XI. STRATEGIES FOR IMPROVING DIABETES CARE D iabetes is a chronic illness that requires continuing medical care and patient self-management education to prevent acute complications and to reduce the risk of long-term complications. Diabetes care is complex and requires that many issues, beyond glycemic control, be addressed. A large body of evidence exists that supports a range of interventions to improve diabetes outcomes. These standards of care are intended to provide clinicians, patients, researchers, payors, and other interested individuals with the components of diabetes care, treatment goals, and tools to evaluate the quality of care. While individual preferences, comorbidities, and other patient factors may require modification of goals, targets that are desirable for most patients with diabetes are provided. These standards are not intended to preclude more extensive evaluation and management of the patient by other specialists as needed. For more detailed information, refer to Bode (Ed.): Medical Management of Type 1 Diabetes (1), Burant (Ed): Medical Management of Type 2 Diabetes (2), and Klingensmith (Ed): Intensive Diabetes Management (3). The recommendations included are diagnostic and therapeutic actions that are known or believed to favorably affect health outcomes of patients with diabetes. A grading system (Table 1), developed by the American Diabetes Association (ADA) and modeled after existing methods, was utilized to clarify and codify the evidence that forms the basis for the recommendations. The level of evidence that supports each recommendation is listed after each recommendation using the letters A, B, C, or E.

Standards of Medical Care in Diabetes

ABI
: ankle–brachial index
ACCORD
: Action to Control Cardiovascular Risk in Diabetes
ADVANCE
: Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified Release Controlled Evaluation
AGREE
: Appraisal of Guidelines Research and Evaluation
AHA
: American Heart Association
apoA1
: apolipoprotein A1
apoB
: apolipoprotein B
CABG
: coronary artery bypass graft surgery
CARDS
: Collaborative AtoRvastatin Diabetes Study
CCNAP
: Council on Cardiovascular Nursing and Allied Professions
CHARISMA
: Clopidogrel for High Athero-thrombotic Risk and Ischemic Stabilisation, Management, and Avoidance
CHD
: coronary heart disease
CKD
: chronic kidney disease
COMMIT
: Clopidogrel and Metoprolol in Myocardial Infarction Trial
CRP
: C-reactive protein
CURE
: Clopidogrel in Unstable Angina to Prevent Recurrent Events
CVD
: cardiovascular disease
DALYs
: disability-adjusted life years
DBP
: diastolic blood pressure
DCCT
: Diabetes Control and Complications Trial
ED
: erectile dysfunction
eGFR
: estimated glomerular filtration rate
EHN
: European Heart Network
EPIC
: European Prospective Investigation into Cancer and Nutrition
EUROASPIRE
: European Action on Secondary and Primary Prevention through Intervention to Reduce Events
GFR
: glomerular filtration rate
GOSPEL
: Global Secondary Prevention Strategies to Limit Event Recurrence After MI
GRADE
: Grading of Recommendations Assessment, Development and Evaluation
HbA1c
: glycated haemoglobin
HDL
: high-density lipoprotein
HF-ACTION
: Heart Failure and A Controlled Trial Investigating Outcomes of Exercise TraiNing
HOT
: Hypertension Optimal Treatment Study
HPS
: Heart Protection Study
HR
: hazard ratio
hsCRP
: high-sensitivity C-reactive protein
HYVET
: Hypertension in the Very Elderly Trial
ICD
: International Classification of Diseases
IMT
: intima-media thickness
INVEST
: International Verapamil SR/Trandolapril
JTF
: Joint Task Force
LDL
: low-density lipoprotein
Lp(a)
: lipoprotein(a)
LpPLA2
: lipoprotein-associated phospholipase 2
LVH
: left ventricular hypertrophy
MATCH
: Management of Atherothrombosis with Clopidogrel in High-risk Patients with Recent Transient Ischaemic Attack or Ischaemic Stroke
MDRD
: Modification of Diet in Renal Disease
MET
: metabolic equivalent
MONICA
: Multinational MONItoring of trends and determinants in CArdiovascular disease
NICE
: National Institute of Health and Clinical Excellence
NRT
: nicotine replacement therapy
NSTEMI
: non-ST elevation myocardial infarction
ONTARGET
: Ongoing Telmisartan Alone and in combination with Ramipril Global Endpoint Trial
OSA
: obstructive sleep apnoea
PAD
: peripheral artery disease
PCI
: percutaneous coronary intervention
PROactive
: Prospective Pioglitazone Clinical Trial in Macrovascular Events
PWV
: pulse wave velocity
QOF
: Quality and Outcomes Framework
RCT
: randomized clinical trial
RR
: relative risk
SBP
: systolic blood pressure
SCORE
: Systematic Coronary Risk Evaluation Project
SEARCH
: Study of the Effectiveness of Additional Reductions in Cholesterol and
SHEP
: Systolic Hypertension in the Elderly Program
STEMI
: ST-elevation myocardial infarction
SU.FOL.OM3
: SUpplementation with FOlate, vitamin B6 and B12 and/or OMega-3 fatty acids
Syst-Eur
: Systolic Hypertension in Europe
TNT
: Treating to New Targets
UKPDS
: United Kingdom Prospective Diabetes Study
VADT
: Veterans Affairs Diabetes Trial
VALUE
: Valsartan Antihypertensive Long-term Use
VITATOPS
: VITAmins TO Prevent Stroke
VLDL
: very low-density lipoprotein
WHO
: World Health Organization

### 1.1 Introduction

Atherosclerotic cardiovascular disease (CVD) is a chronic disorder developing insidiously throughout life and usually progressing to an advanced stage by the time symptoms occur. It remains the major cause of premature death in Europe, even though CVD mortality has …

/pdf/european-guidelines-on-cardiovascular-disease-prevention-in-4z4nw4311i.pdf

European Guidelines on Cardiovascular Disease Prevention in Clinical Practice (Version 2012)

Statistics for Spatial Data.

Appendix I: List of Statistical Fact Sheets. URL: http://www.americanheart.org/presenter.jhtml?identifier=2007

We wish to thank Drs Brian Eigel and Michael Wolz for their valuable comments and contributions. We would like to acknowledge Tim Anderson and Tom Schneider for their editorial contributions and Karen Modesitt for her administrative assistance.

Disclosures 



View this table:







View this table:







View this table:





# Summary {#article-title-2}

Each year, the American Heart Association, in conjunction with the Centers for Disease Control and Prevention, the National Institutes of Health, and other government agencies, brings together the most up-to-date statistics on heart disease, stroke, other vascular diseases, and their risk factors and presents them in its Heart Disease and Stroke Statistical Update. The Statistical Update is a valuable resource for researchers, clinicians, healthcare policy makers, media professionals, the lay public, and many others who seek the best national data available on disease …

Heart Disease and Stroke Statistics—2010 Update A Report From the American Heart Association

1. About These Statistics…e70

2. Cardiovascular Diseases…e72

3. Coronary Heart Disease, Acute Coronary Syndrome, and Angina Pectoris…e89

4. Stroke…e99

5. High Blood Pressure…e111

6. Congenital Cardiovascular Defects…e116

7. Heart Failure…e119

8. Other Cardiovascular Diseases…e122 

9. Risk Factor: Smoking/Tobacco Use…e128

10. Risk Factor: High Blood Cholesterol and Other Lipids…e132

11. Risk Factor: Physical Inactivity…e136

12. Risk Factor: Overweight and Obesity…e139

13. Risk Factor: Diabetes Mellitus…e143

14. End-Stage Renal Disease and Chronic Kidney Disease…e149

15. Metabolic Syndrome…e151

16. Nutrition…e153

17. Quality of Care…e155

18. Medical Procedures…e159

19. Economic Cost of Cardiovascular Diseases…e162

20. At-a-Glance Summary Tables…e164 

21. Glossary and Abbreviation Guide…e168
    Writing Group Disclosures…e171



Appendix I: List of Statistical Fact Sheets:

http://www.americanheart.org/presenter.jhtml?identifier=2007

We thank Drs Robert Adams, Philip Gorelick, Matt Wilson, and Philip Wolf (members of the Statistics Committee or Stroke Statistics Subcommittee); Brian Eigel; Gregg Fonarow; Kathy Jenkins; Gail Pearson; and Michael Wolz for their valuable comments and contributions. We would like to acknowledge Tim Anderson and Tom Schneider for their editorial contributions and Karen Modesitt for her administrative assistance.

# 1. About These Statistics {#article-title-2}

The American Heart Association (AHA) works with the Centers for Disease Control and Prevention’s National Center for Health Statistics (CDC/NCHS); the National Heart, Lung, and Blood Institute (NHLBI); the National Institute of Neurological Disorders and Stroke (NINDS); and other government agencies to derive the annual statistics in this Update. This chapter describes the most important sources and the types of data we use from them. For more details and an alphabetical list of abbreviations, see Chapter 21 of this document, the Glossary and Abbreviation Guide.

The surveys used are:

Heart Disease and Stroke Statistics—2007 Update A Report From the American Heart Association Statistics Committee and Stroke Statistics Subcommittee

ContextModerate alcohol consumption has been shown to be
protective for coronary heart disease, but the relationship between
moderate alcohol consumption and ischemic stroke is more controversial.ObjectiveTo determine the association between alcohol
consumption and risk of ischemic stroke.DesignPopulation-based case-control study conducted between July
1993 and June 1997.SettingMultiethnic population in northern Manhattan, New York,
NY, aged 40 years or older.Patients and Other ParticipantsCases (n=677) had first
ischemic stroke and were matched to community controls (n=1139)
derived through random digit dialing by age, sex, and race/ethnicity.
Mean ± SD age of cases was 70.0 ± 12.7 years; 55.8% were women;
19.5% were white, 28.4% black, and 50.7% Hispanic.Main Outcome MeasureFirst ischemic stroke (fatal or nonfatal).ResultsModerate alcohol consumption, up to 2 drinks per day, was
significantly protective for ischemic stroke after adjustment for
cardiac disease, hypertension, diabetes, current smoking, body mass
index, and education (odds ratio [OR], 0.51; 95% confidence interval
[CI], 0.39-0.67). This protective effect of alcohol consumption was
detected in both younger and older groups, in men and women, and in
whites, blacks, and Hispanics. In a quadratic model of stroke risk,
increased risk of ischemic stroke was statistically significant among
those consuming 7 or more drinks per day (OR, 2.96; 95% CI,
1.05-8.29).ConclusionsModerate alcohol consumption was independently
associated with a decreased risk of ischemic stroke in our elderly,
multiethnic, urban subjects, while heavy alcohol consumption had
deleterious effects. Our data support the National Stroke Association
Stroke Prevention Guidelines regarding the beneficial effects of
moderate alcohol consumption.

/pdf/the-protective-effect-of-moderate-alcohol-consumption-on-4mbs7ffimr.pdf

The Protective Effect of Moderate Alcohol Consumption on Ischemic Stroke

Background and Purpose—Physical activity reduces the risk of premature death and cardiovascular disease, but the relationship to stroke is less well studied. The objective of this study was to investigate the association between leisure-time physical activity and ischemic stroke in an urban, elderly, multiethnic population. Methods—The Northern Manhattan Stroke Study is a population-based incidence and case-control study. Case subjects had first ischemic stroke, and control subjects were derived through random-digit dialing with 1:2 matching for age, sex, and race/ethnicity. Physical activity was recorded through a standardized in-person interview regarding the frequency and duration of 14 activities over the 2 prior weeks. Conditional logistic regression was used to calculate odds ratios (OR) and 95% confidence intervals after adjustment for medical and socioeconomic confounders. Results—Over 30 months, 369 case subjects and 678 control subjects were enrolled. Mean age was 69.9±12 years; 57% were women, ...

Leisure-Time Physical Activity and Ischemic Stroke Risk The Northern Manhattan Stroke Study

BACKGROUND AND PURPOSE: Stroke risk factors have been determined in large part through epidemiological studies in white cohorts; as a result, race-ethnic disparities in stroke incidence and mortality rates remained unexplained. The aim in the present study was to compare the prevalence, OR, and etiological fraction (EF) of stroke risk factors among white, blacks, and Caribbean Hispanics living in the same urban community of northern Manhattan.

METHODS: In this population-based incident case-control study, cases (n=688) of first ischemic stroke were prospectively matched 1:2 by age, sex, and race-ethnicity with community controls (n=1156). Risk factors were determined through in-person assessment. Conditional logistic regression was used to calculate adjusted ORs in each race-ethnic group. Prevalence and multivariate EFs were determined in each race-ethnic group.

RESULTS: Hypertension was an independent risk factor for whites (OR 1.8, EF 25%), blacks (OR 2.0, EF 37%), and Caribbean Hispanics (OR 2.1, EF 32%), but greater prevalence led to elevated EFs among blacks and Caribbean Hispanics. Greater prevalence rates of diabetes increased stroke risk in blacks (OR 1.8, EF 14%) and Caribbean Hispanics (OR 2.1 P<0.05, EF 10%) compared with whites (OR 1.0, EF 0%), whereas atrial fibrillation had a greater prevalence and EF for whites (OR 4.4, EF 20%) compared with blacks (OR 1.7, EF 3%) and Caribbean Hispanics (OR 3.0, EF 2%). Coronary artery disease was most important for whites (OR 1.3, EF 16%), followed by Caribbean Hispanics (OR 1.5, EF 6%) and then blacks (OR 1.1, EF 2%). Prevalence of physical inactivity was greater in Caribbean Hispanics, but an elevated EF was found in all groups.

CONCLUSIONS: The prevalence, OR, and EF for stroke risk factors vary by race-ethnicity. These differences are crucial to the etiology of stroke, as well as to the design and implementation of stroke prevention programs.

Race-Ethnic Disparities in the Impact of Stroke Risk Factors The Northern Manhattan Stroke Study

ContextElevated high-density lipoprotein cholesterol (HDL-C) levels have been
shown to be protective against cardiovascular disease. However, the association
of specific lipoprotein classes and ischemic stroke has not been well defined,
particularly in higher-risk minority populations.ObjectiveTo evaluate the association between HDL-C and ischemic stroke in an
elderly, racially or ethnically diverse population.DesignPopulation-based, incident case-control study conducted July 1993 through
June 1997.SettingA multiethnic community in northern Manhattan, New York, NY.ParticipantsCases (n = 539) of first ischemic stroke (67% aged ≥65 years; 55%
women; 53% Hispanic, 28% black, and 19% white) were enrolled and matched by
age, sex, and race or ethnicity to stroke-free community residents (controls;
n = 905).Main Outcome MeasureIndependent association of fasting HDL-C levels, determined at enrollment,
with ischemic stroke, including atherosclerotic and nonatherosclerotic ischemic
stroke subtypes.ResultsAfter risk factor adjustment, a protective effect was observed for HDL-C
levels of at least 35 mg/dL (0.91 mmol/L) (odds ratio [OR], 0.53; 95% confidence
interval [CI], 0.39-0.72). A dose-response relationship was observed (OR,
0.65; 95% CI, 0.47-0.90 and OR, 0.31; 95% CI, 0.21-0.46) for HDL-C levels
of 35 to 49 mg/dL (0.91-1.28 mmol/L) and at least 50 mg/dL (1.29 mmol/L),
respectively. The protective effect of a higher HDL-C level was significant
among participants aged 75 years or older (OR, 0.51; 95% CI, 0.27-0.94), was
more potent for the atherosclerotic stroke subtype (OR, 0.20; 95% CI, 0.08-0.50),
and was present in all 3 racial or ethnic groups studied.ConclusionsIncreased HDL-C levels are associated with reduced risk of ischemic
stroke in the elderly and among different racial or ethnic groups. These data
add to the evidence relating lipids to stroke and support HDL-C as an important
modifiable stroke risk factor.

https://jamanetwork.com/journals/jama/articlepdf/193886/joc02275.pdf

High-Density Lipoprotein Cholesterol and Ischemic Stroke in the Elderly: The Northern Manhattan Stroke Study

Background and Purpose— Stroke and stroke subtype incidence in young black and Hispanic populations have not been well studied. The purpose of this study was to determine stroke incidence rates in these populations and to compare rates among various race-ethnic, sex, and age groups.

Methods— A population-based incidence study identified all cases of first stroke in Northern Manhattan from 1993 to 1997. Stroke and stroke subtype incidence rates were calculated for younger (20 to 44 years of age) and older (≥45 years of age) adults. The relative risk (RR) of stroke in blacks and Hispanics compared with whites was calculated. Stroke subtypes, infarct subtypes, and case fatality rates were compared in the young and old and in different race-ethnic groups and sexes.

Results— Over 4 years, 74 cases of first stroke in young patients were discovered (47% women, 12% black, 80% Hispanic, 8% white). The stroke incidence rates (cases per 100 000 persons per year) in the young were 23 overall, 10 for infarct, 7 for intracerebral hemorrhage (ICH), and 6 for subarachnoid hemorrhage. The RR of stroke in the young was greatest for blacks (2.4; 95% CI, 0.8 to 6.7) and Hispanics (2.5; 95% CI, 1.1 to 5.8) compared with whites. ICH was more frequent in men with a RR of 3.7 (95% CI, 1.4 to 10.1). Case fatality rates at 30 days were higher in blacks (38%) and Hispanics (16%) compared with whites (0%).

Conclusions— Young blacks and Hispanics have greater stroke incidences than young whites.

I-Feng Lin

Papers

The Protective Effect of Moderate Alcohol Consumption on Ischemic Stroke

Leisure-Time Physical Activity and Ischemic Stroke Risk The Northern Manhattan Stroke Study

Race-Ethnic Disparities in the Impact of Stroke Risk Factors The Northern Manhattan Stroke Study

High-Density Lipoprotein Cholesterol and Ischemic Stroke in the Elderly: The Northern Manhattan Stroke Study

Stroke in the Young in the Northern Manhattan Stroke Study