Several trials addressed residual hypertriglyceridemia in statin treated patients. PCSK-9 inhibition is equally efficacious in those with and without diabetes, with a 27% relative risk reduction of cardiovascular death, myocardial infarction, stroke and hospitalization for unstable angina or revascularization in patients with established cardiovascular disease. However, if LDL-cholesterol remains ≥70 mg/dL despite maximal statin plus ezetimibe or when patients are statin intolerant and ezetimibe alone is not enough, a PCSK-9 inhibitor is warranted. If LDL-cholesterol remains ≥70 mg/dL despite maximally tolerated statin, adding ezetimibe is reasonable. When diabetes and CAD occur simultaneously, high-intensity or maximal statin therapy is strongly recommended. Studies of weight loss show that a weight reduction of 5 to 20%) or multiple ASCVD risk factors, intensifying lipid lowering using high-intensity statins is reasonable. Weight management is very important since excessive adiposity fuels insulin resistance. 8,9 Supervised exercise is favored because it results in greater weight reduction and better HbA1c control. Exercise in the form of at least 150 minutes per week of moderate intensity or 75 minutes of high intensity are recommended by both the AHA/American College of Cardiology (ACC) and the American Diabetes Association (ADA). A sedentary lifestyle should be heavily discouraged. 7 This includes a balanced low-glycemic index diet high in fibers, and vegetables and low in saturated fat. The management of stable CAD in diabetic patients starts with adopting a heart healthy lifestyle. The combination of hypercholesterolemia, inflammation, and endothelial dysfunction are the key mechanisms involved in the initiation and progression of atherosclerotic coronary artery disease. 5 Through obesity and the production of advanced glycation end-products, diabetic patients also have higher levels of subclinical inflammation and develop endothelial dysfunction. 4 Diabetic patients are twice as likely to have HDL-cholesterol levels below the 10th percentile of the population and 50% more likely to have hypertriglyceridemia compared to non-diabetic subjects. Insulin resistance is the hallmark of type 2 diabetes and is closely associated with adiposity, hypertension, and dyslipidemia as part of the metabolic syndrome. The complex association between diabetes and CAD may explain why it is still difficult to optimize cardiovascular risk in patients with diabetes. The mechanisms of how diabetes is linked to CAD have been a subject of increasing attention. In this analysis, we will review and summarize the AHA scientific statement and add some relevant data from recent studies which became available after the publication of the AHA statement. The scientific statement includes emphasis on the new role of sodium-glucose cotransporter-2 (SGLT-2) inhibitors and glucagon-like peptide-1 (GLP-1) agonists for cardiovascular risk reduction and the use of coronary computed tomography angiography (CCTA) for the workup of stable angina. 3 This useful scientific statement provides a comprehensive overview of therapeutic options aimed at reducing cardiovascular risk in CAD patients with diabetes and improving angina symptoms when present. To summarize the current evidence, the American Heart Association (AHA) recently released a scientific statement on the clinical management of stable CAD in patients with type 2 diabetes mellitus. Since then, several advancements in the diagnosis and management of CAD and diabetes have occurred. In 2012, the ACCF/AHA/ACP/AATS/PCNA/SCAI/STS published their guideline for the diagnosis and management of stable CAD with a few specific recommendations for CAD patients with diabetes. Despite the effort to reduce cardiovascular risk in diabetes patients, cardiovascular events remain high. Therefore, the challenge of detecting and managing CAD in patients with diabetes is both significant and common. 2 It is estimated that around 80% of those with diabetes die from cardiovascular causes, mostly from ischemic events. The link between diabetes and cardiovascular disease is strong as diabetes increases the risk for coronary artery disease (CAD) by two to four fold. 1 It is estimated that the burden of diabetes will continue to grow owing to the increase in the prevalence of obesity, high caloric diet, and physical inactivity worldwide. Within the last 2 decades, the number of patients with diabetes quadrupled from 108 million to 422 million in 2014.
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