In 2022, the updated China Expert Consensus on Risk Assessment and Management of Panvascular Diseases in Patients with Type 2 Diabetes (hereinafter referred to as the consensus) has been officially released. This consensus was simultaneously published in 4 major journals: Chinese Journal of Diabetes, Chinese Journal of Health Management, Chinese Circulation Journal, and Cardiology Plus.
The development of the consensus was led by the Chinese College of Cardiovascular Physicians (CCCP), and brought together leading experts from five major fields: Cardiology, Endocrinology, Nephrology, Neurology, and Health Management. It was jointly developed based on significant scientific evidence and the practical experience of clinicians both domestically and internationally.
The consensus offers a comprehensive overview consisting of 5 parts with regard to patients with T2DM:
- Epidemiological Status of Panvascular Diseases
- Pathophysiologic Mechanisms of Panvascular Disease
- Multidisciplinary, Collaborative Diagnosis and Treatment of Panvascular Disease
- Risk Assessment of Panvascular Disease
- Management Strategies for Panvascular Disease
It includes 21 recommendations that provide systematic and standardized clinical guidance for risk assessment and management of panvascular diseases in patients with T2DM. The consensus is applicable across physicians working in clinical settings, including those in internal medicine, surgery, general practice, and medical examination departments.
The consensus emphasizes the importance of early risk assessment for panvascular diseases in patients with T2DM, and recommends assessing risk factors, vascular structure and function, and target organ damage at least once per year. It also stresses that the management of panvascular diseases in patients with T2DM requires the joint efforts of patients and physicians from multiple disciplines. This includes intensive glycemic management, blood pressure, and lipid control, as well as antiplatelet therapy, all built on the foundation of lifestyle interventions.
Risk Assessment for Panvascular Disease in patients with T2DM:
Obtain a thorough medical history, and conduct routine physical examinations and general laboratory tests for patients with T2DM, such as urinalysis, liver function, kidney function, blood glucose, glycated haemoglobin (HbA1c), insulin, and C-peptide levels; additionally, perform a systematic risk assessment for panvascular diseases (Table 1) to detect subclinical atherosclerosis and target organ damage at an early stage.
[Recommendation] Systemic assessment of panvascular disease in patients with T2DM should include risk factors, vascular structure and function, and target organ damage.
| Assessment Item | Assessment Indicators | Frequency of Assessment | ||
| Risk factors | Gender, age, body mass index (BMI), smoking history and alcohol use, duration of diabetes, dyslipidaemia, hypertension, family history of cardiovascular disease and early onset of cardiovascular disease | Baseline * + at least once per year | ||
| Vascular structure and function | Ankle-Brachial Index (ABI), Brachial-Ankle Pulse Wave Velocity (baPWV), carotid ultrasound | Baseline* + at least once per year | ||
| Coronary CT angiography (CTA) | Patients with a long duration of diabetes (e.g., more than 10 years) or those who may have asymptomatic myocardial ischemia or concomitant large or medium-vessel diseases should undergo comprehensive examinations | |||
| Target organ damage | Heart | Myocardial-specific biomarkers: NT-proBNP/BNP and hs-cTn | Baseline* + at least once per year | |
| Electrocardiogram (ECG) | Baseline* + at least once per year | |||
| Transthoracic echocardiography (TTE) | Patients with elevated cardiac biomarkers, concomitant hypertension, abnormal electrocardiogram (ECG) findings, or abnormal cardiac auscultation should undergo comprehensive diagnostic examinations | |||
| Brain | Extracranial blood vessels: Ultrasound of blood vessels in the neck, etc. | Comprehensive examinations should be performed in patients with risk factors such as smoking, dyslipidaemia or hypertension, or those who have experienced cerebrovascular diseases such as stroke or transient ischemic attacks (TIA) | ||
| Intracranial vasculature: Transcranial Doppler ultrasonography, etc. | Comprehensive examinations should be performed in patients with stroke risk factors such as smoking, hypertension, or carotid plaques | |||
| Cognitive function：Mini-Mental State Examination (MMSE), Montreal Cognitive Assessment (MoCA), etc. | For patients with T2DM ≥65 years old, or those experiencing significant clinical decline due to self-care activity issues, a comprehensive cognitive function assessment should be performed, with subsequent assessments conducted every 1-2 years as needed | |||
| Microvasculature and capillaries: Structural brain imaging examinations such as head CT or MRI | Patients with T2DM should undergo at least one microvascular examination after diagnosis, and patients with a high likelihood of cognitive impairment should have comprehensive evaluations | |||
| Peripheral blood vessels | Evaluation of clinical symptoms or signs such as intermittent claudication, measurement of skin temperature, palpation of the dorsalis pedis artery and posterior tibial artery, and auscultation for femoral artery bruits; if any abnormalities are found, further examinations such as Ankle-Brachial Index (ABI) and lower limb arterial ultrasound should be performed | For patients with T2DM >50 years old, or those with high-risk factors for lower extremity atherosclerotic disease (such as cardiovascular and cerebrovascular diseases, dyslipidaemia, hypertension, smoking, etc.), or a duration of diabetes of more than 5 years, these evaluations should be performed at least once per year | ||
| Kidney | Urine albumin-creatinine ration (uACR) | Baseline* + at least once per year | ||
| Retina | Eye examinations: vision, intraocular pressure, anterior chamber angle, iris, lens, and fundus | Baseline* + at least once every 1-2 years | ||
The consensus also specifies the important role that biomarkers play in the management of panvascular diseases in patients with T2DM, and recommends that patients with T2DM should have assessment of cardiac biomarkers (NT-proBNP, hs-cTnT), lipid profile, and renal function indicators at the time of diagnosis and at least annually thereafter.
1. The Value of Applying Cardiac Biomarkers in the Risk Assessment and Management of Panvascular Diseases in T2DM Patients
NT⁃proBNP: For every 100 pg/mL increase in NT⁃proBNP, the 5-year hospitalization rate for cardiovascular events in patients with T2DM increases by 12%. For patients with NT-proBNP levels greater than 125 pg/mL, intensive cardio protective treatment can reduce the risk of cardiovascular disease related hospitalization or death by 65% after 2 years.
hs–cTnT: hs-cTnT is a specific and highly sensitive biomarker for myocardial injury and may reflect chronic subclinical myocardial injury in patients with T2DM. Patients with T2DM have a significantly higher risk of elevated hs-cTnT (≥14 ng/L) compared to those without diabetes, and a significantly increased relative risk of coronary artery disease, heart failure, and all-cause mortality over the next 5 years.
[Recommendation] Assess NT⁃proBNP/BNP and hs⁃cTn at the time of diagnosis and at least once per year during subsequent follow-up for patients with T2DM. If NT⁃proBNP is found to be >125 pg/mL, or BNP >50 pg/mL, or hs⁃cTn exceeds the upper reference limit, or if continuous monitoring reveals elevated NT⁃proBNP/BNP or hs⁃cTn, cardio protective treatment should be initiated immediately, and the frequency of follow-ups should be increased.
2. The Value of Applying Lipid Profile Measurement in the Risk Assessment and Management of Panvascular Disease in Patients with T2DM
[Recommendation] Assess lipid profile (includingtotal cholesterol, TG, LDL⁃C, HDL⁃C, and Apo B) at the time of diagnosis and at least once per year during subsequent follow-up for patients with T2D. Lp(a) levels should be measured at least once after diagnosis of T2DM. LDL-C, non-HDL-C and ApoB should be used as and the primary targets for diagnosis and treatment.
3. The Value of Applying Kidney Function Indicators in the Risk Assessment and Management of Panvascular Disease in Patients with T2DM
Urine albumin-creatinine ratio: Urinary albumin excretion can be measured by measuring uACR, for which UACR≥30 mg/g is considered positive.
Serum creatinine: Used to calculate the estimated glomerular filtration rate (eGFR)
[Recommendation] Evaluate uACR and serum creatinine at the time of diagnosis and at least once per year during subsequent follow-up for patients with T2DM.
[Recommendation] After diagnosis of diabetic kidney disease in patients with T2DM is established, the CKD stage should be further determined based on eGFR and urinary albumin levels, and the risk of progression of DKD should be assessed and the frequency of assessment should be determined.
