Cardioprotective Treatment Options for Diabetes - Episode 2
Keith C. Ferdinand, MD, FACC, FAHA, FASH, FNLA: Seth, I know you like to deal a lot in the world of lipids, which is very important. Let’s see if you can bring these together. I have metabolic syndrome, diabetes, cardiovascular disease—can you kind of put them all together?
Seth J. Baum, MD, FACC, FACPM, FAHA, FNLA, FASPC: Yes. You could do that genetically, but I think that maybe that’s not the right way to go here. I think we should look at it perhaps in the obvious way, which is, if you look at what metabolic syndrome is and the 5 components, which are: an enlarged waist circumference, so central obesity; a low HDL [high-density lipoprotein]; or a high triglyceride level; a high fasting blood sugar; or high blood pressure, these things all predispose to the development of coronary disease, and are also connected to diabetes. So from a metabolic standpoint, one begets the other, and there are genetic links as well.
Keith C. Ferdinand, MD, FACC, FAHA, FASH, FNLA: You know one thing, Peter, he didn’t mention, and it certainly was an excellent answer, he didn’t say “chronic kidney disease.”
Seth J. Baum, MD, FACC, FACPM, FAHA, FNLA, FASPC: I left that for Peter.
Peter McCullough, MD, MPH, FACC, FACP, FAHA, FCCP, FNKF: Chronic kidney disease is something that still is not identified enough in primary care, largely because the urine albumin to creatinine ratio is not measured as it should be in routine practice. Chronic kidney disease elevates the risk platform for a diabetic across all cardiovascular events, and even complications from cardiovascular procedures.
Keith C. Ferdinand, MD, FACC, FAHA, FASH, FNLA: So the presence of chronic kidney disease adds to the risk.
Peter McCullough, MD, MPH, FACC, FACP, FAHA, FCCP, FNKF: It adds to it. I think it’s a risk multiplier.
Keith C. Ferdinand, MD, FACC, FAHA, FASH, FNLA: Anything we are leaving out Chris?
Christopher P. Cannon, MD: Well, the comorbidities, and this is one thing that was really nice in the cholesterol guidelines, is they had a list of like 12 or 14 risk enhancers. And thinking about all those, and very frequently patients will have a higher than optimal blood pressure, and you start counting up the things that family history often weaves into the risk.So going through the exercise of what is the risk and actually checking things off as opposed to, “Oh, you’re here for a follow-up for diabetes,” and you focus on 1 topic, where there are 6 or 7 topics that could be addressed. And so I’ve found myself trying to make sure I cover all the bases of talking about different components of risk.
Keith C. Ferdinand, MD, FACC, FAHA, FASH, FNLA: You know we’re all veteran clinicians, not old, we’re veteran clinicians, and we know that patients can feel fine, correct? Come for a regular visit, no symptoms at all, but really be at high risk.
Christopher P. Cannon, MD: The other thing, I think there have been surveys of, that’s sort of surprising, of patients with diabetes asking them, do you know about heart risk? And it’s surprisingly low. They know all about the diabetes, they’re there, we’re monitoring their sugar, etcetera, and the long-term consequences we know and fear. But it’s making sure that that conversation occurs so that they feel what we’re feeling in terms of intensity and need to give prevention.
Melissa L. Magwire, RN, MSN, CDE: Well to dovetail on to that, because a lot of times our patients living with type 2 don’t have symptoms, aren’t feeling bad, we can talk about risk. But we really try to back that up and say even prior to your diagnosis of type 2 when you were in that metabolic state, some of those macrovascular changes are actually taking place with the inflammation that starts early on in metabolic syndrome. So it’s important to grab on early and prior to them actually having symptoms. Because at that point it’s too late to really jump in.
Seth J. Baum, MD, FACC, FACPM, FAHA, FNLA, FASPC: I totally agree with the exception that it’s too late to jump in, because there’s still; I don’t want to feel….
Melissa L. Magwire, RN, MSN, CDE: Preventive, it’s too late at that point, is what I mean.
Seth J. Baum, MD, FACC, FACPM, FAHA, FNLA, FASPC: OK. I’m noticing as we’re discussing this, and the change in our position with regard to diabetes no longer being a risk equivalent, and then you’re bringing up a very good point, which is that many patients with diabetes don’t know that connection. Are we putting ourselves at risk for doing disservice by saying to the patient, “You don’t necessarily have cardiovascular disease?” We really want to keep driving home that connection.
Keith C. Ferdinand, MD, FACC, FAHA, FASH, FNLA: So though technically correct, we may be having a situation where a patient now underappreciates his or her risk.
Seth J. Baum, MD, FACC, FACPM, FAHA, FNLA, FASPC: Right.
Keith C. Ferdinand, MD, FACC, FAHA, FASH, FNLA: And it might not be that day, but it would 2 years, 3 years, 5 years later.
Seth J. Baum, MD, FACC, FACPM, FAHA, FNLA, FASPC: Right.
Christopher P. Cannon, MD: One component of this is the age. The patients with diabetes are presenting a decade or so earlier, so they’re young. To think about heart disease and stroke is so foreign for a 40 year old, but that’s the trajectory. And so trying to make sure that we’re advanced, preparing them for all that’s ahead, and then trying to get ahead of those risk factors.
Keith C. Ferdinand, MD, FACC, FAHA, FASH, FNLA: I’m glad you brought that up. My Chair is named after Dr. Gerald Berenson, who had the Bogalusa Heart Study, which was in Louisiana. And he identified these risks starting in the preteen and the teenage years. Now we see them as adults, but the disease has already started its process.
Transcript edited for clarity.