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I can understand how they would come to this conclusion though. Select fit off in the fit distribution. They could be processed respectively in a manner which fits you best. Patients with paroxysms of high BP should be evaluated for pheochromocytoma. Anything you do, the key is to do it vigorously enough that it gets your heart rate up for an extended period of time and makes you sweat. Improvements in metabolic condition probably contribute much more to decreases in RHR and in HR elevation during intense physical activity than increases in cardiac output. Polymers are compounds made of carbon and hydrogen essentially; certain polymers also contain nitrogen, oxygen, sulphur, among other elements.

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Central venous Right atrial ventricular pulmonary artery wedge Left atrial ventricular Aortic. Compliance Vascular resistance Pulse Perfusion. Pulse pressure Systolic Diastolic Mean arterial pressure Jugular venous pressure Portal venous pressure.

Baroreflex Kinin—kallikrein system Renin—angiotensin system Vasoconstrictors Vasodilators Autoregulation Myogenic mechanism Tubuloglomerular feedback Cerebral autoregulation Paraganglia Aortic body Carotid body Glomus cell. Retrieved from " https: Cardiovascular physiology Cardiology Circulatory system Heart Cardiac anatomy.

Webarchive template wayback links Wikipedia articles needing clarification from February Views Read Edit View history. Even peer-review means nothing if they are observational or hypothesis, or if the study uses questionable means. It is just difficult for those not in the scientific field to understand it all, and people like Chris and myself are trying to be here to translate it into an easy concept.

Im one of the strongest guys in my guy and have never touched meat, eggs, fish or dairy in the 5 years of lifting.

Have never consumed more than g of plant protein a day as a normal level obviously the odd day here and there I might go above it by 20 or 30 just like on some days I might only get 70 or 80g of veg based protein. Gee I guess I need to add meat to my diet or I will just keep being a scrawny weak man. I would assume with a diet like you eat your cholosterol is in the neighborhood of ? Jim Fixx would attest to that. If it works for you body great, hope you stay healthy.

Read this from Kaiser Permanente: Wish this were true. I just completed a year of a plant based diet. Olive oil, flax seeds, walnuts, pumpkin seeds, steel cut oats, kale, etc and guess what? NONE of my cholesterol numbers changed. How can that be? I thought that at least my LDL would be lowered if nothing else.

Soledad, that is because your levels are suppose to be where they are.. High, or low your body is regulating them just fine in most cases, the numbers are just averages not cut in stone. The math equation to estimate your LDL is missing two variables so that makes a un workable equation yet they still try to estimate your LDL.

I was borderline very high chol and within 90 days of going plant based my chol plummeted in to the low range where it has stayed for the 6 years plus eating plant based. Even eating a higher fruit and carb diet my hemo A1C seems to get lower each year and its already on the low end of the proper range , fasting glucose great, bp great etc.

Im just a normal guy was very fat them and my dropped like a rock. So did my friends when he was diagnosed with hypertension, high chol an type 2 all in the same Dr appoint. I told him how to eat and told him a book to buy by Neal Barnard for his type 2 and within 3 months his high chol and high bp were normal an he was off all but a low dose oral for his type 2.

Three months later for his followup his Dr told him he could quit the oral and just watch his sugar levels on his glucose machine and he has not taken any meds for it since. He did it all with a radical shift from a meat based diet to a plant based diet. You just need to shift what you eat. Im a normal guy, my friend is a normal avg guy and we both had the same rapid results.

We are not special examples. All this article was about that high cholesterol is not bad for health, that cholesterol is vitally important for our bodies. So why do you even want your levels to get changed lowered i guess? The same thing happened to me. Eliminate the oil and nuts and your numbers will drastically reduce. Plant based diet must be oil free.

Eat good fats, butter, grasped meats, etc. Price is an amazing Dr. I am feeling good. Several friends are off statins. Another person I know who was borderline diabetic is no longer at risk. I just read an article from Ketogains website http: He claims that his lipid profile will improve dramatically and he actually documents it.

My point is that there are people on this thread saying that their cholesterol levels are thru the roof on a ketogenic diet. So, are these people metabolic anomalies or does eating saturated fats actually raise your serum cholesterol levels in the long run. I would just like to get to the bottom of this. It does mine, and my cholesterol is always high!! I look at the particle sizes of my blood, not the s. Cholesterol went up a little. Its just Never worried me that my C is high, its genetic and believe me, my genetics have much bigger issues with MTHFR than to worry about this.

However that does affect my cholesterol s. What I am learning is that everyone processes cholesterol differently so you have to find what works for you.

High saturated fat diet for one person may not raise cholesterol while for others it will. I do appreciate all the comments, ideas and suggestions. Cholestorol and saturated fat from animal products can NOT be good for you. As we make cholestorol ourselfes it would be weird to get it from other sources other than yourself.

I butchered a lard type hog in early December. There was 45 pounds of lard on a pound hog. The meat is very fat and both tender and delicious. I eat nearly every bite of the fat. We had our annual health fair in late January and I got my blood work results today. My cholesterol ran and the prior two years. Why do you say that. The tremendous influx in heart disease, diabetes and obesity in this country is in the past 30 years, which just happens to coincide with the latest food pyramid by out govt.

Our body was made to eat meat, look no further than the design of teeth in your mouth. Trans-fats I think all would agree are bad and should be avoided. But if ketones are one of the sources of energy our body recognizes why would you imply getting to that point is negative?

So maybe you can bite through the skin of a cow or goat, or at least you can bite a piece of raw muscle off their body? Simply because we never been designed to be carnivores and eat meat based diet. Yes, we can chew and digest pre-processed! Our sharp teeth, though, are perfect to cut through the skin of fruits and vegetables, and our molars are perfect to chew vegetable nutritious pulp. Our long intestines are very good to efficiently digest vegetable-fruit stuff. Our stomaches have ph of 2.

And no, nobody ever say we are herbivores like cows and rabbits. We are mostly fruitovores ànd situatious omnivores. Not even genuine omnivores like bears look at their teeth. They have no amilase in their saliva, because they are not intended to eat any carbs whatsover. Some people many thousands of years ago migrated from Africa to far north areas where no nutritious plants can grow.

Over these years they adaptated the diet from purely meats, fats and some dairy. But vast majority of people left on the warm lands with wealthy of nutritious plants and conditions for agriculture. So if you are not escimos or someone like that, meat based diet with very low carbs is not how long generations of your ancestors did eat.

Have some common sense, until industrial revolution it was absolutely impossible to grow massive numbers of livestock, because agriculturing was so hard.

Animals did pasture in all warm months and people slaughtered them before winter, when they did gain weight. Most of people peasants did eat lots of meat just once a year. And if we did eat meat every day from hunting i. The design of our teeth are like a herbivore! Just search online and you will see a chart with teeth of a carnivore and a herbivore and you will see for yourself!

Check this chart out! It is way more complicated. Plant based for your body! Plant based for the animals! Plant based for the planet! Plant based for the win! Rob, plant based for the win? Plant based for malnutrition, Plant based for the gullible, Plant based propaganda! More micro nutrients in plant foods and also fiber which meat and dairy have zero of! I know many of them personally and no drugs, no smoking and no alcohol! After 1 year in keto working diligently eating carbs Day, exercising daily, feeling better than ever, I was shocked and terribly discouraged to get my blood work back at my annual exam to see my ldl had gone from to and total cholesterol up to from While my total cholesterol went up, my trigliceride level went down and my HDL went up.

One does not have to pay the price with their income or loss of health though by using these drugs to achieve this benefit. It can be done with diet for just about everyone. It is important to note what lab values ARE associated with risk for heart disease.

Generally the HDL ratio should be above 25 and preferably in the 30s. If it is in the 40s, that nearly guarantees immunity from heart disease. Whereas if it is below 15, and certainly below 10, a heart attack is inevitable.

It is just a matter of when, not if, it will happen. The triglyceride ratio should be below 2. Best is high ldl, medium hdl and looow triglycerides. Cholesterol is produced by the liver and we need it badly to maintain health. High triglyceride and homocystein levels are responsible for cvd. Plus simple carb intake. Minimize plant by products including oils, maximize animal by products. Careful with what you write. The body runs of glucose. Go plant based high carb, low protein, low fat in an 80 — 10 — 10 ratio approx You will not have an issue with chol.

The human body runs best on ketones, especially the brain. Low carb, low protein, high good fats is best but, again, each person has to find that right ratio for themselves. I might suggest Dr. Cancer cells are adaptogenic, they can mutate and adapt to changes. Ketogenic diet to cure cancer have been tried and tried and tried for decades without any success.

Atkins is the father of ketogenic diet in the 90s have Cancer clinic, he was going to cure cancer with ketogenic diet without any success.

By the late 90s he closed his practice. People with Sympathetic dominant body work best with high carb and low fat diet, they utilize glucose better than ketone. Think about South American Indians, they lived of fruits and vegetables Carbs all their lives.

Whereas people Parasympathetic dominant body is the exact opposite, their body work best with high fat low carb diet, they utilize ketone better than glucose. Think about the Eskimoes, they lived of Ketone body all their lives. Check out the new research. The body needs dietary fat for survival. I have never been overweight but my blood cholesterol levels reached LDL and overall. A slim sibling has similar numbers. A statin made me ill and lowered my HDL, so we stopped it after six months.

Now my cholesterol has maintained for 3 years at LDL and overall. The people who care most about such advisories are those with high cholesterol levels, and they are likely also the people to whom this new advice least applies. Being insulting does not take the discussion forward. Masses of research have been disproved in the past by new thinking. Often a piece of research that tells scientists what they were hoping for drives a certain interpretation that starts a trend and suddenly large groups of researchers find theyre coming up with similar results.

The fact of the matter is regardless of cholesterol intake or levels, the overwhelming majority of studies demonstrate a correlation between animal products which are the sources of dietary cholesterol and coronary disease. The distinction of where the source of he problem within the animal products comes from.

This article seems to miss the elephant in the room, so to speak. Enough with the BS already. We seem to be going around in circles. Opinions aside, is there any conclusive evidence supporting the lipid hypothesis or not. As for me personally, the lipid hypothesis is valid. BY keeping saturated fats to a minimum and consuming as little cholesterol as possible my cholesterol levels are as close to ideal as they can get.

This means plant-based, high-fibre. Nothing else works … for me. I am so confused from all the conflicting information that I have read, that I am doing my own research for my body. I started eating whole food plant based January 28th and I will have labs done in May. That is terrible considering all the positive effects testosterone has on your health. Did you know that not just testosterone but every hormone in your body is derived from cholesterol?

I guarentee you that every vegetarian is lacking in some micronutrient. I mean sure you can get by without it because the human body is really resilient but if were talking optimal fuel for your body then its the only way to go.

Also just as important is your source of animal product. Look up the ill effects of phytic acid in wheat and beans on your gut flora and you will be amazed what you find. Also a diet high in fermented foods is very important. I hope that i can change your mind from being vegetarian because it is bad for your health. Vegan for 13 years, have had blood work done and all is good, not lacking in any nutrients and when doctor looked at blood test results she said I have the cholesterol of a healthy 12 year old!

This is easy to verify online. Any advice to a person slowly becoming vegan? Foods for testoserone and omegas? As well as for cholestrol? It is not healthy to be a vegan. In the end they do not live longer than meat eaters. Humans have been eating meat since the beginning of time.

God said to eat meat. All test are subjective. I ate 20 eggs with yolks a week for years and my doctor said I have the lowest cholesterol levels he has seen, so what. Sorry Chris, but you are totally wrong. Of the oldest and healthiest people around, vegans are certainly amongst them. Check out vegan bodybuilding and fitness! There is a lot of crap including rape in that fictional book called The Bible! After years of health issues I discovered I had almost no iron or vitamin D in my body.

I switched to pastured meats, lots of saturated fats coconut oil, lard, etc , and fruits and veggies. My triglycerides, cholesterol, iron and other nutrients are now at normal to optimal levels without supplementation. Every diet should reflect that. Judging people by what they eat is not helping. It is, in fact, hurting people. Do you not go in the sun at all? This is a huge issue because people plaster themselves with sunscreen! Get a few minutes of sunshine on your skin every day and if you live further north than Boston, take a vitamin D supplement in the winter time!

Never in the history of humans has there ever been a true Vegan society. It is a new age phenomena. This is a proven fact over years! The fruit sugars can also be just as bad if over done. Look up your diet by blood type as well, good info.

Its correct that your hormones and brain need cholesterol and giving a statin will NOT make you healthier or lower your HA risk. Mercola can spell that out for ya all. You can become diabetic however with statins…muscle cramps etc.

Grains are deadly, todays wheat is deadly! Grains turn to sugar Read Grain Brain or the other books out on grains and their undesirable health effects if eaten, especially too much. I get plenty of B12 which is a bacteria not an actual vitamin though and Arbonne fizz stick in my water each day.

Also fortified plant based milks have B Meat and dairy have zero fibre and that is a huge health issue! Eating foods like kale, spinach, beets, quinoa, beans, hemp seeds etc give me all the nutrients I need.

As for genetics, both my parents took medication for high cholesterol and my mother ate meat and was always anemic. She died of multiple myeloma at age 71 and my dad still alive at 91 and has had a heart attack, stents, and takes heart medication for his heart, high blood pressure and high cholesterol!! And he was taking cholesterol lowering medication at my age!! I guess I suck because I dont have testosterone in my body.

My suggestion to all of the peeps in this conversation, get your Spectracell Test done. GREAT test, The nutraval test is another one lots of peeps do, to give you a good look at what you are deficient in. The VAP cholesterol test is the best as it gives you the total break down in particle size.. All we can do is to report how exogenous cholesterol affects our own bodies.

In mine, I have spent the last half year eating a low fat diet. No cheese, no eggs along with daily steel-cut oatmeal, chicken, fish and avocados. Previously, I ate lots of cheese, eggs and hamburger. You should start eating more saturated fat thats good your getting your omega 3s from fish and monos from avocado but you need to incorporate more saturated fat in your diet for optimal health.

I would suggest grass fed butter and grass fed beef lard and whole eggs. Maybe even an egg or two raw every now and then. You will be amazed at the difference. It helped me with my cholesterol and other things as well. The micronutrient has 7 patents and 14 clinical studies. It helped me, hope it can help you. Do not get from amazon…higher prices.

The late cardiologist and researcher, Dr. SA Mortensen, concluded from his large body of research that HF is largely due to an energy-starved heart. There is a large review of the study at http: I like the taste of bacon, butter, grilled meats, but I eat plant based and I do not ADD oils such as olive,vanilla or any type of oil to my food. As I am trying to also lose fat from my body, I avoid high fat plant foods such as avocado and nuts.

Once my weight stabilizes, I will include fattier plant foods again. After much exasperation with my dr. Wanting me to take statins, I am now working with a dr who is plant based. Although I was plant based for a year, on my own volition, my cholesterol barely went down. I am not religious, but I often think about what a bunch of gluttons our society has turned into.

Yep, even the thin people lol! Industrial animal agriculture is polluting the planet and oceans. I feel so sorry for your poor body. If you can keep it up you just might achieve 0 cholesterol and then you will be dead.

I hope you do more research on this. Your doctor should have their medical license revoked. That is absolutely horrible advice. I eat tons of healthy fats like avocado and olive oil on everything and I am skinny as a rail. Our bodies are meant to eat fat and have been meant to do so for , years.

I was very scientific in my approach to evaluating the affects of eating carbohydrates refined are worse and processed foods. I did blood tests at the beginning and after 90 days and had a significant drop in Cholesterol.

I have gotten lazy over the years and now at 53 am sitting at I am jumping back on to a diet consisting of fish, chicken, eggs and green vegetables. God the amount of wrong info on this page and comments is horrific. Good luck trying to live a long, healthy life with whatever info you carry in your head! Eskimos being healthy is a myth. Eskimos have a shorter life expectancy, higher rates of strokes and atherosclerosis and so on.. You can also read through the sources and the studies cited for the video..

Another from years ago, a woman in her early 40s — atherosclerosis in her aorta and coronary arteries. Considering the dismal health status of Eskimos, it is remarkable that instead of labeling their diet as dangerous to health, they just accepted and echoed the myth and tried to come up with a reason to explain the false premise.

Such dismal health that the Westernization of their diets actually lowered their rates of ischemic heart disease. So, why do so many researchers to this day unquestioningly parrot the myth? To quote the great scientist Francis Bacon: All of these anti-cholesterol studies are funded by big pharma.

Statins are a big scam, moneymaker. Olive oil damages endothelial cells. You can be skinny and have shit arteries. You can be skinny because of a cocaine habit, chemotherapy and tuberculosis and other problems.. People that died in the army — big tough guys were found to have heart disease. It was the diet..

Yeah, a diet consisting mostly of refined carbs. All that matters is money. The Mediterranean diet that consists of lots of extra virgin olive oil has the lowest rates of heart disease in the world! If extra virgin olive oil was damaging this factual statistic would be impossible! The biggest problem with olive oil is heating it.

There is a huge difference between eating fresh cold pressed extra virgin olive added to food at the table vs cooking with it. Yet your source does not address this issue. How did the test subject eat it? Also, the text of the chart states virgin olive oil, but the speaker says extra virgin olive oil.

Why are there so many stupid nutritionally uneducated M. In Europe where the research came from has a class of olive oil that is not available in North America. Extra virgin olive oil is the first cold pressing of the olive. Then it is pressed again, the additional pressing causing the oil to become heated; this second pressing is called virgin olive oil. Next the olives are subjected to chemical and heat extraction, which is simply called olive oil.

Just like the FACT that people in the tropics that eat lots of coconut fat have almost non-existent heart disease. Having been diagnosed with Hypertension, I went to a plant-based lifestyle and I am now feeling great and no longer have high BP. No fats makes bile sit in your galbladder and form stones. I agree your doctor is killing you, but slowly. You will see story after story of people who who have lost tremendous amounts of weight by eating lots of at with low cholesterol. Eliminating all fat would mean eliminating the essential oils.

That is very bad for your health. Humans are designed to eat a variety of foods for optimal health. If you decide to eliminate entire nutrient types, i.

I am with Lisa. The longest living people around the world Blue Zones eat diets centred around plants. The science is fine. If we grew grass in our open spaces and feed our animals what they really need, which is NOT grains, as they have never had the stomaches to eat grains, only grass.

Too many posts to read. I try to keep it really simple: What were we all born to eat? There are certain processes at work in your body that are ONLY present in carnivores.

You want a diet plan that works? You want the body of your dreams? First, figure out your caloric requirement for whatever you are trying to accomplish. Now divide that up among the meals in your day. Obviously, the bulk of your food should be vege, but most of your calories will undoubtedly come from your fats and meats.

Now train like a beast. This is the reason I respect the most. Everything else about nutrition is just a scare tactic. I have different opinion about the clogging of unsaturated fatty acids. Because most of the re actions taking place in cell and cell-wall are not chemical reactions. They are electrical, mechanical and binding actions due to the electrical and mechanical properties of the molecules. High packing factor of Cholesterol and saturated fatty acids coupled with the presence of tiny calcium compounds can clog the arteries.

Chemistry is by definition electrical, the chemical properties of a substance relate to protons and electrons. ALL my levels were up! Glucose is up also. I have been on a paleo diet for over a year and my cholesterol is the lowset it has ever been.

My blood glucose is perfect as well. I have also lost 50 pounds. But I saw cholesterol improvements within a month or two. Did your HDL go up? Did your triglycerides go down? I went on the high fat diet for the last 6 months and all my numbers shot up except for the HDL which stayed the same. I would definitely get blood work done as you could be doing yourself a great disservice. Same thing happened to me. My cholesterol shot up to over !

My HDLs remained the same. The doctor said in the last year and a half, my new diet has made my health worse according to the blood tests. Fasting Blood glucose is Was around The biggest change you made was adding exercise by riding your bike.

People often make dietary changes at the same time they start an exercise regimen, then when they lose weight and their blood numbers change, they credit their diet. Blood work numbers have little value. They vary from individual to individual, and some people with low cholesterol are unhealthy while some people with high cholesterol are perfectly healthy etc. Truthfully lack of activity is the most likely culprit behind supposed increase in obesity and heart disease in the U.

People who exercise frequently, hard enough to get the heart rate up for a little while each work out, can eat anything they want and remain healthy and at a healthy weight. Those same people generally choose healthier foods in all food groups, however, because their active bodies feel better eating cleanly avoiding processed artificial foods.

The coconut oil is now being used only for skin cream. If you want to know how your body responds to a low carb and high fat diet and all the wonderful benefits.. Extensive research has been done by these doctors on how are bodies respond to a ketogenic diet and all the benefits of switching to a low carb food plan.

Really inform yourselves with current information done with new technology that has made amazing new discoveries about the food we eat. I recommend everyone get blood tests to see how any diet affects them. Started the high fat, low carb no sugar, no grain diet in July.

The good news is that by December, I lost 26lbs most of it fat , from to ! The bad news is my total cholesterol shot up from to !

LDL went from to ! Gonna quit the butter, bacon, and red meat for awhile and go to more veggies, lean chicken, and fatty fish. Hopefully things will come back down — I guess I am sensitive to dietary intake of sat fat.

I highly suggest you learn what doctors like Caldwell Esselstyn have learned at places like the Cleveland Clinic:.

Yay for an intelligent post! Caldwell Esselstyn is a cardiologist from the Cleveland Clinic which is the number 1 place in the world for Cardiology and Heart surgery? Everything else was far shitter and much worse for causing a 2nd episode of cardiac problems and death.. Not even talking about the really bad ones..

An analysis of one of the initial studies suggested that although statins were linked to diabetes risk, the cardiovascular event rate reduction with statins far outweighed the risk of incident diabetes even for patients at highest risk for diabetes The absolute risk increase was small over 5 years of follow-up, 1. A meta-analysis of 13 randomized statin trials with 91, participants showed an odds ratio of 1.

A recent systematic review of the U. Food and Drug Administration's postmarketing surveillance databases, randomized controlled trials, and cohort, case-control, and cross-sectional studies evaluating cognition in patients receiving statins found that published data do not reveal an adverse effect of statins on cognition.

Therefore, a concern that statins might cause cognitive dysfunction or dementia should not deter their use in individuals with diabetes at high risk for ASCVD Dual antiplatelet therapy is reasonable for up to a year after an acute coronary syndrome and may have benefits beyond this period. Aspirin has been shown to be effective in reducing cardiovascular morbidity and mortality in high-risk patients with previous MI or stroke secondary prevention.

Its net benefit in primary prevention among patients with no previous cardiovascular events is more controversial both for patients with diabetes and for patients without diabetes 76 , Previous randomized controlled trials of aspirin specifically in patients with diabetes failed to consistently show a significant reduction in overall ASCVD end points, raising questions about the efficacy of aspirin for primary prevention in people with diabetes, although some sex differences were suggested 78 — The Antithrombotic Trialists' ATT collaborators published an individual patient-level meta-analysis of the six large trials of aspirin for primary prevention in the general population.

These trials collectively enrolled over 95, participants, including almost 4, with diabetes. There was some evidence of a difference in aspirin effect by sex: Conversely, aspirin had no effect on stroke in men but significantly reduced stroke in women.

Sex differences in aspirin's effects have not been observed in studies of secondary prevention In the six trials examined by the ATT collaborators, the effects of aspirin on major vascular events were similar for patients with or without diabetes: The confidence interval was wider for those with diabetes because of smaller numbers. Aspirin appears to have a modest effect on ischemic vascular events, with the absolute decrease in events depending on the underlying ASCVD risk.

The main adverse effects appear to be an increased risk of gastrointestinal bleeding. The excess risk may be as high as 1—5 per 1, per year in real-world settings. This previous statement included sex-specific recommendations for use of aspirin therapy as primary prevention persons with diabetes. However, since that time, multiple recent well-conducted studies and meta-analyses have reported a risk of heart disease and stroke that is equivalent if not higher in women compared with men with diabetes, including among nonelderly adults.

As a result, such risk calculators have limited utility in helping to assess the potential benefits of aspirin therapy in individuals with diabetes.

Noninvasive imaging techniques such as coronary computed tomography angiography may potentially help further tailor aspirin therapy, particularly in those at low risk 87 , but are not generally recommended. Sex differences in the antiplatelet effect of aspirin have been suggested in the general population 88 ; however, further studies are needed to investigate the presence of such differences in individuals with diabetes.

Clinical judgment should be used for those at intermediate risk younger patients with one or more risk factors or older patients with no risk factors until further research is available. There is little evidence to support any specific dose, but using the lowest possible dose may help to reduce side effects Although platelets from patients with diabetes have altered function, it is unclear what, if any, effect that finding has on the required dose of aspirin for cardioprotective effects in the patient with diabetes.

Many alternate pathways for platelet activation exist that are independent of thromboxane A 2 and thus not sensitive to the effects of aspirin A recent trial suggested that more frequent dosing regimens of aspirin may reduce platelet reactivity in individuals with diabetes 93 ; however, these observations alone are insufficient to empirically recommend that higher doses of aspirin be used in this group at this time.

A P2Y12 receptor antagonist in combination with aspirin should be used for at least 1 year in patients following an ACS and may have benefits beyond this period. Evidence supports use of either ticagrelor or clopidogrel if no percutaneous coronary intervention was performed and clopidogrel, ticagrelor, or prasugrel if a percutaneous coronary intervention was performed In patients with diabetes and prior MI 1—3 years before , adding ticagrelor to aspirin significantly reduces the risk of recurrent ischemic events including cardiovascular and coronary heart disease death More studies are needed to investigate the longer-term benefits of these therapies after ACS among patients with diabetes.

In asymptomatic patients, routine screening for coronary artery disease is not recommended as it does not improve outcomes as long as atherosclerotic cardiovascular disease risk factors are treated.

Consider investigations for coronary artery disease in the presence of any of the following: In patients with known atherosclerotic cardiovascular disease, use aspirin and statin therapy if not contraindicated A and consider ACE inhibitor therapy C to reduce the risk of cardiovascular events. In patients with symptomatic heart failure, thiazolidinedione treatment should not be used.

Candidates for advanced or invasive cardiac testing include those with 1 typical or atypical cardiac symptoms and 2 an abnormal resting electrocardiogram ECG. Exercise ECG testing without or with echocardiography may be used as the initial test. Pharmacologic stress echocardiography or nuclear imaging should be considered in individuals with diabetes in whom resting ECG abnormalities preclude exercise stress testing e.

In addition, individuals who require stress testing and are unable to exercise should undergo pharmacologic stress echocardiography or nuclear imaging.

The screening of asymptomatic patients with high ASCVD risk is not recommended 96 , in part because these high-risk patients should already be receiving intensive medical therapy—an approach that provides similar benefit as invasive revascularization 97 , There is also some evidence that silent MI may reverse over time, adding to the controversy concerning aggressive screening strategies However, a randomized observational trial demonstrated no clinical benefit to routine screening of asymptomatic patients with type 2 diabetes and normal ECGs Despite abnormal myocardial perfusion imaging in more than one in five patients, cardiac outcomes were essentially equal and very low in screened versus unscreened patients.

Accordingly, indiscriminate screening is not considered cost-effective. Studies have found that a risk factor—based approach to the initial diagnostic evaluation and subsequent follow-up for coronary artery disease fails to identify which patients with type 2 diabetes will have silent ischemia on screening tests , Any benefit of newer noninvasive coronary artery disease screening methods, such as computed tomography and computed tomography angiography, to identify patient subgroups for different treatment strategies remains unproven.

Although asymptomatic patients with diabetes with higher coronary disease burden have more future cardiac events , , , the role of these tests beyond risk stratification is not clear. Their routine use leads to radiation exposure and may result in unnecessary invasive testing such as coronary angiography and revascularization procedures.

The ultimate balance of benefit, cost, and risks of such an approach in asymptomatic patients remains controversial, particularly in the modern setting of aggressive ASCVD risk factor control.

Intensive lifestyle intervention focusing on weight loss through decreased caloric intake and increased physical activity as performed in the Action for Health in Diabetes Look AHEAD trial may be considered for improving glucose control, fitness, and some ASCVD risk factors While clear benefit exists for ACE inhibitor and ARB therapy in patients with nephropathy or hypertension, the benefits in patients with ASCVD in the absence of these conditions are less clear, especially when LDL cholesterol is concomitantly controlled , Data on the effects of glucose-lowering agents on heart failure outcomes have demonstrated that thiazolidinediones have a strong and consistent relationship with heart failure — Therefore, thiazolidinedione use should be avoided in patients with symptomatic heart failure.

Recent studies have also examined the relationship between dipeptidyl peptidase 4 DPP-4 inhibitors and heart failure and have had mixed results. Alogliptin had no effect on the composite end point of cardiovascular death and hospital admission for heart failure in the post hoc analysis hazard ratio 1. TECOS showed a nonsignificant difference in the rate of heart failure hospitalization for the sitagliptin group 3. Recently published cardiovascular outcome trials have provided additional data on cardiovascular outcomes in patients with type 2 diabetes with cardiovascular disease or at high risk for cardiovascular disease.

The FDA recently added a new indication for empagliflozin, to reduce the risk of cardiovascular death in adults with type 2 diabetes and cardiovascular disease. Whether other SGLT2 inhibitors will have the same effect in high-risk patients and whether empagliflozin or other SGLT2 inhibitors will have a similar effect in lower-risk patients with diabetes remains unknown. The Liraglutide Effect and Action in Diabetes: Evaluation of Cardiovascular Outcome Results—A Long Term Evaluation LEADER trial was a randomized, double-blind trial that assessed the effect of liraglutide, a glucagon-like peptide 1 receptor agonist, versus placebo and standard care on cardiovascular outcomes in patients with type 2 diabetes at high risk for cardiovascular disease or with cardiovascular disease.

Study participants had a mean age of 64 years and a mean duration of diabetes of nearly 13 years. LEADER showed that the composite primary outcome MI, stroke, or cardiovascular death occurred in fewer participants in the treatment group Whether other glucagon-like peptide 1 receptor agonists will have the same effect in high-risk patients or if this drug class will have similar effects in lower-risk patients with diabetes remains unknown.

Cardiovascular disease and risk management. In Standards of Medical Care in Diabetes— Diabetes Care ;40 Suppl. Readers may use this article as long as the work is properly cited, the use is educational and not for profit, and the work is not altered. More information is available at http: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail.

We do not capture any email address. Skip to main content. Diabetes Care Jan; 40 Supplement 1: Screening and Diagnosis Blood pressure should be measured at every routine visit. A Treatment for hypertension should include drug classes demonstrated to reduce cardiovascular events in patients with diabetes ACE inhibitors, angiotensin receptor blockers, thiazide-like diuretics, or dihydropyridine calcium channel blockers.

Screening and Diagnosis Blood pressure should be measured by a trained individual and should follow the guidelines established for the general population: Treatment Strategies Lifestyle Intervention Although there are no well-controlled studies of diet and exercise in the treatment of elevated blood pressure or hypertension in individuals with diabetes, the Dietary Approaches to Stop Hypertension DASH study evaluated the impact of healthy dietary patterns in individuals without diabetes and has shown antihypertensive effects similar to those of pharmacologic monotherapy.

Pharmacologic Interventions Lowering of blood pressure with regimens based on a variety of antihypertensive agents, including ACE inhibitors, angiotensin receptor blockers ARBs , diuretics, and calcium channel blockers has been shown to be effective in reducing cardiovascular events 9 , Combination Drug Therapy The blood pressure arm of the ADVANCE trial demonstrated that routine administration of a fixed-dose combination of the ACE inhibitor perindopril and the thiazide-like diuretic indapamide significantly reduced combined microvascular and macrovascular outcomes, as well as death from cardiovascular causes and total mortality.

Bedtime Dosing Growing evidence suggests that there is an association between absence of nocturnal blood pressure dipping and the incidence of ASCVD. Other Considerations An important caveat is that most patients with diabetes and hypertension require multiple-drug therapy to reach blood pressure treatment goals Pregnancy and Antihypertensive Medications Since there is a lack of randomized controlled trials of antihypertensive therapy in pregnant women with diabetes, recommendations for the management of hypertension in pregnant women with diabetes should be similar to those for all pregnant women.

E Obtain a lipid profile at initiation of statin therapy and periodically thereafter as it may help to monitor the response to therapy and inform adherence. C For patients of all ages with diabetes and atherosclerotic cardiovascular disease, high-intensity statin therapy should be added to lifestyle therapy. C For patients with diabetes aged 40—75 years without additional atherosclerotic cardiovascular disease risk factors, consider using moderate-intensity statin and lifestyle therapy.

A For patients with diabetes aged 40—75 years with additional atherosclerotic cardiovascular disease risk factors, consider using high-intensity statin and lifestyle therapy.

B In clinical practice, providers may need to adjust intensity of statin therapy based on individual patient response to medication e. A Statin therapy is contraindicated in pregnancy. Lifestyle Intervention Lifestyle intervention, including weight loss, increased physical activity, and medical nutrition therapy, allows some patients to reduce ASCVD risk factors. View inline View popup. Age 40—75 Years In low-risk patients with diabetes aged 40—75 years, moderate-intensity statin treatment should be considered in addition to lifestyle therapy.

Ongoing Therapy and Monitoring With Lipid Panel In adults with diabetes, it is reasonable to obtain a lipid profile total cholesterol, LDL cholesterol, HDL cholesterol, and triglycerides at the time of diagnosis, at the initial medical evaluation, and at least every 5 years thereafter.

Treatment of Other Lipoprotein Fractions or Targets Hypertriglyceridemia should be addressed with dietary and lifestyle changes including abstinence from alcohol Combination Therapy Statin and Fibrate Combination therapy statin and fibrate is associated with an increased risk for abnormal transaminase levels, myositis, and rhabdomyolysis. Diabetes With Statin Use Several studies have reported an increased risk of incident diabetes with statin use 72 , 73 , which may be limited to those with diabetes risk factors.

Statins and Cognitive Function A recent systematic review of the U. B Dual antiplatelet therapy is reasonable for up to a year after an acute coronary syndrome and may have benefits beyond this period. Risk Reduction Aspirin has been shown to be effective in reducing cardiovascular morbidity and mortality in high-risk patients with previous MI or stroke secondary prevention. Indications for P2Y12 Use A P2Y12 receptor antagonist in combination with aspirin should be used for at least 1 year in patients following an ACS and may have benefits beyond this period.

Screening In asymptomatic patients, routine screening for coronary artery disease is not recommended as it does not improve outcomes as long as atherosclerotic cardiovascular disease risk factors are treated. A Consider investigations for coronary artery disease in the presence of any of the following: Treatment In patients with known atherosclerotic cardiovascular disease, use aspirin and statin therapy if not contraindicated A and consider ACE inhibitor therapy C to reduce the risk of cardiovascular events.

B In patients with symptomatic heart failure, thiazolidinedione treatment should not be used. Cardiac Testing Candidates for advanced or invasive cardiac testing include those with 1 typical or atypical cardiac symptoms and 2 an abnormal resting electrocardiogram ECG. Screening Asymptomatic Patients The screening of asymptomatic patients with high ASCVD risk is not recommended 96 , in part because these high-risk patients should already be receiving intensive medical therapy—an approach that provides similar benefit as invasive revascularization 97 , Lifestyle and Pharmacologic Interventions Intensive lifestyle intervention focusing on weight loss through decreased caloric intake and increased physical activity as performed in the Action for Health in Diabetes Look AHEAD trial may be considered for improving glucose control, fitness, and some ASCVD risk factors Antihyperglycemic Therapies and Cardiovascular Outcomes Recently published cardiovascular outcome trials have provided additional data on cardiovascular outcomes in patients with type 2 diabetes with cardiovascular disease or at high risk for cardiovascular disease.

Achievement of goals in U. N Engl J Med ; Primary prevention of cardiovascular diseases in people with diabetes mellitus: Diabetes Care ; Effect of a multifactorial intervention on mortality in type 2 diabetes.

Crude and age-adjusted hospital discharge rates for major cardiovascular disease as first-listed diagnosis per 1, diabetic population, United States, — [Internet]. Accessed 27 August Arch Intern Med ; Prognostic value of ambulatory and home blood pressures compared with office blood pressure in the general population: Circulation ; Age-specific relevance of usual blood pressure to vascular mortality: Lancet ;

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