Primary Prevention of ASCVD and T2DM in Patients at Metabolic Risk
Diagnosis
Definitions and Diagnosis
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.
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.
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.
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.
Treatment
Lifestyle and Behavioral Therapy
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.
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.
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.
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.
Medical and Pharmacological Therapy
Risk Assessment and Evaluation
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.
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.
Cholesterol Reduction
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.
Technical Remark:
- Avoid gemfibrozil in this situation.
Blood Pressure Reduction
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.
Reducing Progression to Type 2 Diabetes
Recommendation Grading
Overview
Title
Primary Prevention of ASCVD and T2DM in Patients at Metabolic Risk
Authoring Organization
Endocrine Society
Publication Month/Year
July 31, 2019
Last Updated Month/Year
October 8, 2024
Supplemental Implementation Tools
Document Type
Guideline
External Publication Status
Published
Country of Publication
US
Document Objectives
To develop clinical practice guidelines for the primary prevention of atherosclerotic cardiovascular disease (ASCVD) and type 2 diabetes mellitus (T2DM) in individuals at metabolic risk for developing these conditions.
Target Patient Population
Individuals with metabolic risk
Inclusion Criteria
Male, Female, Adult, Older adult
Health Care Settings
Ambulatory
Intended Users
Nurse, nurse practitioner, physician, physician assistant
Scope
Counseling, Assessment and screening, Treatment, Prevention
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