An estimated 19.7 million American adults struggle with type 2 diabetes mellitus [38]. Among adults, most studies and meta-analyses do not find significant male–female differences in the overall prevalence of type 2 diabetes [39–42]. It is thought, however, that undiagnosed diabetes is more common in men than in women, with men accounting for 5.3 million of the 8.2 million such cases. Type 2 diabetes is disproportionately more prevalent among underrepresented minorities: non-Hispanic whites (7.7 %), non-Hispanic blacks (13.5 %), and Mexican Americans (11.4 %) [38]. In subgroup analyses of specific demographic groups, however, when a significant male–female difference is found, it is usually greater in the males [43]. Several studies even report male gender as an independent risk factor for the incidence [44].

The approach to screening and diagnosis of diabetes is generally similar between men and women, with the glycosylated hemoglobin (HbA1c) slowly becoming the method of choice for screening, although fasting plasma glucose and 2-hour glucose tolerance tests remain common ways to screen for diabetes. HbA1c values above 6.5 % are considered to be diagnostic of diabetes, and levels between 5.7 and 6.4 % are considered to be in the prediabetic range where aggressive interventions should be pursued to address patients who are at significant risk for developing diabetes. Fasting plasma glucose levels of 126 mg/dL or greater are considered diagnostic, with levels between 100 and 126 mg/dL considered prediabetic [45, 46].

Overall, treatment goals should be individualized, but generally recommended glycemic targets include HbA1c <7 % in nonpregnant adults. A more stringent target of <6.5 % has been suggested for selected individual patients if this can be achieved without significant hypoglycemia or other adverse effects of treatment such as those who have a short duration of diabetes, type 2 diabetes treated with lifestyle or metformin only, long life expectancy, or no significant cardiovascular disease. Less stringent targets may be appropriate for patients with a history of severe hypoglycemia, limited life expectancy, advanced microvascular or macrovascular complications, extensive comorbid conditions, or long-standing diabetes in whom the general goal is difficult to attain [45, 46]. Blood pressure goals vary across guidelines but range from <130/80 mm Hg to <140/90 mm Hg. Antiplatelet treatment with aspirin 75–162 mg/day should be considered as primary prevention strategy for patients with diabetes at increased cardiovascular risk (such as most men >50 years old and women >60 years old with ≥1 additional major risk factor) but should not be recommended for patients with low cardiovascular risk. Lipid goals often include LDL cholesterol <100 mg/dL, and many suggest a target LDL of <70 mg/dL in patients with cardiovascular disease [45].

As with most chronic illnesses, diabetic care is enhanced when patients experience interprofessional, comprehensive patient-focused management plan in a continuity primary care setting. Initial visits for diabetes should address cardiovascular issues directly related to diabetes care, as well as related conditions that are more prevalent among patients with diabetes such as depression, obstructive sleep apnea, fatty liver disease, cancer, fractures, or periodontal disease. Based on a foundation of self-management education and support, over time patients acquire the knowledge and skill to manage this chronic condition [47]. Nutrition therapy, carbohydrate management, weight loss, and physical activity are all important components of the initial treatment strategy for any patient with diabetes. Smoking cessation is advised for all diabetic patients, as is screening for depression, which is a comorbid and complicated condition in 20–25 % of patients with diabetes. Immunizations against pneumococcal disease, influenza, and hepatitis B are recommended in addition to all other routine vaccinations. Patients should have annual fasting lipid profiles, assessments of kidney function (e.g., serum creatinine and urine microalbumin), monofilament foot exams, and dilated retinal exams [46].

Medication therapy, beginning with metformin, should be considered if patients are not attaining the recommended glycemic target goals. Whether targets are assessed using patient self-monitoring of blood glucose, plasma glucose, HbA1c, or other methods, treatment recommendations should acknowledge patient-specific goals, as well as risks and benefits of treatment. Contraindications to metformin are relatively rare and most side effects are manageable and abate over time. Although estimates suggest that over half of patients eligible for metformin have some conventionally regarded contraindication [48], the often-cited risk of lactic acidosis is reported to be only 6.3 per 100,000 patient years [49]. Gastrointestinal intolerance of any kind occurs in approximately 25 % of all patients who begin metformin [50], usually in the form of abdominal pain, flatulence, and diarrhea [51]. Most of these effects are transient and subside once the dose is reduced or when administered with meals. However, as much as 5 % of patients do not tolerate even the lowest dose of metformin [52].

If treatment goals are not achieved with metformin as monotherapy, then adding a second agent is indicated. A comparative effectiveness meta-analysis [53] suggests that overall each new class of non-insulin agents added to initial therapy lowers A1C approximately 0.9–1.1 %, regardless of what class of agents is chosen. Drug choice should be based on patient preferences as well as various patient, disease, and drug characteristics, with the goal of reducing blood glucose levels while minimizing side effects, especially hypoglycemia. Evidence in favor of one agent over another, however, is mixed. Initiating dual therapy for patients with HbA1c >9 % is recommended to achieve glycemic control more rapidly and early consideration of utilizing insulin for initiating dual therapy is reasonable when blood glucose is ≥300–350 mg/dL and/or A1C is ≥10–12 %. Long-acting insulin may be slightly more effective than oral antidiabetic agents as add-on therapy but may increase rate of hypoglycemic events. When initiating insulin, it is recommended that patients self-monitor blood glucose in order to anticipate and manage hypoglycemia [46].

Atrial fibrillation is the most common dysrhythmia with a reported prevalence in the general population of 1–2 %. Men are slightly more predisposed to developing atrial fibrillation than women, due in large majority to the higher prevalence of risk factors among men (e.g., underlying coronary artery disease [CAD], HTN, valvular disease, obesity, and alcohol use). Diagnosis is made on the basis of electrocardiographic findings of rapid oscillatory (“fibrillatory”) baseline waves varying in amplitude, shape, and timing, the absence of P waves, and an irregularly irregular ventricular response. Additional laboratory evaluation for underlying causes, especially thyroid disease, is recommended when first diagnosing atrial fibrillation. Serum levels of both B-type natriuretic peptide (BNP) (assessed by measuring BNP or N-terminal proBNP) and atrial natriuretic peptide are elevated in patients with paroxysmal or persistent atrial fibrillation but decrease rapidly after restoration of normal sinus rhythm [54].

Treatment for chronic atrial fibrillation consists primarily of rate control, as opposed to rhythm control, except for those patients whose symptoms persist despite rate control. Factors favoring rate control over rhythm control include advanced age, long-standing persistent atrial fibrillation, severe left atrial enlargement (and associated mitral valvular heart disease), several prior attempts to restore sinus rhythm minimal symptoms comorbidities with impact on quality of life [55]. Use of beta-blockers or non-dihydropyridine calcium channel blockers recommended as initial treatment, with a target resting heart rate below 110 beats per minute [56]. Ablation therapy by a catheter or surgery should be considered in the treatment of symptomatic patients with atrial fibrillation, especially if there is symptomatic paroxysmal AF without apparent structural heart disease [57].

Thromboembolism is a major complication of atrial fibrillation that can result in stroke or death. For this reason, the decision to offer prophylaxis against thromboembolism is a common clinical quandary for patients and clinicians alike. Antithrombotic therapy can reduce the risk of thromboembolism, but this benefit must be balanced against the risk of spontaneous or traumatic bleeding. Risk stratification scores (e.g., CHADS2 or CHA2DS2-VASc) can be helpful in this regard. The CHADS2 score gives 1 point for each of congestive heart failure, hypertension, age ≥75 years, diabetes mellitus; 2 points for prior stroke or transient ischemic attack. The CHA2DS2-VASc score assigns 1 point each for female sex, age 65–74 years, congestive heart failure or left ventricular dysfunction, hypertension, diabetes mellitus, history of myocardial infarction, or peripheral artery disease; 2 points for age ≥75 years; and 2 points for history of stroke, transient ischemic attack, or thromboembolism. There is strong evidence that antithrombotic therapy is indicated for most patients with atrial fibrillation or atrial flutter, along with anticoagulation for patients at high risk for stroke [58].

Dyslipidemia, specifically increased LDL-C or decreased HDL-C, is one of the traditional risk factors for atherosclerotic cardiovascular disease. Evidence has shown that interventions to improve cholesterol levels decrease risk of cardiovascular events. The use of statin therapy decreases incidence of major cardiovascular events and all-cause mortality, with similar benefits shown in men as well as women [59–61]. As with other cardiovascular risk factors, healthy lifestyle modifications including increased physical activity and dietary modifications are also an important foundation in management.

The USPSTF guidelines recommend screening for dyslipidemia in adult men beginning at age 35 years or beginning at age 20 years for those who have cardiovascular risk factors, with a fasting serum lipid profile. An alternative screening modality would be non-fasting total cholesterol and high-density lipoprotein levels. Evidence has not shown an optimal screening frequency [31]. Previously, the indications of lipid-lowering treatment for primary prevention of cardiovascular disease had been based primarily on achievement of target cholesterol levels. However, updated ACC/AHA guidelines released in 2013 recommend a shift to lipid treatment for cardiovascular prevention based on 10-year risk and inclusion of cardiovascular risk factors, with less focus on initiation or goals of treatment based on specific cholesterol levels [62]. While these guidelines would notably increase the use of statins in the general population, studies using the presence of plaque and atherosclerosis on imaging as a surrogate marker for cardiovascular risk suggest that those with greater risk would more consistently be prescribed statin therapy when compared to prior treatment recommendations [63–65].

The ACC/AHA guidelines recommend initiation of statin therapy for primary prevention in individuals over 20 years of age with primary LDL-C greater than or equal to 190 mg/dL, individuals with diabetes aged 40–75 years, and individuals aged 40–75 years with 10-year risk for ASCVD greater than or equal to 7.5 %. The 10-year ASCVD risk is determined by use of the pooled cohort equations ASCVD risk calculator. Those with clinical atherosclerotic CVD (defined as prior myocardial infarction, acute coronary syndrome, angina, transient ischemic attack or stroke, arterial revascularization, or peripheral arterial disease) should also be treated with statin therapy for secondary prevention. Baseline serum liver transaminases should be measured prior to initiation of statin medication and followed yearly thereafter [62].

High-intensity statin therapy, if tolerated, is preferred for men with clinical ASCVD or LDL-C greater than or equal to 190 mg/dL, with moderate-intensity statin use being a secondary option. Individuals in the described benefit groups with diabetes or increased 10-year ASCVD risk should be treated with a moderate-intensity statin (see Table 8.1). For those with diabetes or increased risk, but outside of the specified age ranges or with LDL-C less than 70 mg/dL, initiation of statin therapy should be tailored to the individual with consideration of potential adverse effects versus benefits. Monitoring of lipid levels while on statin therapy should occur within 4 months of dose adjustments and at least annually to assess for appropriate response to treatment. When indicated, addition of a non-statin lipid-lowering medication, such as fibric acid derivatives, niacin, bile acid-binding resins, or cholesterol absorption inhibitors, may be considered to further reduce ASCVD risk [62].

Dyslipidemia in particular is a risk factor that contributes to inflammation and atherosclerosis, thereby increasing the risk for ASCVD events. Atherosclerosis progresses with narrowing of vessels or causing thrombi, leading to clinical presentations including coronary heart disease, stroke, or peripheral vascular disease. With regard to gender, men have a higher risk of atherosclerosis as compared to women. Thus, promoting cardiovascular health in men is paramount in reducing risk of cardiovascular morbidity and mortality.

Overall, women have a higher lifetime risk of stroke as compared to men, with lifetime risk from age 55 to 75 years being 1 in 5 for women and approximately 1 in 6 for men [66]. Coronary artery calcium (CAC) score, measured by CT imaging, provides assessment of coronary atherosclerosis and is an independent predictor of stroke. A lack of CAC is associated with reduced risk of cardiovascular events. Measurement of carotid intima media thickness (CIMT) by neck ultrasound is also a surrogate for early atherosclerosis and is associated with increased coronary disease risk. However, there is insufficient evidence to support routine screening with CAC or neck ultrasound in asymptomatic and low-risk individuals, and screening in higher risk populations have not been shown to clearly improve clinical outcomes [66, 67].

Modifiable risk factors of stroke are similar to those of other ASCVD, including hypertension, diabetes, dyslipidemia, atrial fibrillation, and carotid stenosis, as well as smoking status, obesity, physical inactivity, and diet. Reduction of elevated blood pressure is the most important risk factor modification in prevention of stroke, with less emphasis on the choice of specific antihypertensive medication. Statin therapy is indicated in those at risk given the associated benefits of decreased atherosclerosis, with evidence supporting greater beneficial effect with increasing intensity of statin treatment, as indicated by measured carotid intima media thickness. Carotid artery stenosis is associated with increased risk of stroke, though routine screening is not recommended as there is no evidence of reduction in population stroke risk. In certain instances for those with carotid artery stenosis, such as with 60 % or greater stenosis regardless of symptoms, prophylactic carotid endarterectomy (CEA) may be considered for reduction in stroke risk. Stroke risk assessment and management in individuals at risk for VTE is further addressed in the atrial fibrillation section [68].

The prevalence of abdominal aortic aneurysm (AAA) increases with age and is more predominant in men than in women. Typically, AAAs are asymptomatic prior to rupture. The larger the aneurysm size, the higher the risk of rupture, which is a life-threatening medical emergency that classically presents with hypotension, abdominal and/or back pain, and pulsatile mass of the abdomen. Dissected and ruptured AAAs are associated with high mortality rates [66]. Screening has been associated with decreased AAA rupture and AAA-related mortality. USPSTF guidelines recommend a one-time abdominal ultrasound screening in men aged 65–75 years of age with prior smoking history (at least 100 lifetime cigarettes) [69]. Additionally, ACC/AHA guidelines also recommend screening for men 60 years of age and older with family history of AAA [70].

Dilation of the abdominal aorta to size 3.0 cm or greater is diagnostic for AAA. Following diagnosis, management options include optimization of modifiable risk factors, ongoing ultrasound surveillance, and consideration of beta-blocker therapy, which has been shown to decrease perioperative mortality when undergoing repair and may slow AAA expansion. For aneurysms with high expansion rate or those greater than or equal to 5.5 cm, elective surgical repair is recommended [71, 72].

Peripheral artery disease (PAD) is defined by ankle-brachial index (ABI) less than or equal to 0.9 and represents a marker of atherosclerotic disease. Symptomatic lower extremity PAD may present with claudication. Following diagnosis, management should include optimization of modifiable risk factors, with consideration of antiplatelet therapy to decrease risk of cardiovascular events (including MI, stroke, and CV-related mortality). Aspirin is the preferred antiplatelet therapy, with clopidogrel also recommended as an alternative medication option. Further treatment with claudication medications and evaluation for possible revascularization may be considered for those with symptoms when clinically indicated [73].

Coronary artery disease (CAD) is the leading cause of mortality in the USA, affecting approximately 1 in 7 deaths in 2011. It is accountable for over half of cardiovascular events occurring in those aged less than 75 years. The average age for first MI in men is younger compared to women, at 65.0 and 71.8 years, respectively. Additionally, men have a higher lifetime risk of coronary disease as compared to women, even when adjusted to assume optimal risk factors [66]. USPSTF guidelines recommend against routine screening for coronary artery disease with electrocardiogram in asymptomatic, low-risk individuals. There is insufficient evidence to provide recommendation regarding screening in those with higher CAD risk [74].

CAD is caused by atherosclerosis of the coronary arteries. Clinical presentation of disease may range from stable or unstable angina to symptoms of acute coronary syndrome and myocardial infarction. Management of CAD should include risk factor reduction with lifestyle modifications as well as pharmacotherapy to improve lipid levels and control blood pressure. Beta-blockers should be considered as initial antihypertensive therapy for individuals with comorbid CAD and should also be considered in those with CAD with normal blood pressure values when tolerated. Beta-blocker medications decrease myocardial oxygen demand, improving symptoms of angina, and further reduce risk of cardiovascular events following an MI as compared to other antihypertensive therapies. ACEIs should also be considered, which have been shown to decrease cardiovascular mortality following an MI. Calcium channel blockers would be a secondary or adjunctive option to beta-blockers if clinically indicated. Additional management for angina may include nitrate therapy, and antiplatelet therapy should be recommended in the absence of contraindications, as addressed elsewhere in this chapter [75]. For individuals with disease progression, surgical treatment options include revascularization by coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) [76].

Congestive heart failure (CHF remains extremely common in the USA. About 2.7 million males alive today have CHF. Each year, about 350,000 new cases are diagnosed in males. In 2010, the overall prevalence for people age 20 and older is 2.1 %. Among men, the following have heart failure: 2.2 % of non-Hispanic whites, 4.1 % of non-Hispanic blacks, and 1.9 % of Mexican Americans [38]. Gender-specific risk factors for CHF are related to the underlying causes, most commonly hypertension, coronary heart disease, history of MI, valvular heart disease, and cardiac dysrhythmias, among others. Regardless of the etiology, lifestyle modifications to reduce risk include smoking cessation, weight management, and regular exercise. In one large prospective cohort study, subjects rated as having diets in the highest quintile of quality (as measured by the modified Alternative Healthy Eating Index) had a 38 % lower risk of having heart failure [77]. Such diets were typically higher in vegetables, fruits, fish, nuts, and soy protein and low in deep-fried foods.

Although classic signs and symptoms can be suggestive of CHF [78], the diagnostic standard for HF is the transthoracic echocardiogram [79]. Clinical prediction rules incorporating novel biomarkers, such as NT-proBNP, along with other patient characteristics may be helpful in predicting CHF [80]. Once the diagnosis of HF is made, guideline-directed treatment should begin with risk factor modification in all individuals—smoking cessation and treatment of hypertension, ischemic heart disease, diabetes, and dyslipidemia. The assessment of CHF severity can be facilitated by the use of the NYHA classification of HF or the ACC/AHA classification.