Cardiometabolic Risk: Treating the Whole Patient

Peter L. Salgo, MD: Thank you for joining us for this MD Magazine^® Peer Exchange^® on multidisciplinary perspectives on reducing cardiometabolic risk. The relationship between type 2 diabetes mellitus and cardiovascular disease is, at the very least, complex. Fortunately, many of the risk factors are modifiable, and effective therapies are available. I am pleased to be joined today by a multidisciplinary panel of experts to review the current diabetes treatment landscape in the context of the latest cardiovascular outcomes trials. We will also discuss the importance of treating the whole patient to reduce overall risk.

I’m Dr Peter Salgo. I’m a professor of medicine and anesthesiology at Columbia University College of Physicians and Surgeons and associate director of Surgical Intensive Care at New York-Presbyterian Hospital. Joining me for this discussion is Dr Stephen Brunton, adjunct clinical professor in the Department of Pharmacy Practice at Roseman University of Health Sciences in Salt Lake City, Utah, and executive director for the Primary Care Metabolic Group, in Los Angeles, California; Dr Rosemarie Lajara, adjunct professor at the University of Texas and professor of medicine in endocrinology at Diabetes of America, in Dallas, Texas; Dr Christian Ruff of the TIMI Study Group, part of the Cardiovascular Division at Brigham and Women’s Hospital, Harvard Medical School, in Boston, Massachusetts; and Dr Karol Watson, professor of medicine and cardiology, co-director of the UCLA Program in Preventive Cardiology, and director of the UCLA Barbra Streisand Women’s Heart Health Program in Los Angeles, California.

Thank you all for being with me today. Why don’t we get right to work? We mentioned the whole patient here. Doesn’t everybody treat the whole patient? If not, why not? And if so, how does that relate to metabolic risk anyway?

Stephen A. Brunton, MD, FAAFP: The whole patient is such an interesting thing. Diabetes is the patient’s problem. We, in a sense, can’t just segment the patient in terms of cardiometabolic risk or whatever else. And really, because it’s the patient that manages diabetes, we need to understand what their priorities are and kind of mix them with ours. It’s not just the issue of treating diabetes, it’s treating, as you say, the whole person. Part of our problem has been that we have been so glucocentric that we haven’t really looked at some of the other risk factors. And frankly, it’s lipids and hypertension that may be even a greater risk for the patients.

Peter L. Salgo, MD: But you know, I was always taught that you take care of the sugar, the metabolic syndrome, the vascular disease, the ocular disease, and all of that’s going to take care of itself. Is that not true?

Rosemarie Lajara, MD, FACE: Not true.

Peter L. Salgo, MD: I feel so misinformed. Why so?

Rosemarie Lajara, MD, FACE: All the interventions that have been geared to control glycemia have proven to not really have an impact. However, blood pressure and lipid management does translate into better outcomes.

Peter L. Salgo, MD: We’re talking about cardiovascular-related morbidity and mortality here, right?

Rosemarie Lajara, MD, FACE: Correct.

Peter L. Salgo, MD: You’re not really saying, “Ignore the sugar.” You didn’t say it didn’t have an impact, did you?

Rosemarie Lajara, MD, FACE: No, I didn’t.

Christian T. Ruff, MD, MPH: There’s longstanding evidence that hyperglycemia is bad for both microvascular and macrovascular complications. But, importantly, weight loss and, certainly, controlling blood pressure and lipids are very important to modify the risk of the end-stage complications of diabetes and also what many diabetic patients ultimately die from—cardiovascular disease.

Peter L. Salgo, MD: Good. But what about that is unique to diabetes? In other words, if I take somebody with an A1C of 5% and a fasting blood glucose (which nobody does any more, apparently) and it’s normal, and that person’s overweight, hypertensive, has a bad metabolic profile, lipids are off-scale, you’re still going to tell them to do the same stuff, right? You’ll still going to tell them to lose weight, exercise, control blood pressure, and control lipids (whether or not they’ve got diabetes), right?

Karol E. Watson, MD, PhD, FACC: That’s exactly right. We’re never going to stop recommending lifestyle—at least we shouldn’t. But what’s important to remember is that if a patient comes to you, they’ve heard the message, “I have diabetes. I’ve got to control the sugar.” They are really focused on that. It’s our job to educate them about the whole patient. “Yes, we will control your glucose, but we’re going to make sure you control your cholesterol, blood pressures, lose some weight, move every day, and eat properly.”

Stephen A. Brunton, MD, FAAFP: See, that’s part of the problem. We’re asking people to change 25 different things about their lifestyle, and I think when I say physicians can’t change their lifestyle risks, you have more than 1 or 2 at a time. And yet, with diabetes, once you get that diagnosis, it implies that everything is over. So, it’s really, once again, about working with the patient’s priorities. I think that we recognize, as you said, Peter, that all these things are important, but you can’t do it all at once. You need to work on a gradient with patients.

Christian T. Ruff, MD, MPH: And I think it’s also not 1 physician who can manage this all in the confines of busy clinical practice (especially, in this day and age, where you have 20 minutes to see a patient). Now, we’re realizing, for a diabetic patient (like other patients), that managing the patient through primary care, endocrinology, and cardiologists is important. Everybody can focus, potentially, on different areas because this patient’s not going to be able to get all of their risk factor modification of treatment of their diabetes all within the confines of 1 physician.

Peter L. Salgo, MD: I would love to explore the 20-minutes that the doctor seems to have with his patient, but I don’t think most doctors even have that amount of time. But is it fair to say that, “Yes, all these things are important,” whether it’s lipids, hypertensive weight, or exercise? In the setting of an A1C that’s elevated, they become that much more important because there’s a preexisting risk that other people don’t have. Is that fair?

Rosemarie Lajara, MD, FACE: I think so. And one of the other variables that determines cardiovascular risk is a duration of diabetes, that high A1C, among other things. So, we have to prioritize. It doesn’t mean that we’re not approaching the patient from a global risk reduction perspective. You set your priorities depending on what you think is the most relevant.

Peter L. Salgo, MD: What have we learned, then, about this link? We seem to know that there’s a link between diabetes, metabolic syndrome, and cardiovascular-related morbidity and mortality. Where’s the link? What’s doing this?

Christian T. Ruff, MD, MPH: No, I think you’re very right to highlight that the stakes are even higher in patients who have diabetes (with respect to cardiovascular disease). We know that diabetics have a much happier atherosclerotic burden. And they often have very abnormal plaque phenotypes, so they’re more likely to be unstable and experience rupture. And we know that even with the modifications that we have to aggressively treat cardiovascular disease; they don’t seem to be as modifiable as in other patients. So, cardiovascular disease is a big problem, but it’s an even bigger problem in diabetics because they seem to have a more malignant type of cardiovascular disease.

Karol E. Watson, MD, PhD, FACC: think what you were asking is, what is the underlying pathophysiology that holds it all together? We don’t know exactly why, but we do think insulin resistance underlies a lot of it. And the problem with insulin resistance is that it’s absolutely invisible for a lot of years.

Peter L. Salgo, MD: OK.

Karol E. Watson, MD, PhD, FACC: So, by the time the patient is actually diagnosed with type 2 diabetes, they probably had 10, 15, maybe even longer, years of insulin resistance, which means higher insulin levels and vascular toxins. And they’re set up for disease.

Peter L. Salgo, MD: Did I just hear you say that insulin is a vascular toxin?

Karol E. Watson, MD, PhD, FACC: Well, insulin resistance is a vascular toxicity.

Rosemarie Lajara, MD, FACE: It’s considered an independent risk factor.

Stephen A. Brunton, MD, FAAFP: And also, having diabetes is a proinflammatory state, too. You have a worsening situation with an increase of endothelial problems, as well, and there are so many different hypotheses and physiological explanations. But there’s no question that people with diabetes really are in a vascular-pathic state.

Peter L. Salgo, MD: I think it’s worth noting that the more we learn about cardiovascular disease and ischemic heart disease, it’s an inflammatory problem. And if diabetes is the proinflammatory state, then it sort of does make sense. But I can’t tell you how thrilling it is to hear you say, on camera, that we don’t know.

Karol E. Watson, MD, PhD, FACC: We don’t know.

Peter L. Salgo, MD: After all these years of studying diabetes, we still really, on a very fundamental level, don’t know.

Karol E. Watson, MD, PhD, FACC: This is true.

Transcript edited for clarity.