LDL-C and Diabetes: Primary and Secondary Prevention Strategies in Diabetes

I’m Erin Ferranti, Board President for PCNA, and I’d like to welcome you to this episode of the Heart to Heart Nurses Podcast. PCNA is the proud home of cardiovascular nurses and one of the leading figures in the fight against cardiovascular disease. We have the resources you need for your day-to-day practice or to follow your passion to new areas of learning and growth.

Geralyn Warfield (host):

I’d like to welcome our audience to today’s episode, which is the 2nd of a 3-part mini-series on LDL-C and diabetes.

Our previous episode focused on the pathophysiology of LDL-C and how insulin resistance and hyperglycemia can increase atherogenesis of those LDL particles. Today, we’re going to shift gears just slightly and focus on primary and secondary prevention strategies in diabetes. And we’re so grateful to Lisa Maher for being present today and being our guest to speak a little bit more about those prevention strategies.

Lisa, could you introduce yourself to our audience?

Lisa Maher (guest):

Yes, great. Thanks, Geralyn. Thank you so much to yourself, and to PCNA for hosting this podcast series. I’m very excited to be here.

Like Geralyn said, my name is Lisa. I’m a Nurse Practitioner for UnityPoint Health, which is in Waterloo, Iowa. I’ve been a cardiac nurse practitioner about 17 years now and primarily focus in general cardiovascular disease, but also have a specialty management in prevention, cardiovascular risk prevention, not so much diabetes, but it is still something that I deal with on a daily basis, any type of cardiovascular risk factor, and see patients also in a specialty sleep clinic.

When I’m not busy at work, I also help with PCNA. So, I’m the immediate Past President and continue to serve on the Board.

Geralyn Warfield (host):

Lisa, thank you so very much for all you do for PCNA and for all you do for your patients and colleagues each day. We’re really grateful to you.

And today’s topic is near and dear to, I think, all of our hearts because most of the patients that we see have an issue that’s related to our content today. So, I’m so excited to talk to you.

We know, for example, that the LDL levels have a big impact on the risk of cardiovascular disease. And I’m hoping that today’s conversation can talk about that role of the interplay of diabetes, blood pressure, of smoking, and family history in shaping someone’s ASCVD risk. Could you talk about that for us, please?

Lisa Maher (guest):

Oh, you bet. Like I said, this is something I deal with on a daily basis. And oftentimes, you don’t just see one of these conditions alone. So, they never really occur in isolation. You’re always treating more than one at the same time. And unfortunately, when they combine, they oftentimes amplify the effect of one another.

So, if you remember back to those early pathophysiology classes, we know that ASCVD develops through endothelial injury and inflammation, that plaque formation, and then eventual plaque rupture. What we want to do is obviously prevent that, but each risk factor has a different biological pathway. And again, those pathways dramatically increase that risk.

So, when we specifically talk about diabetes, we should consider it an equivalent to underlying cardiovascular coronary artery disease. And we want to do that because we have to think of the chronic underlying condition, which is inflammation in all of these conditions. And then we combine that with oxidative stress.

It accelerates that atherosclerosis, causes that dyslipidemia or hyperlipidemia, and it can damage blood vessels.

Hypertension, on the other hand, we know that it causes vascular injury and again, endothelial dysfunction, LVH or that left ventricular hypertrophy, and that can raise your risk for heart failure and any type of arrhythmia, let alone plaque instability.

Smoking is also detrimental. It affects nearly every stage of atherosclerosis. So, inflammation, oxidative stress, reduces HDL, increases platelet activation, and increases our risk for thrombosis. It causes that direct effect on endothelial injury and increases insulin resistance.

And so lastly, we want to talk about family history and what that does and why we should assess for that in ASCVD risk.

So, any type of genetic dyslipidemia, early onset hypertension, and any prothrombotic tendencies or metabolic disorders should be evaluated when we’re talking to a patient about that family history.

Again, these risk factors, when alone they increase your cardiovascular risk; when you couple them together, or in groups or clusters, that risk significantly increases. So again, endothelial dysfunction, chronic systemic inflammation, lipid oxidation, hypercoagulation, and that accelerated plaque formation and instability.

Again, when they’re all combined together, that’s when that risk for ASCVD goes up exponentially or that lifetime risk. Again, when you have them individually too, your risk goes up. But when we combine them all together, ASCVD risks, myocardial infarction, stroke, peripheral artery disease, we all want to be definitely more aware of at that point.

Geralyn Warfield (host):

So, with this interplay of all of these different impacts on our risk for ASCVD, how does decision-making come into play? How does it impact, actually, the decision-making when a clinician and a patient are having a discussion about when and how to initiate therapy? How does that impact that discussion and those decisions?

Lisa Maher (guest):

So, a lot of times I talk to my patients about shared decision-making. So, it’s never just, I never want it to be a one-sided conversation. So, I usually talk about that.

But what it’s important to know is that any one of these conditions can enhance your risk for ASCVD. So, we want to talk about that. What does that look like?

So, if we have that or if they are at risk that, the decision-making should be, or should lean towards, an earlier intervention, more aggressive intervention. Even when traditional risk calculators show borderline or intermediate risk, at times it’s those times that I have those meaningful conversations or those shared decision moments with patients to say, “Hey, we’re here, but we really should be here. How can we get you to that lower level?”

Or, “What can we do so that 5 years from now, or 10 years from now, you’re still healthy?”

So again, at that point, I shift to using one of the traditional calculators. When we look at those, we are reminded of the 2019 ACC AHA guidelines on the prevention of cardiovascular disease. And the single most effective way to prevent CVD is to adopt and sustain those healthy lifestyle habits.

So, sometimes we get so focused on those risk factors that we forget the simple things that are right in front of us. What can we do in our diet? What can we do in our lifestyle? How can we address those things first? Because a lot of times it’s those simple changes that can lead to those long-lasting effects.

Major lifestyle, again, healthy diet, healthy eating, weight and weight management, smoking cessation. And with that, we use the risk calculator.

So, for adults aged 40 through 75, it is recommended to predict the 10-year risk or ASCVD risk. When we do that, we get a calculated score that tells us if they are low or less than 5% risk.

A borderline risk is anywhere from 5-7.5%.

And intermediate is > 7.5 up to 20%.

And then high is > that 20% risk.

So, when we get into those categories, we want to help them and focus on those risk factors when we get to that point.

Geralyn Warfield (host):

I’d like our audience to know that we’ve got links for those guidelines in the show notes so that you don’t have to have this all memorized by the time you’re done listening or watching. So, know that those will be available to you if you don’t have them already at your fingertips.

Lisa Maher (guest):

Yeah, definitely. We don’t want you to have to memorize those because I oftentimes look back at the actual numbers too.

Geralyn Warfield (host):

Thanks so much, Lisa. For our clinicians, or our healthcare professionals that are working with individuals with patients that have diabetes, how exactly does the timing of therapeutic intervention matter for those individuals specifically?

Lisa Maher (guest):

Yeah, again, we want to think often and earlier. So, the quicker we can get in to look at those, the better we’re going to be able to make a difference, immediate difference, but also we’re looking at long-term risk and increasing that long-term risk.

So, for adults with diabetes, especially those in that age group, that 40 through 75, even without ASCVD risk, the recommendation is that we are aggressive, that we start at least moderate-intensity statin therapy for primary prevention. Plus, again, always talk about those lifestyle approaches, so diet, exercise, weight loss, and smoking cessation.

But if a patient has additional risk factors, so your hypertension, your smoking, your family history, elevated LDL, many will automatically start high-intensity statin therapy at that point, aiming for a greater than 50% reduction in that LDL-C. And so, according to the current guidelines, we recommend an LDL < 70.

For younger adults, if they’re not hitting that 40 age mark yet, but they’re still diabetic, age 20-39, statin therapy may still be reasonable. And again, at this point, it’s when we want to talk about what are their risks, what does their future look like, what are our long-term goals in prevention.

Geralyn Warfield (host):

We are going to take a quick break, and we will be right back for our continued conversation about LDL-C and diabetes.

Geralyn Warfield (host):

I’d like to welcome our audience back to our continued conversation about the connection between LDL-C and diabetes. But there are some other factors that can affect a patient’s overall health, and one of those main primary points that we need to all be worried about, no matter what our clinical setting is, is hypertension. And Lisa, could you talk just briefly about that for us so that we can understand the context of that within our conversation?

Lisa Maher (guest):

Oh, you bet, Geralyn. Hypertension is so important. And it’s something that until just recently, until this fall, fall 2025, we haven’t had updated guidance on. So, we have an idea of what it should be, but now we know that the more aggressive we can be, the better off our patients will be in the long run.

So, looking at blood pressure, if blood pressure is greater than 130/80, and there’s another major risk factor—diabetes, smoking, family history—guidelines support earlier intervention. And earlier intervention for not only lifestyle, but also medication at that point.

So, I always, when I’m educating even patients or other clinicians, I always tell them, if we can do it by lifestyle, that’s great, that’s awesome. But we also have to remember that it has to be a sustainable approach long-term.

So, if we’re doing our best that we can in lifestyle and our blood pressure is still going up and down and we’re not getting consistent control, we’re not going to benefit, get the most benefit long-term. So, medication is not a bad option. In fact, there are several medication groups that are still very beneficial.

The other thing I want to point out is for patients with stage 1 hypertension, in that range of 130-139 and that diastolic pressure of 80-89, medication could be indicated if that ASCVD risk is > than 10%, or if additional risk factors are present, like diabetes, like smoking.

And then for the blood pressure > 140/90, it should be immediate pharmacotherapy or immediate management, regardless of any other risk factors.

Geralyn Warfield (host):

Lisa, you’ve mentioned a couple of times family history. And how does that information come to a clinician or a healthcare professional that’s dealing with a patient? Because those aren’t really present on those risk factor calculators, are they?

Lisa Maher (guest):

No, you’re correct. They, the risk factor calculators, it’s hard to put a value to family history and, to identify that. And what I have learned is it’s really important to be intentional about your questions when talking about family history with patients because sometimes, they don’t know or sometimes they assume that everybody’s family has high blood pressure or something like that. They’re diabetic, so you should assume that everybody in their family is diabetic.

And what we want to do is we want to use that shared decision-making at that point to assess if their risk is borderline. Well, if there’s a family history of premature cardiovascular disease, yeah, we want to be more aggressive at that point. And just talking to them about, “Hey, you know, this is where we sit. Let’s talk. Let’s get really in depth about family history. Do you ever remember,” and sometimes it’s simple as, “Do you ever remember Mom or Dad being on any blood pressure medication? Do you ever remember them talking about their cholesterol?”

“Do you ever remember Grandma and Grandpa having any heart events?” And kind of sifting through that information at that point. Because sometimes it’s not always black and white. they don’t know, “Hey, Dad had a stent to the RCA in 1999.” They, a lot of times, don’t know that information, you know, to those specifics. So, pulling out the information that’s important.

Geralyn Warfield (host):

I think the flip side of that probably is an issue sometimes too, that if they’ve got issues themselves, this patient that’s in front of you, having them have the capacity and the wherewithal to share that with their family, too, for others that might be at risk.

Lisa Maher (guest):

You’re right. Yeah, that’s important too. Once they have these conditions, especially if we’re concerned about something genetic, you know, a genetic risk that can be carried on, the importance of talking to your family. I know a lot of people are private and maybe don’t want to share that information, but at least having it written down somewhere or something that if something would come up in the family that you can have those conversations.

Geralyn Warfield (host):

So, if you’re working with a patient and they have ASCVD—or they haven’t had ASCVD—what do those discussions look like in terms of treatment guidelines, the recommendations that we might be aiming for?

Lisa Maher (guest):

Yeah, so primary prevention. When we talk about primary prevention, those are going to be those patients that don’t have documented ASCVD but have the risk factors for ASCVD. So that’s when these calculators, the guideline calculators come into play. And that helps us use that as our risk strategy.

So that age of that 40-75, that’s where we can use those risk calculators and stratify their risk as low, or intermediate, or borderline intermediate, and high. And that’s what can help us guide into those decisions.

Now, when a patient has ASCVD, they already have documented coronary disease in the form of CAD in the arteries, carotid disease, stroke, or PAD, then these calculators won’t be as pertinent. So, at that point, you want to go with the most aggressive guidelines.

Geralyn Warfield (host):

I have so enjoyed our conversation thus far, and we have covered a lot of ground when it comes to topics related to LDL-C, diabetes, and other risk factors for ASCVD. So, my one remaining question for you is, what one key takeaway would you have for our audience as a result of our conversation?

Lisa Maher (guest):

This is always a hard question for me to answer because I always have so much to say. But if I would have the one key takeaway, it would be that any ASCVD risk factor, whether that be diabetes, or hypertension, or smoking, or that family history, or lipids, you know, in the case too that have been addressed during other podcasts, but any risk factor should be considered an ASCVD equivalent.

And again, early intervention and aggressive intervention.

Geralyn Warfield (host):

Well, thank you so very much, Lisa, for being here today and sharing with us your enthusiasm, and your expertise about this particular topic.

I would also like to thank Amgen for their support of this podcast mini-series.

As I mentioned earlier, we will have some information in the show notes to lead you to some other resources that will help you in your clinical practice, wherever it is that you work.

And then we will also have some information in our other podcasts in this mini-series, so I’d encourage you to check that out.

I’d like to again thank our guest, Lisa Maher, and this is Geralyn Warfield, your host, and we will see you next time.

Thank you for listening to Heart to Heart Nurses. We invite you to visit pcna.net for clinical resources, continuing education, and much more.