based on recent trial data is the use of sodium–glucose cotransporter 2 (SGLT2) inhibitors in people with diabetes and
heart failure.

COMMUNITY HEALTH WORKERS’ ROLE

New guidance also recommends using community health workers to support the management of diabetes and cardiovascular risk factors, particularly in underserved areas and health systems. Nonphysician professionals can assist with screening for food insecurity, another new recommendation. Screening for food insecurity shouldn’t be something only dieticians do. Clinicians are urged to partner with community health workers, who can help identify food insecurity and point patients and providers toward tools to screen for and address this social detriment to healthy outcomes. Community health workers can be a link to help people navigate and engage with the health system for better outcomes.

Source: Dr Grazia Aleppo, Cardiometabolic Health Congress. https://www.cardiometabolichealth.org/updated-2023-ada-standards-of-care