HCPLive: What is the prevalence of CVD associated with type 2 diabetes mellitus and coronary artery disease?
Bhatt: Cardiovascular disease is highly prevalent in people with diabetes. In fact, it's the usual cause of death in people with diabetes. They tend to have very high rates of myocardial infarction. That's been appreciated for a while. In fact, lots of data is supporting that diabetes is essentially conferring the same risk as someone without diabetes has had a prior MI. That was shown in some older data which perhaps was called into question. But even more recent data have confirmed that association, so that seems to be true.
But what's equally important though—quite under-recognized—is that people with diabetes also have a high rate of ischemic stroke. So it's not just MI risk, it's ischemic stroke risk, obviously, this is known, they have a risk for amputation, which while it may not be so high on an absolute level, in those that have peripheral artery disease and diabetes can be quite substantial—especially if they smoke, but even if they don't.
And the final risk that hasn't been as widely advertised is the risk of heart failure which is quite substantial and probably approximates the risk of MI. So a number of cardiovascular outcome trials have highlighted the fact that all these risks are present people with diabetes. And that's beyond the other risks that are well-known of microvascular complications—things like kidney failure, diabetes causing foot problems, which of course is tied into the amputation, but also things like neuropathy as well can be symptomatically quite problematic. And also, retinopathy and blindness.
So there obviously many bad things diabetes can do, but in terms of things that can lead to death, cardiovascular diseases is right at the top of that list.
HCPLive: What is the link between metabolic syndrome, diabetes, and CV-related morbidity and mortality?
Bhatt: It's sort of a continuous course. There's metabolic syndrome and diabetes, and eventually, if the diabetes isn't well controlled and treated—or sometimes even if it is—development of overt cardiovascular disease. So all these different conditions are quite interrelated and highlights the importance of identifying people with metabolic syndrome and diabetes early on, and getting them on treatment, diet, and exercise.
And weight loss being the first line of treatment, of course, but then oftentimes medical therapy focusing on glycemic control, on lipid control, and blood pressure control.
HCPLive: When should patients be screened for cardiovascular risks?
Bhatt: In terms of screening for cardiovascular risk, I think especially for any of the primary care physicians in the audience, it's really important to do every visit. For sure, you want to screen for things like cholesterol, blood pressure and glucose, the way the various societal guidelines recommended, in a formal sense.
But in an informal sense, in terms of asking patient's lifestyle habits and what they're doing with respect to diet and weight maintenance, or weight loss, if appropriate—in terms of daily exercise or daily physical activity.
Those are things that I would say every patient encounter should be emphasizing, because that can have a lot of impact on patients over the course of a lifetime, and can do a lot to prevent the development of things like metabolic syndrome and diabetes, or cardiovascular disease, or the combination.