Cardioprotective Treatment Options for Diabetes - Episode 6

CV Risk Reduction in T2D: Putting Guidelines Into Practice

Keith C. Ferdinand, MD, FACC, FAHA, FASH, FNLA: Well, that leads me to the next question, and Pete, I’ll let you take the lead, and everyone can comment. Is it hard for clinicians to follow guidelines? You guys are talking about blood pressure, cholesterol, A1Cs [glycated hemoglobin levels], the newer agents; and promise, we’re going to get into the outcomes trials. But just the fact that you have now, in New Orleans we call it a gumbo, a little shrimp, a little crawfish, a little okra. A gumbo of medications. It looks like it would be hard for a clinician to keep up with all of this.

Peter McCullough, MD, MPH, FACC, FACP, FAHA, FCCP, FNKF: Sure; they’re not only a gumbo of medications, but there’s clearly kind of a gumbo of guidelines. And guidelines are put forward by specialty societies, and then there’s all these different providers. And so whenever, any time we encounter something that’s not completely in our field, believe it or not there’s guidelines by some other society we may not be aware of. But in general, physicians respect guidelines. They are a wonderful summary of the evidence. They also help bring to bear expert opinion, which is valuable for the practitioner, so the practitioner is not unsupported in making a decision. So I think they’re terribly important. And the challenge is really dissemination of the information into digestible pieces for the clinician in the office.

Keith C. Ferdinand, MD, FACC, FAHA, FASH, FNLA: Before we go on to the outcomes trials with the newer antidiabetic medicines, how about everybody give me their take. I think what I just heard was that the guidelines are important. It can be complex but we need to try to adhere as best we can. Let’s go first to Chris and I’ll come back to you guys. The guidelines.

Christopher P. Cannon, MD: Oh, they’re terrific, but of course there are so many things that we can do that they’re then an inch thick. And so time is probably the factor, of going through all the relevant risk factors and how to modify them. So moving toward team-based approaches where someone else can recheck, “Oh, wait a minute, how was your last cholesterol? Or, what was the creatinine?” Some of the things we’re making sure you’ve gone through all the different risk factors could be a way to try and optimize compliance with statins and other factors.

Keith C. Ferdinand, MD, FACC, FAHA, FASH, FNLA: We have a team leader on the panel. What do you think, team approach helps?

Melissa L. Magwire, RN, MSN, CDE: I think team approach really helps. And I’m really liking the fact that recently we’ve seen the American College of Cardiology [ACC], and the American Diabetes Association [ADA] merging on consensus pathways. And I think over the last couple of years we’ve seen these societies that have been putting out their own individual guidelines actually starting to work together, and I think we’re going to be moving even more so in the future with that. I think that helps. And I think, to your point, actually taking all the guidelines and building an expert consensus pathway then, because you’re right, they’re 5 inches thick and there’s so many ways you can take them. But actually learning from our fellow practitioners on the best way to put those into practice with some of these consensus algorithms and pathways I think has been important.

Keith C. Ferdinand, MD, FACC, FAHA, FASH, FNLA: Seth, the last remarkable comment on guidelines. I set you up, it’s got to be something profound.

Seth J. Baum, MD, FACC, FACPM, FAHA, FNLA, FASPC: Well, it may actually stimulate some more conversation. I think actually we have guideline fatigue. There are over 40 cardiovascular guidelines, each one being 75 to 150 pages long. So I don’t think clinicians in practice really can follow the guidelines. And I think some of them have just said, “enough,” another guideline. You bring up the ADA and ACC, the recent statements regarding diabetes. I think that’s a great way to do this—come up with a singular point, which is, when we see a diabetic patient in our practice, we have to stop and think about the fact that that individual patient might have cardiovascular disease. And if the patient has cardiovascular disease, is the patient being treated appropriately?

Keith C. Ferdinand, MD, FACC, FAHA, FASH, FNLA: I’m smiling because now I can recall, and I think all of us have given lectures in big rooms, especially with primary care providers, and we’re really smoking, we’re going over the outcomes and the guidelines. And the first question from the microphone, somebody says, “OK, so what am I supposed to do?”

Peter McCullough, MD, MPH, FACC, FACP, FAHA, FCCP, FNKF: There’s a working example of success though on consensus, and what comes to mind is the universal definitions of myocardial infarction. If you ever look at those papers, that group lists every single society that possibly could touch a patient with myocardial infarction to set a definition. And maybe a future dream, we would have universal guidelines that all the relevant societies would sign off on, so the doctors wouldn’t lead to where we get these fractured sets of guidance and end up with fatigue.

Keith C. Ferdinand, MD, FACC, FAHA, FASH, FNLA: So you won’t get that first question after your very broad talk that you’ve just given. “You really did well, but the first question, so, now what am I supposed to do?”

Peter McCullough, MD, MPH, FACC, FACP, FAHA, FCCP, FNKF: Listen, we’ve got a single point source here.

Transcript edited for clarity.