Primary prevention of heart disease, diabetes in patients at metabolic risk: Endocrine Society Guideline

1. Definitions and diagnosis

• In individuals aged 40 to 75 years in the office setting, we suggest providers screen for all five components of metabolic risk at the clinical visit. The finding of at least three components should specifically alert the clinician to a patient at metabolic risk (at higher risk for atherosclerotic cardiovascular disease and type 2 diabetes mellitus).


• In individuals aged 40 to 75 years in the office setting who do not yet have atherosclerotic cardiovascular disease or type 2 diabetes mellitus and already have at least one risk factor, we advise screening every 3 years for all five components of metabolic risk as part of the routine clinical examination. (Ungraded Good Practice Statement)


• To establish metabolic risk in the general population, we recommend that clinicians measure waist circumference as a routine part of the clinical examination.


• In individuals previously diagnosed with prediabetes, we suggest testing at least annually for the presence of overt type 2 diabetes mellitus.


• We recommend that all individuals at metabolic risk in the office setting have their blood pressure measured annually and, if elevated, at each subsequent visit.


• For individuals with elevated blood pressure >130 mm Hg systolic and/or >80 mm Hg diastolic who are not documented as having a history of hypertension, we recommend confirmation of elevated blood pressure on a separate day within a few weeks or with a home blood pressure monitor.

• In individuals at metabolic risk, we recommend that lifestyle modification be first-line therapy.


• For individuals at metabolic risk with excess weight (defined by body mass index and/or waist circumference), we recommend that comprehensive programs to support the adoption of a healthy lifestyle should aim to achieve a weight loss of ≥5% of initial body weight during the first year.


• In individuals at metabolic risk, we recommend prescribing a cardiovascular-healthy diet.


• In individuals at metabolic risk, we recommend prescribing daily physical activity, such as brisk walking, and reduction in sedentary time.

Risk assessment and evaluation

• In individuals identified as having metabolic risk, we recommend global assessment of 10-year risk for either coronary heart disease or atherosclerotic cardiovascular disease to guide the use of medical or pharmacological therapy.


• In individuals with low-density lipoprotein cholesterol ≥190 mg/dL (4.9 mmol/L) or triglycerides ≥500 mg/dL (<5.6 mmol/L), we recommend that, before considering the diagnosis of primary hyperlipidemia, practitioners should rule out secondary causes of hyperlipidemia. If a secondary cause can be excluded, primary hyperlipidemia should be suspected.

• In individuals 40 to 75 years of age with low-density lipoprotein cholesterol ≥190 mg/dL (≥5.9 mmol/L), we recommend high-intensity statin therapy to achieve a low-density lipoprotein cholesterol reduction of ≥50%.


• In individuals 40 to 75 years of age with low-density lipoprotein cholesterol 70 to 189 mg/dL (1.8 to 4.9 mmol/L), we recommend a 10-year risk for atherosclerotic cardiovascular disease should be calculated.
  
  
  
  • In individuals 40 to 75 years of age without diabetes and a 10-year risk ≥7.5%, we recommend high-intensity statin therapy either to achieve a low-density lipoprotein cholesterol goal <100 mg/dL (<2.6 mmol/L) or a low-density lipoprotein cholesterol reduction of ≥50%.
  
  
  • In individuals 40 to 75 years of age without diabetes and a 10-year risk of 5% to 7.5%, we recommend moderate statin therapy as an option after consideration of risk reduction, adverse events, drug interactions, and individual preferences, to achieve either a low-density lipoprotein cholesterol goal <130 mg/dL (<3.4 mmol/L) or a low-density lipoprotein cholesterol reduction of 30% to 50%.
  
  
  • In individuals with metabolic risk, without diabetes, on statin therapy, we suggest monitoring glycemia at least annually to detect new-onset diabetes mellitus.
  
  
  • In individuals aged >75 years without diabetes and a 10-year risk ≥7.5%, we recommend discussing the benefits of statin therapy with the patient based on expected benefits vs possible risks/side effects.
  
  
  
  


• In individuals at metabolic risk who are taking statins with adequate low-density lipoprotein cholesterol reduction, elevated triglyceride levels [≥200 mg/dL (2.3 mmol/L)], and reduced high-density lipoprotein levels [≤50 mg/dL (1.3 mmol/L) in females, or ≤40 mg/dL (1.0 mmol/L) in males], we suggest considering fenofibrate adjunct therapy.


• In individuals ≥40 years of age at metabolic risk with low-density lipoprotein cholesterol at target, an estimated 10-year atherosclerotic cardiovascular disease risk of >7.5%, and without clinical atherosclerotic cardiovascular disease or other atherosclerotic cardiovascular disease risk factors, we suggest treatment with a moderate-intensity statin.

Blood pressure reduction

• In individuals with blood pressure >130/80 mm Hg and a 10-year cardiovascular risk ≤10%, we suggest lifestyle management to lower blood pressure to <130/80 mm Hg and to reduce the risk for atherosclerotic cardiovascular disease.


• In individuals without a history of atherosclerotic cardiovascular disease with metabolic risk who have a 10-year cardiovascular risk of >10% and blood pressure of >130/80 mm Hg, we suggest the use of blood pressure–lowering medication in addition to lifestyle modifications for primary prevention of atherosclerotic cardiovascular disease only when lifestyle modification alone has failed.

• In individuals with prediabetes, we recommend prescribing lifestyle modification before drug therapy to reduce plasma glucose levels.


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  In individuals with prediabetes who have limitations to physical activity or are not responding to lifestyle modifications, we recommend metformin as a first pharmacologic approach to reduce plasma glucose levels.