2nd Annual Heart iN Diabetes Medical Conference:

Diabetes and Cardiovascular Disease Impact Essentially Every Organ in the Body

With Yehuda Handelsman, MD, and Joshua Beckman, MD

In Philadelphia, EndocrineWeb spoke exclusively with Yehuda Handelsman, MD, medical director and principal investigator at the Metabolic Institute of America, and an endocrinologist in private practice, who was co-chair of the Heart in Diabetes medical conference; he stressed the importance of considering the full array of concomitant challenging that clinicians must address in managing patients with diabetes.

Nearly 30 years ago, Steven M. Haffner, MD, proposed that the clock for heart disease started before prediabetes was even diagnosed, presenting the position that diabetes was a coronary artery disease equivalent.1 While others, including epidemiologists and cardiologists, refuted this position and did so for many years, "we now know that people with diabetes have been undertreated for far too long," said Dr. Handelsman.

"While they believed that addressing cardiovascular disease mattered most, what we understand now is that CVD isn’t about equivalences, it's about the much higher risk faced by people with type 2 diabetes as compared to those without diabetes," he said.  "How much greater is the risk? 30%, double, six times—it all depends on which database or source is cited; yet, the point remains that diabetes increases the risk for heart disease significantly."

Diabetes Demands New Thinking: A Cardiorenal Approach

"In looking at heart disease and diabetes, we now recognize that congestive heart failure (CHF) is so much a part of the picture and that people with diabetes have a higher incidence of kidney complaints, especially chronic kidney disease, which is worsening over time," Dr. Handelsman said.

People with kidney disease, too, are at a greater risk for cardiovascular disease and the combination of kidney disease and heart disease in people with diabetes is amplified. "The constellation of co-morbid conditions arising in concert with diabetes and cardiovascular disease has led to the need for a new approach, a cardiorenal approach, to diabetes management," he said.

We have also gained insight into how the liver is directly affected by diabetes, said Dr. Handelsman, "and from which heart disease affords clinicians a much more nuanced understanding of the interrelationship between heart, liver, kidney, nerves, brain, and possibly lung, may be attributed to insulin resistance, metabolic syndrome and/or obesity. This is the reason for the Heart in Diabetes program."

"Not only are there different aspects of cardiovascular disease risk in people with diabetes, there are other factors that are not often highlighted sufficiently when it comes to diabetes management," he said.

Clinical Comanagement Promises Best Way Forward in Diabetes Care

While not every cardiologist will address every aspect of CVD in patients with diabetes, the same may be said for endocrinologists and diabetologist: This elevates the argument for a team approach to diabetes care, in which every clinician must be aggressive with lipid control, blood pressure control, and coagulation, in addition to glucose management, according to Dr. Handelsman.

"Some patients with diabetes may experience arrhythmias, leading to severe congestive heart failure (CHF) while others may have left or right ventricle hypertrophy, which may be occurring because of or exacerbated by diabetes and insulin resistance, and necessitating closer management," he said.

Also, autonomic neuropathy may cause physiological changes in the lower extremities or impact the peripheral vasculature, raising concerns about the patient—is it a case of arrhythmia or hypoglycemia?

These are some of the takeaway messages gleaned from the meeting presentations. Peripheral artery disease is another consideration for clinicians in the setting of patient care for those with diabetes and heart disease.        

Peripheral Artery Disease Warrants Attention in Patients with Diabetes and CVD

Up to 33% of patients with diabetes who are screened, present with peripheral artery disease (PAD), an independent risk factor of athersclorosis.2 In fact, people with diabetes face an increased risk of developing severe complications ranging from peripheral neuropathy, foot deformities and ulcerations to amputation and increased mortality if left untreated.3

EndocrineWeb sat down for an exclusive interview with Joshua Beckman, MD, professor of medicine and director of vascular medicine at Vanderbilt University School of Medicine in Nashville, Tennessee, to discuss the need to incorporate the risk of PAD when managing patients with diabetes and CVD.4

“Peripheral artery disease in combination with diabetes is killer with substantial rates of adverse outcomes, and diabetes is responsible for more than half of all traumatic amputations in the United States,”4 he said.

We have been doing a better job, of addressing cardiovascular problems,” he said, in general, achieving a reduction in myocardial infarction and stroke over the past decade or so, but the prevalence of amputations has flattened over the last 5 years.

Some of the reasons for this trend involve management differences from those relied on to reduce the risk of CVD, and the medications we use to reduce the risks of MI and stroke don’t seem to be having much of an effect on reducing the critical ischemia and amputation,5 according to Dr. Beckman.

Effective Treatments for PAD in Patients with T2D and CVD

An examination of the foot is an essential part of diabetes care.When was the last time you looked at your patients feet?

“Most of the therapies we have are good for those patients [with diabetes and CVD] overall. But in patients with PAD who have diabetes, the way that risk is reduced in patients with MI and stroke from baseline atherosclerotic disease, current treatments haven’t done much for the legs,” he said.

There are a couple of exceptions, for example, vorapaxar seems to decrease the requirements for revascularization and has been very effective but its hard to know if it is still being marketed.4  Evolocumab was shown to reduce the rate of amputations,5 which will be useful if it receives approval from the Food and Drug, said Dr. Beckman.

“In the COMPASS trial,6 the addition of rivaroxaban to aspirin also reduced the rate of critical ischemia and lower limb amputation. Although, the numbers in this trial were small because the study was cut short in response to the overwhelmingly positive results, “ he said.

“I think that medical therapies are going to be the way to [manage these patients]; otherwise, it’s hard to know where we go from here to reduce amputations. Adverse limb outcomes are what we really need to pay attention to so I strongly suggest that every clinician treating a patient with diabetes ask them to take their socks and shoes off at least once annually,” Dr. Beckman said.

The relevance of foot health is so significant that if a patient develops a toe ulcer on one food, there is a 50% increased risk that a toe ulcer will form on the other foot within five years,4 according to Dr. Beckman. So the combined risk of death when both legs are involved is high given the likelihood of amputation, yet our ability to reduce the risk of cardiovascular events suggests that there is value in checking our patients' feet is not that big of a deal, he said.

Next Summary:
Diabetes and Heart Failure: Converging Conditions Require Greater Attention
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