Improving Care by Increasing the Cardiometabolic Focus

Peter L. Salgo, MD: How can the cardiologists and the PCPs [primary care physicians] and the endocrinologists all get together, on the same page, with the same recommendations?

Stephen A. Brunton, MD, FAAFP: You’ve just done it. We’re actually all on the same page, Peter. I think it’s recognizing that it’s actually not just the specialist, but the patient, too. The patient is the center of all diabetes management, and I think reflecting that each of us brings different skillsets and decent knowledge, and I think working together as a team with the patient at the center of the team, will give us some optimism about making a positive impact.

Peter L. Salgo, MD: That’s encouraging.

Rosemarie Lajara, MD, FACE: Yes, but nothing is certain. Now, more than ever, cardiologists and endocrinologists need to be constantly working together and in communication with each other.

Karol E. Watson, MD, PhD, FACC: I completely agree.

Peter L. Salgo, MD: I can remember when I first heard the statin data. It was at the diabetes meetings, and it was Dr Nissen who actually presented some of the early stuff. And when I went to the endocrinology meetings, they hadn’t heard, yet, about some of this. The cardiologists kind of knew, but didn’t kind of know, because they weren’t interfaced. How do you make the interface?

Christian T. Ruff, MD, MPH: Like all things, I think we have these 2 different fiefdoms. You had cardiovascular disease and we were worried about the atherosclerosis. Then we had endocrinology, which was worried about managing glycemia, microvascular complications, nephropathy, and the neurologic issues. Now we realize that’s a totally arbitrary distinction. The companies have combined the two and they call it “cardiometabolic.” But these patients are all the same patients. Their abnormalities, metabolic dysregulation, coronary disease, and their heart failure, they’re all intermixed. And so, now we’re actually all talking about the same thing.

And rather than just focusing on management of glucose (which the cardiologists totally abdicated because the endocrinologists are the only ones who could figure it out), now, it’s a team effort. Now, we’re potentially prescribing drugs, not necessarily to manage their glucose, but to identify their risk—their risk of heart failure and their risk of MI. When you’re getting to this patient-level focus, that’s where you need the primary care doctor, the endocrinologist, and the specialist.

Peter L. Salgo, MD: So, in the future you see more of this? More collaboration, more integration?

Rosemarie Lajara, MD, FACE: We have to. We don’t have any other choice.

Peter L. Salgo, MD: Yes, but the human body doesn’t say, “I’m going to get this far, but that’s a cardiologist’s problem, from that point on,” right?

Rosemarie Lajara, MD, FACE: Right.

Peter L. Salgo, MD: What papers do you read? Do you read on all of these specialties?

Stephen A. Brunton, MD, FAAFP: There’s primary care literature, and I think it’s directed to us. Obviously, I’ve read landmark trials. I’m actually the editor of the ADA’s (American Diabetes Association’s) Clinical Diabetes publication, which is the primary care journal of the ADA.

Peter L. Salgo, MD: So, that’s what you read?

Stephen A. Brunton, MD, FAAFP: That’s what I read. I have to read that one. But the point is, the important studies do get out to all of us, and I think that’s part of it—just being aware of that. The problem isn’t primary care. We’re not just managing diabetes and cardiovascular disease, we’re managing broken legs. We’re managing everything. And so, condensing this down to be very practical is important.

Peter L. Salgo, MD: You’ve got to boil it down. We have come to the end of this portion of our discussion, although we could go on for hours, more, but they won’t let us. What I’d like to do, though, before we leave is ask each of you to sum up something that you’d like our viewers to take away from this program. Dr Brunton, why don’t you start?

Stephen A. Brunton, MD, FAAFP: Well, you mentioned you’ve been managing diabetes patients since, sort of, the giants roamed the United States. I’ve been managing diabetes since all we had were leaches. So, it’s a very exciting time to be managing diabetes. Now we have so many different agents and we have so much greater understanding of what diabetes is. And now, with the impact of the cardiovascular outcomes trials, it gives us much more opportunity to work with our patients and develop an intervention that’s going to not just reduce their blood sugar, but also reduce their overall risk.

Peter L. Salgo, MD: Dr Lajara?

Rosemarie Lajara, MD, FACE: I agree. I would add that we are at a very unique time in the historical perspective in the management of diabetes, and we can impact other metrics (other than sugar). I think it takes a village, and it’s time that this village works together, because now we have the agents that have commonalities for the different specialties.

Peter L. Salgo, MD: Dr Ruff?

Christian T. Ruff, MD, MPH: This is, really, a transformative time in the treatment of diabetic patients. On the cardiovascular side, it’s been decades of frustration where we try to, as aggressively as we can, manage their glucose. But these patients are then ravaged 10 to 20 years down the line by heart attacks, stroke, and heart failure. We had little to offer them. And now, all of a sudden in the span of 2 years, we have multiple drugs, different classes, that have profound effects on how long patients live, their quality of their life, and in reducing heart failure and atherosclerotic events. I don’t think there’s ever been more optimism about treating patients with diabetes—not just to control their diabetes, but to actually impact their lives for decades.

Peter L. Salgo, MD: And Dr Watson, the last word?

Karol E. Watson, MD, PhD, FACC: I agree with what everyone has already said, so I want to just end by saying it’s a new day, with a new bar, and cardiovascular mortality has to be considered when you’re treating diabetes. But I don’t want us to ever forget there’s always going to be the other thing. Patients have to feel better and their quality of life is important. So, we can’t ever forget that, but I agree with you.

Christian T. Ruff, MD, MPH: Also, wanting to take their medicine.

Karol E. Watson, MD, PhD, FACC: They won’t even take their medications. And again, if I tell them they’re going to gain weight, or whatever, they’re not going to do it. But it’s certainly an exciting time.

Peter L. Salgo, MD: What a terrific discussion. I want to thank all of you for being here. I want to thank you for watching, as well. I’m Dr Peter Salgo, and on behalf of MD Magazine^®, I want to thank you for joining us. I’ll see you next time.

Transcript edited for clarity.