Pathophysiology of Type 2 Diabetes & Cardiovascular Disease

Keith C. Ferdinand, MD, FACC, FAHA, FASH, FNLA: Hello, and thank you for joining this MD Magazine® Peer Exchange entitled, “Cardioprotective Treatment Options for Diabetes.” Today we’ll be talking about cardiovascular risk in diabetes and how to optimize treatment approaches and pharmacotherapy to help prevent complications in our patients.

I’m Dr. Keith C. Ferdinand, professor of medicine and the Gerald S. Berenson Chair in Preventive Cardiology at the Tulane University School of Medicine in New Orleans, Louisiana.

Participating today on our distinguished panel are:

Dr. Seth Baum, immediate past president of the American Society for Preventive Cardiology and professor of medicine at the Charles E. Schmidt School of Medicine in Boca Raton, Florida.

Dr. Chris Cannon, senior physician at the Brigham and Women’s Hospital and professor of medicine at the Harvard Medical School in Boston, Massachusetts.

Melissa Magwire, master’s prepared RN and certified diabetes educator and practice manager for the Hervade Cardiometabolic Center of Excellence at the Saint Luke’s Health System in Merriam, Kansas.

And, Dr. Peter McCullough, professor of medicine and vice chief of internal medicine at Baylor University Medical Center in Dallas, Texas.

Thank you so much for joining us. Let’s begin.

All right, so first let’s talk about the pathophysiology of type 2 diabetes and its relationship to cardiovascular disease. Peter, do you want to lead that?

Peter McCullough, MD, MPH, FACC, FACP, FAHA, FCCP, FNKF: Well, sure. I think it’s a good way to start to understand that type 2 diabetes is a pervasive problem today in Western societies, and its pathogenesis relies on the presence of excess adiposity and genetic predisposition as a general rule. And type 2 diabetes has been consistently shown to be a cardiovascular risk factor for atherosclerotic cardiovascular disease. And more recently in epidemiologic studies it’s been identified to be an independent risk factor of heart failure. In fact, all forms of heart failure, both those with reduced and preserved ejection fraction.

Keith C. Ferdinand, MD, FACC, FAHA, FASH, FNLA: I’m glad you mentioned heart failure because we often say cardiovascular disease, and people are thinking just heart attacks and strokes. But heart failure may be even more common as a cause of death, morbidity, and mortality related to the heart in patients with diabetes.

Peter McCullough, MD, MPH, FACC, FACP, FAHA, FCCP, FNKF: That’s true, heart failure is the leading nontraumatic cause of hospitalization in the United States today.

Keith C. Ferdinand, MD, FACC, FAHA, FASH, FNLA: Now one thing I noted, and anyone can chime in, he didn’t use the term diabetes is a cardiovascular risk equivalent. We saw that in some of the older guidelines, but you didn’t make it a risk equivalent, why not? Anyone? Some of you should say, “Diabetes equals heart disease.” Chris?

Christopher P. Cannon, MD: Well certainly in initial studies looking at people who had had an MI [myocardial infarction] and those with diabetes, their risk of long-term mortality seem to be similar, although we’ve seen thankfully and potentially from some of the advances and prevention that if you’ve not had a heart attack but have diabetes, you’re certainly at higher risk but not quite as high as if you’ve had a heart attack or a stroke. So sort of good news and bad news that it is a pervasive risk, and the heart failure risk as you’ve pointed out is just a huge epidemic of both heart failure and diabetes.

Keith C. Ferdinand, MD, FACC, FAHA, FASH, FNLA: Seth.

Seth J. Baum, MD, FACC, FACPM, FAHA, FNLA, FASPC: I think we’ve also learned from calcium scoring that there is a not insignificant minority of diabetic patients who have 0 calcium scores. And our most recent cholesterol guidelines reflect the distinction of the diabetes as a cardiovascular risk equivalent that we used to say, and now we’re saying, no, actually we look at patients with diabetes, and say, “What is their risk?” If their risk is high enough, then we treat them in that risk equivalent position. If not, then we treat them a little less aggressively.

Keith C. Ferdinand, MD, FACC, FAHA, FASH, FNLA: Now I don’t want to get too detailed on coronary calcium scoring, but let’s say if your coronary calcium score is in the single digits—3, 4, 5—is that the same as 0?

Seth J. Baum, MD, FACC, FACPM, FAHA, FNLA, FASPC: Not at all. So 0 is the only 0. You’ve got to have 0 to be in that low-risk category. One to 100, you’re in a higher risk than the average patient. A 100 and above, you’re in a very high risk, and there’s those people who think that that’s a reasonable enough cut point.

Keith C. Ferdinand, MD, FACC, FAHA, FASH, FNLA: Cut point.

Seth J. Baum, MD, FACC, FACPM, FAHA, FNLA, FASPC: And then there are others who think, well, we should go for a much higher cut point, like 300 or 400, depending on who you see there.

Keith C. Ferdinand, MD, FACC, FAHA, FASH, FNLA: So, Melissa, you’re seeing a lot of patients with diabetes. You don’t tell them all that they have heart disease, it’s not a risk equivalent in everyone?

Melissa L. Magwire, RN, MSN, CDE: Actually, we really do spend a lot of time talking about that, and the fact that they are at higher risk, and it’s something that we start from the very onset to get them to thinking about the 2 diseases, or the 2 disease states at the same time, and really putting it all in 1 bucket. Because they are facing that. So it is something we talk about a lot.

Transcript edited for clarity.