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Diabetes in the Presence of Cardiovascular Disease


Jaime Murillo, MD, discusses the impact of diabetes on cardiovascular disease.

Yehuda Handelsman, MD, FACP, FNLA, FASPC, MACE:Jaime, you’re a cardiologist?

Jaime Murillo, MD: I am.

Yehuda Handelsman, MD, FACP, FNLA, FASPC, MACE: And you practice cardiology?

Jaime Murillo, MD: For 20 years.

Yehuda Handelsman, MD, FACP, FNLA, FASPC, MACE: Have you seen [patients] with diabetes in your practice?

Jaime Murillo, MD: That was a big part of why I get excited about partnering with experts like you, where we can see that the human body is a unit. If someone is affected by diabetes, that means there’s an underlying pathophysiology that will affect several organs, including the heart. And as you mentioned, Jennifer, cardiovascular mortalities, unfortunately, are a major cause of mortality among [patients with diabetes], so it is an important part of the cardiology practice. Now we’re starting to see that beyond the cardiac part of it when we treat a patient [with diabetes] in a cardiology practice, we have to think of the possibility of [them] having kidney disease, peripheral arterial disease, retinopathy, and so on. And that work also has to be coordinated with a primary care physician, an endocrinologist, and other specialists.

Yehuda Handelsman, MD, FACP, FNLA, FASPC, MACE:I want to highlight something that Jennifer said because it’s very important, [which is] this distinction between microvascular and macrovascular. A lot of it depends on the way studies were done, the randomized control studies where you saw the benefit, where you think that if you manage hyperglycemia you see the benefit. Supposedly you see it in just 1 area, not other areas, but you’re correct. Nephropathy and kidney disease are major cardiovascular risks, and in several of the studies, when they came out later on the ACCORD trial [NCT00000620], we saw retinopathy was a huge marker for cardiovascular disease. And we discussed before that. You mentioned neuropathy, and we talked about Aaron Vinik, MD, PhD, [who is] a professor of internal medicine and program director of the endocrinology fellowship program at Eastern Virginia Medical School in Norfolk, Virginia. He was showing a very strong relationship between neuropathy and cardiovascular diseases. So I think this distinction needs to go away. I think we need to look at the patient with diabetes and look at the whole aspect. I like this holistic [approach] as you said because if 1 organ has damage, probably another organ has an issue. What are other complications? By the way, in terms of naming, we used to say, “Diabetes is a cardiovascular disease.” [This was] the term I put together in 1998, after Steve Haffner [showed] that diabetes is a coronary artery disease equivalent. It was bad because the cardiologists were [arguing] it, and it’s too bad. They’re [arguing] now that chronic kidney disease is a cardiovascular equivalent. [That] is something that the cardiologists like to fight about for some reason.

We used to say diabetes and cardiovascular disease or comprehensive management of diabetes as a cardiovascular disease, but now we have kidney [disease]. So the leadership in kidney renal disease come and say, “It’s a cardiorenal disease.” Or others say, “It’s not cardiorenal [disease]; I thought it was cardiovascular disease.” And then we’ve got liver [disease] and the thing behind all of it is obesity, which started it all. So what do we call it? Maybe metabolism would work. Maybe metabolism would be the 1 word to describe it all, but right now it’s a mouthful. Even the think tank that we have, Diabetes Cardiorenal [&] Metabolism, is a mouthful that we need to look at. But within that frame, what are other conditions that patients with diabetes have beyond hyperglycemia or heart disease?

Eugene E. Wright Jr, MD: Well, you’ve listed some. They’re at risk for liver disease and nonalcoholic fatty liver disease. And we’re seeing an explosion of that with obesity and type 2 diabetes. Kidney disease, we’re seeing that. We’ve talked about that. But then there’s obesity and cardiovascular disease. Then there [are] mental health aspects: high degree of diabetes is stress and depression. So it really is a disease that affects multiple systems. To that extent, I think it’s going to require a coordinated, collaborative approach in identifying and [managing] many aspects of this disease.

Jaime Murillo, MD: Can I interrupt here and [establish] a little consensus, [because] I’m surrounded by experts on diabetes? Are all [patients with diabetes similar]? The reason I’m asking is because we have a vast list of complications that could affect the patient [with diabetes], but does that mean they are going to occur in every single [one]? From a cardiac standpoint, we know that 30% to 40% of them may have clean coronary arteries; no signs of arteriosclerosis, 30% to 40% of them may have a mild degree of complications, and only 6% to 13% of them [have] severe complications. So what makes them more likely to develop complications and therefore [a] group of patients we need to identify earlier? I wanted to say that from the beginning because I know it’s going to be a big part of our conversation today.

Yehuda Handelsman, MD, FACP, FNLA, FASPC, MACE: Jennifer?

Jennifer B. Green, MD: It’s important we remember that no [patient] with diabetes is without risk for complications, but there are [patients] who appear to be at greater risk and progress faster in their development of complications to a certain extent, which may be due to a greater burden of hyperglycemia. So perhaps they’ve had higher glucose levels for longer periods than [patients who received diagnoses] at the same age. But that’s an oversimplification, and there may be [patients] who are at enhanced risk for a variety of other reasons. They may have a greater burden of other cardiovascular or kidney risk factors, so they may have obesity, poorly controlled hypertension, or marked dyslipidemia, if not all of those things, and perhaps genetic factors that predispose them to develop diabetes-related complications at an accelerated rate. It is hard to identify that [patient] in advance, but I think patients who have a number of risk factors at presentation or a diabetes diagnosis really should get our attention.

Eugene E. Wright Jr, MD: We’re learning much more now about the socioeconomic determinants of health, so a person’s lived situation oftentimes can have as much of an influence on their health outcomes as their genetic code. So as we have explored this area, we’re seeing that a big risk factor for some of these complications is the [patient’s] lived situation, their life experience.

Transcript edited for clarity.

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