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EX0-004 - Management of Risk(R) Foundation - Dump Information

Vendor : Exin
Exam Code : EX0-004
Exam Name : Management of Risk(R) Foundation
Questions and Answers : 140 Q & A
Updated On : April 19, 2019
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EX0-004 Questions and Answers

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EX0-004 Management of Risk(R) Foundation

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EX0-004 exam Dumps Source : Management of Risk(R) Foundation

Test Code : EX0-004
Test Name : Management of Risk(R) Foundation
Vendor Name : Exin
Q&A : 140 Real Questions

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Exin Management of Risk(R) Foundation

distinct chance component control for the Prevention of heart problems and Mortality in category 2 Diabetes | killexams.com Real Questions and Pass4sure dumps

it is neatly based that cardiovascular chance aspect control is necessary to the management of diabetes, as people with diabetes have an improved risk of heart problems and dying. hence, over the ultimate 1-2 many years, the idea of numerous possibility component control in diabetes has obtained extended attention. Yet, the impact of multiple possibility factor handle and the contributory effect of individual risk elements has now not been well quantified in inhabitants-based mostly reports except currently. for instance, Rawshani, et al.1 showed that diabetes sufferers with five modifiable possibility factors inside target range had the identical risk of acute myocardial, stroke, and mortality as the ordinary inhabitants.

The researchers explored the research question: "Can the excess risk of loss of life and cardiovascular activities among sufferers with class 2 diabetes be reduced or eliminated?" In a large retrospective cohort examine, they investigated the have an effect on of chance component control on cardiovascular risk amongst 271,274 sufferers with category 2 diabetes recognized through the Swedish country wide Diabetes Register. each and every affected person changed into matched to controls (1,355,870) from the typical inhabitants and followed for a median time of 5.7 years.

The crew examined right here 5 possibility factors: accelerated hemoglobin A1C, increased LDL ldl cholesterol, albuminuria, smoking, and improved blood force. They then studied how control of these (i.e., target degrees) become associated with demise, myocardial infarction, stroke, and hospitalization for coronary heart failure (HF).

The main discovering was that adequate handle of all five possibility components renders about the same chance of demise (HR: 1.06, CI 1.00-1.12), myocardial infarction (HR: 0.eighty four, CI 0.75-0.93), and stroke (HR: 0.ninety five, CI 0.eighty four-1.07) as in comparison with the matched typical population, and particularly they followed a gradual lessen in cardiovascular possibility with an incremental raise in variety of possibility components managed.

a fair decrease possibility of acute myocardial infarction and stroke was observed among these with reduce than goal degrees of hemoglobin A1c, LDL cholesterol, and systolic blood pressure. common, the strongest predictors of death were discovered to be smoking, physical undertaking, marital fame, hemoglobin A1C, and use of lipid-reducing treatment.

despite the mitigated risk followed with gold standard risk aspect manage, there became nonetheless a markedly expanded risk of HF among diabetic individuals (HR: 1.45, CI 1.34-1.fifty seven). The chance components discovered to have essentially the most prognostic have an effect on on heart failure had been atrial fibrillation, BMI, actual exercise, eGFR, and hemoglobin A1c. The study helps the skills that diabetes is an impartial risk component of HF,2-3 and that advanced cardiac and renal mechanisms are at play that extends past what can be modified with usual atherosclerotic chance component control.

an important strength of the analyze is the inhabitants-based scope and the detail of the baseline risk elements listed in the Swedish Diabetes Registry. in addition, Sweden has a tax-funded healthcare system that offers free and equal access to healthcare services, and hence socioeconomic ameliorations should no longer have an effect on the consequences.

The look at provides compelling evidence to the growing to be body of literature highlighting the value of chance component in diabetes. The Steno-2 (Intensified Multifactorial Intervention in sufferers With type 2 Diabetes and Microalbuminuria) examine become the first to systematically investigate the effect of intensive multifactorial chance aspect manage in type 2 diabetes and located that an intensive versus usual care regimen become associated with a long-term survival improvement extending past the trial length.4

The findings by way of Rawshani, et al., despite the fact, had been observational, and it is important to be aware that the risk components assessed were baseline values, hence subsequent risk component control including pharmacotherapy throughout the comply with-up duration was no longer regarded. Yet, as pointed out with the aid of the authors, the use of baseline values may take care of the interpretation from reverse causation.

a further element to consider is that the associations outlined in the examine represent the prognostic weight of various possibility factors, however don't necessarily reflect causal consequences. To that end, it is not sudden that patients diagnosed with diabetes but with an in any other case choicest cardiovascular profile have a decrease possibility of future cardiovascular disease and death. consequently, scientific implications of reducing off-goal possibility elements cannot be drawn from this analyze.

as an instance, the examine indicates that decrease degrees (<fifty three mmol per mole) of hemoglobin A1c turned into a powerful marker of all consequences. Yet intensive lowering of hemoglobin A1c has, in randomized controlled stories, not been proven to have a significant impact on reducing mortality and has even been found to enhance mortality.5,6 rather, besides the fact that children strict blood sugar handle early within the disorder direction could be linked to benefits, as indicated by using Rawshani, et al., this may also not be a good strategy later on and will even be dangerous. This represents a remedy paradox important to bear in mind when translating findings to the health facility.

The authors raise a vital point that younger sufferers may advantage from extra aggressive medicine, as they examine a monotonic relationship between more youthful age, variety of variables now not inside target, and cardiovascular risk. still, this further highlights the hazards associated with achieving an unhealthy cardiometabolic profile early in life and underscores the essence of picking americans with diabetes and prediabetes early.

In summary, with the recent examine by Rawshani, et al., we now have strong proof that the number of risk factors controlled at analysis are prognostic of later cardiovascular hobbies. This helps the concept that a multifaceted strategy directed at controlling cardiovascular possibility components is crucial in curbing cardiovascular issues in class 2 diabetes. Healthcare suppliers and patients should collectively center of attention on assessing and improving chance elements early on and ahead; primarily via lifestyle administration established on plant based mostly foodstuff, actual exercise, most fulfilling sleep, behavioral support, and smoking cessation, supplemented through concomitant individualized polypharmacotherapeutic efforts.7

The look at by using Rawshani, et al. shows us that most useful chance aspect control theoretically can get rid of the extra possibility of atherosclerotic heart problems and dying. whether we almost are in a position to abolish the elevated cardiovascular chance in patients with diabetes by enhancing varied off-target risk factors is not yet clear, but unless then we will also be cautiously optimistic and do our best to improve chance aspect handle and the lives of people living with diabetes.

References

1. Rawshani A, et al. possibility factors, mortality, and cardiovascular results in patients with class 2 diabetes. N Engl J Med 2018; 379: 633-644.

2. Zarich S, Nesto R. Diabetic cardiomyopathy. Am heart J 1989; 118: 1000.

three. Boudina S, Abel ED. Diabetic cardiomyopathy revisited. Circulation 2007; 115: 3213-3223.

4. Gaede P, et al. effect of a multifactorial intervention on mortality in type 2 diabetes. N Engl J Med 2008; 358: 580-591.

5. increase Collaborative group, Patel A, et al. Intensive blood glucose control and vascular results in sufferers with class 2 diabetes. N Engl J Med 2008; 358: 2560-2572.

6. motion to handle Cardiovascular possibility in Diabetes study community, Gerstein HC, et al. effects of intensive glucose decreasing in category 2 diabetes. N Engl J Med 2008; 358: 2545-2559.

7. Garber AJ, et al. Consensus observation with the aid of the American association of medical Endocrinologists and American faculty of Endocrinology on the complete class 2 diabetes administration algorithm – 2018 executive abstract. Endocr Pract 2018; 24: 91-a hundred and twenty.

This review changed into funded by means of an independent research furnish from the Danish heart foundation to cover Dr. Noergaard's revenue; the Danish heart foundation had no role within the conduct of any aspects of the assessment.

final up to date 03.29.2019


Evanston firefighters and AMITA St. Francis will assist E.R. sufferers avoid return journeys | killexams.com Real Questions and Pass4sure dumps

EVANSTON fire DEPT., ST. FRANCIS WORK TO retain ER sufferers FROM RETURNING: AMITA health St. Francis medical institution and the Evanston fireplace department are collaborating in an effort to cut back return trips to the emergency room. The Evanston community fitness Outreach (ECHO) software will identify emergency room patients at excessive chance for readmission, and present them free in-home medical visits, fitness training, social provider referrals, home safeguard inspections, and different components. The aim is to increase residents' basic fitness and cut back expensive and infrequently useless emergency room and sanatorium visits.

“through inserting knowledgeable caregivers out in the community, we hope to more suitable handle key fitness concerns and issues before they strengthen into some thing that requires a trip to the emergency room,” noted Kenneth Jones, president of AMITA health Saint Francis medical institution. “many of our sufferers locate it difficult to locate transportation for common visits and checkups, we’re also assisting to clear up those concerns by way of bringing the care to them.”

Evanston firefighter/paramedics and nurses from AMITA fitness Saint Francis clinic will function "community paramedics" providing a number services to application participants selected through AMITA health Saint Francis health facility's Emergency branch. those that choose to sign up will finished the software in four weeks. Funding for ECHO comes from the AMITA fitness Saint Francis medical institution groundwork.

LIGHTBANK, HYDE PARK ANGELS, again mental health facts company: Chicago project capital organizations Lightbank and Hyde Park Angels are main a $1.3 million circular of funding for Blueprint, a know-how enterprise that offers intellectual health experts with statistics collection and analysis for clinical determination making.

A Blueprint cellular app prompts sufferers to comprehensive standardized assessments between appointments and combines these effects with their pastime, sleep, and flow patterns, captured via smartphone sensors. Lightbank managing accomplice Vic Pascucci III is a member of Blueprint's board.

food DEPOSITORY SPURNS JUNK meals: The stronger Chicago food Depository (GCFD) has joined the Partnership for a more fit the usa (PHA) in a three-12 months commitment to cut back the estimated 25 percent of donations to food depositories that are considered unhealthy snack foods. GCFD will work to raise donations of fruit, vegetables and other fit meals by using 25 percent, while chopping donations of unhealthy foods with the aid of 10 percent.

With the addition of GCFD, the PHA initiative now has 22 food counsel partners serving greater than 5 million americans, pretty much 20 % of all meals-insecure people in the U.S. PHA become created to keep on the work of former First woman Michelle Obama's Let's circulate! initiative after her husband left the White residence. 

UCHICAGO drugs providing ROBOTIC TECH TO treat PROSTATE melanoma: university of Chicago medical core is the primary Midwest clinic, and the fifth nationwide, to present a robotic ultrasound know-how that aims diseased prostate tissue without disposing of the entire gland. The non-invasive, precision medication reduces the probability of commonplace surgical aspect outcomes like incontinence and impotence.  

in the event you overlooked IT:

• Walgreens Boots Alliance Inc. shares plunged the previous day after the U.S.’ greatest standalone drugstore chain fell victim to lots of the pressures rippling through health care and retailing.

at the pharmacy counter, which generates more than two-thirds of U.S. store sales, Walgreens is filling extra prescriptions however making much less funds on them. Upfront, identical-store merchandise sales dropped 3.8 %, as the business sold fewer cough and cold items and introduced in much less from tobacco. study more.

• Illinois Medicaid managed care program is costing hospitals, Stephanie Goldberg experiences in this week's concern of Crain's. under HealthChoice Illinois, the state pays inner most insurers a group volume per affected person instead of paying for each and every scientific carrier offered. The intention is to enrich health and handle costs through making certain all care is acceptable and wonderful. despite the fact, it has enormously expanded administrative expenses for some hospitals—many of which are already strapped for cash.

"Hospitals and techniques are having to group of workers up with dozens and dozens of employees to chase down claims," says A.J. Wilhelmi, CEO of the Illinois fitness & health facility association. "counting on the measurement of the company, some are spending hundreds of thousands of dollars—and sure hundreds of thousands of bucks—to address the denials and delays in charge. For smaller hospitals, this further administrative can charge is rarely in their funds so that they do the best they can with the team of workers they have got." read greater.

Illinois officers should still ease the financial drive on security internet hospitals by way of streamlining HealthChoice methods and establishing stricter guidelines to prevent unreasonable claim denials, Crain's columnist Joe Cahill writes.

americans ON THE movement:

• Mark Stevens joined Navigant as a managing director in its lifestyles sciences apply in Chicago. Stevens got here from Publicis health, where he was chief approach officer. He has also served in leadership roles at Novartis, Bristol Myers Squibb, Sanofi, and Schering Plough.

“The complexity of the world life sciences market continues to speed up,” Eduardo Schur, managing director and leader of Navigant’s international existence sciences apply. Stevens “will work with one of the biggest pharmaceutical and medical device organizations worldwide to construct insightful and value-based options.”

• advertising consulting firm Prophet hired health care branding veteran Jeffrey Nemetz as a companion in its Chicago workplace. Nemetz founded fitness manufacturer community has labored with agencies including Aramark Healthcare, Abbott Laboratories, American clinical affiliation, AT&T, and Baxter overseas. With more than twenty years' journey, Nemetz also has served on income and never-for-profit boards together with the American clinical affiliation foundation, The core For Enriched residing, Craig Capital management and the Yellow Brick foundation. 

• Timothy Connors turned into named CEO of Advantice health, an over-the-counter pharmaceutical business formed via RoundTable Healthcare partners of Lake forest and manhattan-primarily based Signet Healthcare companions to acquire a portfolio of first help and footsore items from Moberg Pharma AB. Advantice plans to promote the items below the brands Kerasal, Kerasal Nail, New epidermis, Dermoplast, Domeboro, Emtrix, and Zanmira. Conners joins Advantice from prestige manufacturers, where he was government vp of sales and advertising.

"OTC prescribed drugs are poised for appreciable growth as consumers take extra accountability and make choices for his or her own healthcare,”  spoke of Thomas P. Kapfer, RoundTable’s senior working partner and chairman of the board of Advantice.

• Lake woodland strong point pharmaceutical enterprise Assertio Therapeutics, Inc. appointed James J. Galeota, Jr. to the company’s board of administrators. Galeota most currently served because the president and chief operating officer of G&W Laboratories, Inc. From 1988 to 2016, Galeota held various positions at Merck & Co.

• Alison Shipley joined Chartis neighborhood as a most important in its profits cycle performance observe in Chicago. Shipley specializes in fitness care advice expertise, clinical operations efficiencies and salary cycle improvement. She changed into prior to now a director in PricewaterhouseCoopers’ profits performance management observe. 


Vail Valley groundwork declares Sarah Johnson as senior VP of schooling and humanities | killexams.com Real Questions and Pass4sure dumps

Sarah Johnson

Sarah Johnson has been named senior vice president of schooling and the arts for the Vail Valley foundation, a brand new place both for the corporation and Johnson.

“we're extraordinarily happy to have Sarah be part of our team, and she or he is already proving to be a pretty good and considerate leader,” Mike Imhof, president of the Vail Valley foundation, mentioned in a news free up. “Sarah’s historical past is an ideal fit for this new position, and her journey, insights and wisdom will enable our firm to continue to flourish.”

Johnson involves the Vail Valley foundation after 5 years at Vail Mountain school, where she most currently served because the director of development and neighborhood engagement. Johnson’s experience at Vail Mountain school is just one aspect of a profession that runs deep in training, the humanities and legislation as neatly: she was common assistance and director of risk administration for Augustana school, and has her J.D. from DePaul institution faculty of legislations and her undergraduate diploma in human and organizational development from Vanderbilt university. right through and after school, Johnson worked in schooling both professionally, in provider on a number of nonprofit boards and as a volunteer during her career.

Her passion for arts is equally lengthy-lived. She has been an active member of the Vail Dance competition committee and has been a pioneering chief for young people and the arts throughout her lifestyles, including taking management roles in dance programming for Vail Valley adolescence.

“The Vail Valley groundwork is fully interesting in its capability to give such a big selection of programs, activities and services to our neighborhood, and i am excited to join this out of the ordinary team in pursuing the company’s mission,” Johnson pointed out. “The Vail Valley groundwork does a superb job discovering tips on how to unify its arts and training missions — S.T.A.R.S. on the VPAC, master courses with the Vail Dance competition and extra — I look ahead to working with present programming and exploring new and innovative tips on how to have interaction both 12 months-circular residents and guests to the Vail Valley.”

Johnson’s first day in the position became Feb. 28. amongst her first fundamental projects may be the appointment of a new executive director of schooling to steer the Vail Valley foundation’s YouthPower365, and the appointment of a director of the Gerald R. Ford Amphitheater, which is decided to begin its summer season this June. Johnson will also oversee the Vilar Performing Arts middle, which is led by executive director Duncan Horner; as smartly because the Vail Dance festival, led by means of inventive director Damien Woetzel.

Johnson grew up on the banks of the Mississippi River in Bettendorf, Iowa. She now lives in East Vail with her husband, Tait, and their two children, Grace and Drew.

To study greater in regards to the Vail Valley basis activities and movements talk over with http://www.vvf.org.


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Risk of sea level rise 'hasn't hit home' for coastal R.I. property owners, experts say | killexams.com real questions and Pass4sure dumps

PROVIDENCE — Although the risks of sea level rise to coastal properties are becoming more widely understood, they may not being fully accounted for in the real estate market.

“The price of any asset, be it commodities, gold, stocks, depends fundamentally on people’s beliefs,” said Lint Barrage, assistant professor of economics and environmental studies at Brown University. “If people are excessively optimistic about the future value of an asset, there is potential for mispricing, and bubbles and overinvestment.”

Speaking Friday at a one-day conference at Brown on the political and economic consequences of climate change, Barrage described her research on the coastal property market, which included going door-to-door in Rhode Island and interviewing homeowners about flood risk. People with homes in federally designated flood zones tended to underestimate the risk of flooding when compared with people who lived further inland, she found.

“The reason all this matters is that markets cannot price risks efficiently if people don’t believe in them,” she said.

And if the risks of climate change aren’t being accurately factored into prices now, then it could mean a steep drop in values somewhere down the line.

Part of the reason for the disconnect, at least in Rhode Island and neighboring states, is that the region hasn’t been hit hard or in a widespread manner by a hurricane or other extreme weather event in recent years, said Curt Spalding, former New England regional administrator of the U.S. Environmental Protection Agency who is now a professor at Brown.

“We have not had a shockingly catastrophic climate-connected event,” he said. “It hasn’t hit home yet.”

But when it does, the impact could be profound. Home ownership represents the financial foundation for many people, said Spalding, so if home values erode, it will damage their overall financial well-being. Cities and towns that depend on property taxes will also suffer if home value is lost.

As much of 40 percent of the U.S. population lives in counties adjacent to a shoreline, and the value of real estate within one-eighth of a mile of the coast is estimated to be $1.4 trillion.

Recent studies have found that properties at risk of flooding are starting to see their values affected. Just last week, researchers from Columbia University and the nonprofit First Street Foundation released a study that concluded that Rhode Island lost $44.7 million in home appreciation between 2005 and 2017 because of increased tidal flooding due to sea level rise.

One of the problems in communicating flood risks that Barrage and other speakers raised at the conference was the federal flood mapping program. Flood-risk maps created by the Federal Emergency Management Agency are backward-looking and fail to account for future sea level rise.

In Rhode Island, the Coastal Resources Management Council and the University of Rhode Island have developed maps that do factor in sea level rise. Those maps, through an online program called STORMTOOLS, and flood-damage visualizations for parts of Warwick and South County and, more recently, for the East Bay created as part of a separate initiative called the Coastal Environmental Risk Index aim to educate the public about the increasing risks.

“My guess is that these types of visualizations will be very helpful to people to try and internalize these risks,” Barrage said.

—akuffner@providencejournal.com 

(401) 277-7457


W. R. Berkley Corporation Charitable Foundation on Behalf of Key Risk Donates a Total of $55,000 to Kids’ Chance Chapters in Six States | killexams.com real questions and Pass4sure dumps

GREENSBORO, N.C.--(BUSINESS WIRE)--W. R. Berkley Corporation Charitable Foundation on behalf of Key Risk (a Berkley Company), a leading provider of workers compensation insurance products and services for employers throughout the United States, today announced their annual fundraising contribution of $55,000 for Kids’ Chance chapters in six states. Formed by workers compensation professionals, Kids’ Chance state chapters award scholarships to students (ages 16-25) whose parent’s on-the-job death or catastrophic injury resulted in a substantial decline in family income.

“All of us at Key Risk understand the impact a work-related accident has on a family and we are proud to support local Kids’ Chance chapters each year,” said Rob Standen, president of Key Risk.

“Year after year our team finds new and innovative ways to support Kids’ Chance in our local states. Supporting students and families who have been impacted is an integral part of our organizational culture,” added Mr. Standen.

Over the past eight years, Key Risk has raised over $320,000 for local Kids’ Chance chapters across their footprint.

Contributions were given through the W. R. Berkley Corporation Charitable Foundation to Kids’ Chance chapters in Georgia, Maryland, North Carolina, Pennsylvania, South Carolina and Virginia. Funds were raised for state chapters through the efforts of Key Risk associates on behalf of W. R. Berkley Corporation and Key Risk.

ABOUT KIDS’ CHANCE:

Established in 1988, Kids’ Chance is committed to helping the children of injured workers pursue and achieve their educational goals. Scholarship funds come from donations by individuals, groups, organizations, foundations, medical, legal and other professionals. For more information about Kids’ Chance, visit www.KidsChance.org.

ABOUT KEY RISK:

Key Risk (a Berkley Company) provides employers with workers compensation insurance, risk management, claims, and managed care services. Through their Alternative Risk Services division, Key Risk provides workers compensation third-party administrative services to self-insured clients. Additionally, Key Risk offers nationwide specialty insurance solutions to employers in the industries of Temporary Staffing and USL&H.

Key Risk is a member company of W. R. Berkley Corporation, whose insurance company subsidiaries are rated A+ (Superior), Financial Size Category XV by A.M. Best Company and A+ (Strong), by S&P.

For further information about Key Risk please visit www.KeyRisk.com.


Multiple Risk Factor Control for the Prevention of Cardiovascular Disease and Mortality in Type 2 Diabetes | killexams.com real questions and Pass4sure dumps

It is well established that cardiovascular risk factor control is integral to the management of diabetes, as individuals with diabetes have a higher risk of cardiovascular disease and death. Thus, over the last 1-2 decades, the concept of multiple risk factor control in diabetes has received increased attention. Yet, the effect of multiple risk factor control and the contributory effect of individual risk factors has not been well quantified in population-based studies until recently. For example, Rawshani, et al.1 showed that diabetes patients with five modifiable risk factors within target range had the same risk of acute myocardial, stroke, and mortality as the general population.

The researchers explored the research question: "Can the excess risk of death and cardiovascular events among patients with type 2 diabetes be reduced or eliminated?" In a large retrospective cohort study, they investigated the impact of risk factor control on cardiovascular risk among 271,274 patients with type 2 diabetes identified through the Swedish National Diabetes Register. Each patient was matched to controls (1,355,870) from the general population and followed for a median time of 5.7 years.

The team examined the following five risk factors: elevated hemoglobin A1C, elevated LDL cholesterol, albuminuria, smoking, and elevated blood pressure. They then studied how control of these (i.e., target levels) was associated with death, myocardial infarction, stroke, and hospitalization for heart failure (HF).

The main finding was that adequate control of all five risk factors renders approximately the same risk of death (HR: 1.06, CI 1.00-1.12), myocardial infarction (HR: 0.84, CI 0.75-0.93), and stroke (HR: 0.95, CI 0.84-1.07) as compared with the matched general population, and notably they observed a gradual decrease in cardiovascular risk with an incremental increase in number of risk factors controlled.

An even lower risk of acute myocardial infarction and stroke was observed among those with lower than target levels of hemoglobin A1c, LDL cholesterol, and systolic blood pressure. Overall, the strongest predictors of death were found to be smoking, physical activity, marital status, hemoglobin A1C, and use of lipid-lowering medication.

Despite the mitigated risk observed with optimal risk factor control, there was still a markedly increased risk of HF among diabetic individuals (HR: 1.45, CI 1.34-1.57). The risk factors found to have the most prognostic impact on heart failure were atrial fibrillation, BMI, physical activity, eGFR, and hemoglobin A1c. The study supports the knowledge that diabetes is an independent risk factor of HF,2-3 and that complex cardiac and renal mechanisms are at play that extends beyond what can be modified with traditional atherosclerotic risk factor control.

A major strength of the study is the population-based scope and the detail of the baseline risk factors listed in the Swedish Diabetes Registry. Furthermore, Sweden has a tax-funded healthcare system that offers free and equal access to healthcare services, and thus socioeconomic differences should not influence the results.

The study adds compelling evidence to the growing body of literature highlighting the importance of risk factor in diabetes. The Steno-2 (Intensified Multifactorial Intervention in Patients With Type 2 Diabetes and Microalbuminuria) study was the first to systematically investigate the effect of intensive multifactorial risk factor control in type 2 diabetes and found that an intensive versus standard care regimen was associated with a long-term survival benefit extending beyond the trial period.4

The findings by Rawshani, et al., however, were observational, and it is important to note that the risk factors assessed were baseline values, hence subsequent risk factor control including pharmacotherapy during the follow-up period was not considered. Yet, as pointed out by the authors, using baseline values may safeguard the interpretation from reverse causation.

Another aspect to consider is that the associations outlined in the study represent the prognostic weight of various risk factors, but do not necessarily reflect causal effects. To that end, it is not unexpected that patients diagnosed with diabetes but with an otherwise optimal cardiovascular profile have a lower risk of future cardiovascular disease and death. Thus, clinical implications of lowering off-target risk factors cannot be drawn from this study.

For example, the study shows that lower levels (<53 mmol per mole) of hemoglobin A1c was a strong marker of all outcomes. Yet intensive lowering of hemoglobin A1c has, in randomized controlled studies, not been shown to have a significant effect on reducing mortality and has even been found to increase mortality.5,6 Rather, although strict blood sugar control early in the disease course may be associated with benefits, as indicated by Rawshani, et al., this may not be a favorable approach later on and could even be harmful. This represents a treatment paradox important to keep in mind when translating findings to the clinic.

The authors raise an important point that younger patients may benefit from more aggressive treatment, as they observe a monotonic relationship between younger age, number of variables not within target, and cardiovascular risk. Still, this further highlights the dangers associated with reaching an unhealthy cardiometabolic profile early in life and underscores the essence of identifying people with diabetes and prediabetes early.

In summary, with the recent study by Rawshani, et al., we now have strong evidence that the number of risk factors controlled at diagnosis are prognostic of later cardiovascular events. This supports the concept that a multifaceted approach directed at controlling cardiovascular risk factors is central in curbing cardiovascular complications in type 2 diabetes. Healthcare providers and patients should together focus on assessing and improving risk factors early on and forward; primarily through lifestyle management centered on plant based nutrition, physical activity, optimal sleep, behavioral support, and smoking cessation, supplemented by concomitant individualized polypharmacotherapeutic efforts.7

The study by Rawshani, et al. shows us that optimal risk factor control theoretically can eliminate the excess risk of atherosclerotic cardiovascular disease and death. Whether we essentially are able to abolish the increased cardiovascular risk in patients with diabetes by improving multiple off-target risk factors is not yet clear, but until then we can be cautiously optimistic and do our best to improve risk factor control and the lives of people living with diabetes.

References

1. Rawshani A, et al. Risk factors, mortality, and cardiovascular outcomes in patients with type 2 diabetes. N Engl J Med 2018; 379: 633-644.

2. Zarich S, Nesto R. Diabetic cardiomyopathy. Am Heart J 1989; 118: 1000.

3. Boudina S, Abel ED. Diabetic cardiomyopathy revisited. Circulation 2007; 115: 3213-3223.

4. Gaede P, et al. Effect of a multifactorial intervention on mortality in type 2 diabetes. N Engl J Med 2008; 358: 580-591.

5. ADVANCE Collaborative Group, Patel A, et al. Intensive blood glucose control and vascular outcomes in patients with type 2 diabetes. N Engl J Med 2008; 358: 2560-2572.

6. Action to Control Cardiovascular Risk in Diabetes Study Group, Gerstein HC, et al. Effects of intensive glucose lowering in type 2 diabetes. N Engl J Med 2008; 358: 2545-2559.

7. Garber AJ, et al. Consensus statement by the American Association of Clinical Endocrinologists and American College of Endocrinology on the comprehensive type 2 diabetes management algorithm – 2018 executive summary. Endocr Pract 2018; 24: 91-120.

This review was funded by an independent research grant from the Danish Heart Foundation to cover Dr. Noergaard's salary; the Danish Heart Foundation had no role in the conduct of any aspects of the review.

last updated 03.29.2019



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Exin EX0-004 Exam (Management of Risk(R) Foundation) Detailed Information



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