Is a patient with type 2 diabetes mellitus (T2DM) and a hemoglobin A1c (HbA1c) level indicating good glycemic control still considered at high risk for cardiovascular disease (CVD) and requiring statin therapy?

From the Guidelines

Yes, a patient with type 2 diabetes mellitus (T2DM) and a hemoglobin A1c (HbA1c) level indicating good glycemic control is still considered at high risk for cardiovascular disease (CVD) and would typically benefit from statin therapy. The American College of Cardiology and American Heart Association guidelines recommend statin therapy for most adults with diabetes aged 40-75 years, as stated in the 2020 guidelines on the management of blood cholesterol in diabetes 1. The recommended statin intensity depends on the individual's overall risk profile, with moderate-intensity statins being appropriate for many diabetic patients without additional major risk factors, while high-intensity statins may be recommended for those with multiple risk factors or established cardiovascular disease. Some key points to consider in the management of cardiovascular risk in diabetes include:

• Diabetes itself is an independent risk factor for cardiovascular disease, regardless of how well-controlled the blood glucose levels are 1.
• The cardiovascular risk in diabetes stems from multiple mechanisms beyond just high blood sugar, including inflammation, endothelial dysfunction, and abnormal cholesterol metabolism 1.
• Even with excellent glycemic control, these underlying pathophysiological processes continue to increase cardiovascular risk, which is why statin therapy remains important for risk reduction regardless of A1c levels 1.
• The evidence for a cardiovascular benefit of intensive glycemic control remains strongest for those with type 1 diabetes, but subset analyses suggest that patients with shorter duration of type 2 diabetes and without established atherosclerosis might reap cardiovascular benefit from intensive glycemic control 1.
• The American Diabetes Association recommends an A1c goal of 7% for most adults with diabetes, recognizing that more or less stringent goals may be appropriate for certain patients 1.
• The general goal of 7% appears reasonable for macrovascular disease, although the evidence obtained from ACCORD, ADVANCE, and VADT does not suggest the need for major changes in glycemic control targets but rather additional clarification of the language that has consistently stressed individualization 1.
• Comprehensive care for diabetes involves treatment of all vascular risk factors—not just hyperglycemia, including blood pressure control, lipid lowering with statin therapy, aspirin therapy, and lifestyle modifications 1.
• Routine monitoring of liver function tests or muscle enzymes is not recommended except in specific circumstances for patients with type 2 diabetes who are taking statins 1.
• For those patients with type 2 diabetes who are taking statins, at least moderate doses of a statin should be initiated 1. In summary, statin therapy is recommended for most adults with diabetes aged 40-75 years, regardless of their A1c levels, to reduce the risk of cardiovascular disease 1.

From the Research

Risk of Cardiovascular Disease in Patients with Type 2 Diabetes Mellitus

• Patients with type 2 diabetes mellitus (T2DM) are at high risk for cardiovascular disease (CVD) due to various factors, including hyperglycemia, dyslipidemia, and hypertension 2.
• Even with good glycemic control, as indicated by a hemoglobin A1c (HbA1c) level < 7.0%, patients with T2DM may still be at risk for CVD 3, 2.

Statin Therapy in Patients with T2DM

• Statin therapy is recommended for patients with T2DM to reduce the risk of CVD, regardless of their HbA1c level 4, 5.
• The choice of statin and its intensity should be individualized based on the patient's risk factors and glycemic control 5.
• Some studies suggest that certain statins, such as pitavastatin, may have a more favorable effect on glycemic control compared to others, such as atorvastatin 5.

Glycemic Control and CVD Risk

• Achieving an HbA1c level < 6.0% may reduce the risk of major adverse cardiovascular events (MACE) in patients with T2DM 6.
• However, the relationship between glycemic control and CVD risk is complex, and other factors, such as LDL level, use of cardiovascular medications, and medication adherence, also play a role 3, 2.
• Patients with T2DM who achieve good glycemic control may still be at risk for CVD, and statin therapy should be considered to reduce this risk 4, 5.