Diabetes & The Heart: It's Not Just The Sugar

Type 2 diabetes and cardiovascular disease are directly linked -- but not because of blood sugar.  Metabolic disorders play the major role in increasing heart disease risk in diabetic patients. 

Miami Cardiac & Vascular Institute's cardiometabolic and prevention center is taking a comprehensive approach to these patients, aimed at controlling blood pressure, cholesterol, triglycerides, obesity and other factors.  Medications can play a role that goes beyond treating symptoms to actually helping prevent negative cardiac events.

Host, Jonathan Fialkow, M.D., a preventative cardiologist at Miami Cardiac & Vascular Institute, welcomes  guests Lisa Davis, PA, a clinical lipid specialist, and clinical pharmacist Jennifer Miles, PharmD., for a discussion about using medications to reduce diabetic cardiac risk.





 

 

Transcript

Announcer:

At Baptist Health South Florida. It's our mission to care for you when you're injured or sick and help you stay healthy and fit. Welcome to the Baptist HealthTalk Podcast, where our respected experts bring you timely practical health and wellness information to improve your family's quality of life.

Dr. Fialkow:

Hello, Baptist HealthTalk Podcast listeners. I'm your host, Dr. Jonathan Fialkow. I'm a practicing preventative cardiologist and lipidologist at the Miami Cardiac and Vascular Institute in Baptist Health South Florida, as well as Chief Population Health Officer at Baptist Health. When it comes to two of the most serious health problems in this country, type two diabetes and cardiovascular disease, there's a clear correlation.

Dr. Fialkow:

Adults with diabetes are between two and four times more likely to die from heart disease than those without diabetes. And upwards of 68% of people over the age of 65 who have diabetes will die from some form of heart disease. We often think of diabetes as a condition related to one's blood sugar. And while that is an important component of the disorder, you may be surprised to learn that the risk of cardiac and vascular disease, --which includes a fatal heart attack or stroke, as well as a heart attack or stroke that doesn't kill you as well as bypass surgery and other vascular illnesses -- is not related to the control of one's sugar, but more related to other factors in one's health, metabolic conditions. As such, a more comprehensive approach aimed at controlling blood pressure, cholesterol and triglycerides, obesity, of course, smoking, and more is needed. Baptist Health South Florida, Baptist Health Medical Group, and the Miami Cardiac and Vascular Institute are leading the collaborative efforts to identify, educate, and treat patients with this complex condition.

Dr. Fialkow:

For today's podcast, we're going to speak with two experts in diabetic cardiac risk reduction and the role of medical therapies and advancements to prevent these bad cardiac outcomes. I'm pleased to have two of my colleagues as guests: Lisa Davis PA, a Clinical Lipid Specialist with Miami Cardiac and Vascular Institute, and Jennifer Miles, a Clinical Pharmacist with Baptist Health who supports MVCI cardiology and Baptist Health Medical Group. Welcome to the podcast, guys.

Lisa Davis:

-Thank you.

Jennifer Miles:

Thank you.

Dr. Fialkow:

So, Lisa, let's start with a couple of the terms that I mentioned. I mentioned cardiac outcomes, which actually has a specific meaning in the medical community. Can you unpack what we mean by the term cardiac outcomes? And why really, going forward, we want to meet that standard of an intervention, medication or otherwise, that actually impacts an outcome?

Lisa Davis:

Sure. So, we often talk about putting patients on medications or doing interventions that make their cholesterol numbers look better or their blood pressure looks better. But what we really want to see is that by doing the interventions, putting patients on certain medications that we're actually lowering their cardiovascular risk. So lowering the risk of having a heart attack, lowering the risk of having stroke. So I like to tell the patients that it's one thing to say, "We're putting you on medications." It's not just to make your numbers look better on paper. What we're choosing to do, we're choosing the therapies of the interventions to lower the risk of having a heart attack or stroke or some other complications from that.

Dr. Fialkow:

So, in the old days, for example, a medication could easily be approved to say it changed this blood test result or something like that. We really want now to show that we're keeping people alive, as you mentioned, and preventing those heart attacks and strokes. So it's a higher standard. We talked about cardiometabolic disorder. Again, these are new terms to the listeners. Can you speak a little bit about that? What is the cardiometabolic syndrome, or what are cardiometabolic disorders? Why is that relevant towards our cardiac prevention?

Lisa Davis:

So cardiometabolic disorder, these are various risk factors that increase the risk of cardiovascular events. And so when we look at the diagnosis of metabolic syndrome, we look at patient's having, for example, elevated triglycerides, a low HDL, elevated fasting blood sugar, high blood pressure, high waist circumference, and that's all part of metabolic syndrome. But there's other things as well, sleep disorders, fatty liver. There are other diseases that we look at all part of this sort of cardiometabolic disorder that, ultimately, these risk factors increase the risk of cardiovascular disease and cardiovascular events.

Dr. Fialkow:

So I love how you brought up those components because I think that's the important or at least one of the important take-home points. We tend to treat a medical condition in isolation. "Oh, you have high blood pressure, take these pills." But how many people, high blood pressure also have a lipid abnormality? Or how many diabetics also have sleep apnea? How many people with a big belly wind up with other metabolic disturbances? And I think what we're now showing and how we're treating this is they're all related. They all ultimately lead to cardiovascular outcomes, and we want to address them across the spectrum of those abnormalities.

Lisa Davis:

Absolutely.

Dr. Fialkow:

So again, very, very well said. Jennifer, again, as a clinician, we talk about prevention, and we put people on medications, and patients feel well. And they're like, "Why are you giving me this pill? I feel okay." Can we speak a little bit about that concept of prevention and how medications can be beneficial in preventing certain, again, outcomes? How do you get someone who feels well to say, "Oh, I understand. And I will take this medication that may cost me money, or might have side effects?"

Jennifer Miles:

Patients will be familiar with the concept of prevention from things like mammograms or colonoscopies. But certainly, in the space of medication use, we're beginning to find more and more that much in the same way we would do these procedures or interventions proactively to stop a patient from becoming ill, medications are also able to help prevent patients from advancing with certain conditions they already have, as well as with the conditions they may not yet have. And in the space of diabetes, as my colleague Lisa mentioned earlier, this is certainly the case. With many of the new medications that are now on the market through additional research.

Jennifer Miles:

We've actually found that they're beneficial, not just for type two diabetics, but also for patients that do not have diabetes at all. And so we are looking at, instead of having a patient wait on a particular type of medication or a regimen of medications to continue using them, and they may end up having a heart attack or a stroke, or they may end up with kidney damage. We will give medications that will be helpful in preventing patients from advancing to that point.

Jennifer Miles:

And so even though they may not feel some of these effects with diabetes, we frequently hear this that, well, they don't feel anything with their blood sugar being out of control. Lipids are another area where we often hear this. They don't feel any issues with having an LDL over 200, for instance. We know through a lot of the research that this can be problematic. And so, patients should know that we're not going to just have everyone come in and receive the same treatment. We'll do things that are prescriptive to the individual, along with lifestyle modifications, to try and minimize risks as their conditions advance.

Dr. Fialkow:

So, for a summary to point before we start getting into some of these therapies. Diabetes is very prevalent. It's measured by your blood sugar. But the metabolic disturbances in a diabetic are beyond the blood sugar. Diabetics are at a higher risk of cardiovascular outcomes, heart attacks, strokes, death from heart attack, and strokes bypasses. And we want to recognize who has those risks. And we now want to get into what we can do to improve those risks, meaning decrease the chances of the heart attacks or strokes, as you mentioned, kidney failure.

Dr. Fialkow:

So again, great prelude to the medication points. So, let's start with, of course, near and dear to my heart, pun intended. Lisa, let's start with lipids. Diabetic is put on medications. The blood sugar has improved. Arguably, we'd like to think that they're on a proper diet and their weight is controlled. Are we done? Are they like, "Okay, good to go. You're not going to have a heart attack." What do we look at in terms of what their risk remains in a diabetic even when the sugar is controlled?

Lisa Davis:

Yeah. I always like to, and you alluded to this in the beginning. I always like to talk about that. When we look at really getting good control of someone's diabetes, we think that we are lowering their overall risk and when it comes to what we call small vessel disease. So problems with eyes, the kidneys, or the nerves, better tighter glucose control does seem to lower the risk of having those types of complications. Oh, and when we look at risk of heart attack and stroke, what we call macrovascular disease.

Lisa Davis:

Tighter blood glucose control, does it lead to necessarily lower risks? So, what we focus on then is we need to focus on other things, and that has shown to lower risk by really being aggressive at lowering your cholesterol, for example. Your LDL cholesterol from making sure that you don't start smoking, or if you smoke to quit smoking. That our blood pressure control. All of these therapies in diabetic patients have been shown to lower cardiovascular risk.

Dr. Fialkow:

So what would be some of the medications or families of medications in the lipid world, cholesterol, triglycerides, et cetera, that have been shown to have cardiovascular outcomes? So not they make the number better on your blood tests, but they actually in that diabetic will decrease the risk of heart attack stroke or death from heart attack and stroke?

Lisa Davis:

Yeah. We have some really good therapies that have been shown to have great cardiovascular risk reduction outcome. So again, lowering risk of heart attack, strokes, and need for interventions like catheterizations or bypass. So the statins are the first group. I know for some people, that may sound like a bad word. Assure you it's not, and that's a whole other conversation, but statins are first-line.

Lisa Davis:

And those have shown in diabetic patients to have significant risk reduction. PCSK9 inhibitors, which are these newer cholesterol, lipid-lowering medications. Vascepa, which is prescription-grade omega three, has been shown to have cardiovascular risk reduction. And then, like Jennifer was talking about some of these newer diabetic medications, SGLT2 inhibitors have been shown. GLP1 receptor agonist have been shown to lower cardiovascular risk in diabetic patients as well.

Dr. Fialkow:

So let's talk about those for a second. And Jennifer, I'll get to you in a second. I want to talk about obviously hypertension and medications in general. So, Lisa, this family of medications you talked about were developed for the diabetic. Again, to lower their sugar, which they don't do remarkably well, but we've subsequently found they actually decrease the risk of cardiac outcomes and even renal failure in the diabetic. Again, speaking to that metabolic improvement, can you speak to a little bit where we will use these medications in the diabetic and what we look for when we treat them if anything?

Lisa Davis:

Sure. Yeah. And this has just been... it's been really interesting to see sort of the evolution of these medications and how they're being used. Again, they're diabetic medications. They do lower the sugar. But what we've found is that they have had these other cardiovascular benefits. And it seems to be that in many cases, even independent of lowering glucose, or even when used in perhaps non-diabetic patients who just have established cardiovascular disease, that they've been shown to lower the risk of coronary artery disease, lower the risk of heart failure, or worsening of heart failure.

Lisa Davis:

Lower the risk of progression of kidney disease. So again, these medications are... we're looking at really using them first-line almost not just for the treatment of diabetes, but independent of treating diabetes, being used specifically for cardiovascular risk reduction medications, which is...

Dr. Fialkow:

So again, great point. We're talking about the diabetic population due to that extremely high risk of cardiovascular outcomes, bad outcomes. But these medications actually have indications in non-diabetics for various situations, heart failure, and other conditions to decrease cardiac outcomes. So again, great advancements in therapies to avoid those complex high morbidity conditions. Jennifer, hypertension, again, the diabetic, all that more important, more aggressive guidelines.

Dr. Fialkow:

Speak a little bit about, again, most people don't come in saying, "I feel terrible. My blood pressure's high. Oh, can I have a pill?" How do we assess the patients when we put them on medications? What do you tell them? What are the common pushback you get? Or what kind of problems my patients get when they're put on hypertensive therapies?

Jennifer Miles:

Well, definitely, we like to always work in collaboration with our partners on the medical side. Folks like Lisa, like yourself, Dr. Fialkow, in terms of screening patients and talking to them about lifestyle modifications. Even as a pharmacist, that's one of the big things that I'm a believer in is that we like to talk to patients definitely about the non-pharmacologic things that they can do, like controlling their salt intake and eating certain types of foods or limiting certain things that can place them at high risk. The tablets will get you so far, but there's a lot of things that we have to do in terms of the care that we give ourselves globally to be able to assist the medications in helping us to stay well or to get well in certain cases.

Jennifer Miles:

But beyond that, definitely once the decision has been made that we have to start a patient on a particular medication. We definitely like to go through and kind of give them some of that rationale. Many patients may have that fear when they come into the doctor's office that they're going to be imposed upon and told that they have to do something. We like to really give patients the latitude to have that conversation with us, definitely in the vein of talking about preventive interventions that we're doing. We're big believers that patients need to be an active part of the process with their healthcare. And so, we like to engage in that conversation and explain to them what the thought process is.

Jennifer Miles:

That's something I frequently hear from patients. "Well, I'm already taking a blood pressure medication. Why are you giving me another one?" And so we sort of go through that rationale with them of different blood pressure medications, targeting specific parts of the body, or having certain beneficial effects. Some may be great for helping with protecting their kidney because of the way that they work, where they may be taking another medication because maybe they've unfortunately had a heart attack and we need to have them on something that can control heart rate and have other beneficial impacts to a different part of their body. So their outcomes may be the same. These are the lowering the blood pressure. But the manner in which the medications work will be completely different.

Jennifer Miles:

So these are things that, as pharmacists, we like to sit down and have that kind of a conversation with the patients. So they don't feel overwhelmed by new products being added to their list of medications they're already taking. And then certainly we like to try and give them good feedback and guidance in terms of maybe the time of day. That's another big thing with patients is they may take a diuretic, for instance, too late in the evening and end up having the untoward effect of going to the bathroom often. Maybe they're accustomed to taking everything in the morning time with food and perhaps what we're starting them on, that's not a really good idea. So we try to walk the patients through.

Jennifer Miles:

Ensure that they're comfortable. They understand how they're taking the medications as well. And so definitely these are things that whenever Lisa and I work together to see patients in clinic, definitely, we want to make sure our patients walk out with that good information at hand, because to your point, Dr. Fialkow, a lot of patients don't feel when their blood sugar increases. They don't necessarily feel when they have a blood pressure of maybe 170 over 100. Some people may, but not everyone. And so these are the things that we want to make sure patients are comfortable with and don't get, again, to that point with their health.

Dr. Fialkow:

So, great stuff. What you brought to the table is we kind of, when done correctly, we identify the patient need, we create an individual treatment plan. What specifically will benefit that person, that patient? Educate them? Why are we doing this? What are the guidelines supporting it? What's the medical data? Listen to the patient, obviously, if the patient says, "I don't want this." We won't force them.

Dr. Fialkow:

It's ultimately the patient's decision, but with the proper education and support, we're able to get patients on the proper preventive therapies. So, Lisa, we're developing this Miami Cardiac and Vascular Institute, the Cardiometabolic and Prevention Center, great benefits to the community. Speak a little bit. Why you think what we're talking about now, and more will be enhanced by the care of our patients through this programmatic approach to the Cardiometabolic Center.

Lisa Davis:

Yeah, it's interesting when we look at traditionally cardiologists have not been involved in the specific management of diabetes. That's been deferred to the primary care doctor or the endocrinologist. And looking at the statistic, I read recently where it said, "Cardiologists seem more type two diabetics than endocrinologists do," because there's such a high incidence of cardiovascular disease and type two diabetics.

Lisa Davis:

And with these new medications, again, that specifically have been shown to lower cardiovascular risk, independent of lowering the blood sugar. These lines of who is treating diabetes and the cardiovascular risk associated with it really has been blurred. And so, there's this push for really looking at, again, more of a sort of holistic approach to these patients.

Lisa Davis:

And they're not really independent risk factors to be managed independently by specialists. It's really, we need to look at treating the whole patient, and part of it is treating them with these medications that, again, conventionally, maybe initially were diabetes medications, but now, we know that they have these other indications and benefits as well.

Dr. Fialkow:

The Miami Cardiac and Vascular Institute, Cardiometabolic and Prevention Center, as you mentioned, it's a collaborative effort with endocrinology and primary care and cardiology, and obviously, a clinical pharmacist and lots of other components to it where patients can kind of get that full holistic evaluation and treatment recommendations rather than going to four or five different sites or not getting it at all, which is all too common [crosstalk 00:19:09]-

Lisa Davis:

The focus really Is a team-based approach to managing patients. And that hopefully is going to lead to patients having the best outcomes.

Dr. Fialkow:

Very exciting. And there are other metabolic disorders as well, like sleep apnea and fatty liver, and gestational diabetes. And these are also part of that metabolic components that we're looking to address. Final points, and again, great information, guys, and very exciting developments in identifying and treating these conditions. Jennifer, you mentioned it a little bit, but what should patients do if they're confused about the medications.

Dr. Fialkow:

These patients with these metabolic disturbances clearly could be on three, four, five medications to keep them out of that cardiovascular risk range. What resources are available? What if it's a cost issue? Obviously, broad question, but how do you approach it when it comes to your attention?

Jennifer Miles:

Definitely, so with these medications, we're still looking a lot in terms of educating the patients and ensuring that they're comfortable. As Lisa mentioned earlier, we're going to have patients that potentially will see us as part of these clinical services with our members of the team that may not be diabetics at all, and could benefit from the use of some of these medications and in that family the SGLT2's, as well as another family of injectables, which doesn't tend to be very popular with patients. But certainly, they've got a lot of benefits. And so, we'll be working with patients to educate them in terms of why, if they're not a diabetic, they might be placed on these medications?

Jennifer Miles:

And if they are a diabetic, some of the extended benefits of using these medications as part of their armament of therapy that we're giving to them. Certainly, as you said, there is a little bit of trepidation right now, because as with any other type of medication, there are side effects. And so, we'll definitely be working, not just with patients, but also because we're going to be stepping into the realm of not just the primary care physicians or maybe a endocrinologist. But now, cardiologists and dieticians, and other folks that may not have normally have been part of this process, interacting with these medications, will be working on the part of us as pharmacists and educating both patients and our colleagues to make sure that everyone's comfortable with things.

Jennifer Miles:

So there are some concerns about some of the side effects, for instance. But we definitely make sure that we stay on top of any of the articles that are published out there, research being done so that we can speak to that. And assuage some of patients, some fears in terms of using the medications. But the benefits are definitely there. Whether it's helping to reduce your risk of heart attack or stroke, some of these medications carry weight loss benefits, protecting your kidneys and stopping you from advancing, like we talked about earlier with prevention. And so these are the reasons why more and more were feeling that this is going to be sort of that wave of the future.

Jennifer Miles:

Stepping away from the traditional backbone therapies of things like Metformin or certain other medications, which will absolutely continue to play a part in patient's treatment. But moving forward, patients and other professionals alike should start to develop a comfort with these medications. They've been out for a few years now, but certainly, the space that we see them going into, I think, will open up a whole new demographic that will be using these therapies. And so, pharmacists are working very closely in collaboration with our colleagues to ensure that everyone is comfortable. The right patients end up on these medications and to really kind of reduce a lot of that fear around giving these [inaudible 00:22:45].

Dr. Fialkow:

Well, thank you very much, guys, for your time, your expertise. Again, to the listeners, diabetes is prevalent. It is controllable. It is preventable. We didn't get into the lifestyle, which of course, those are the components that we would start with and addressing diabetes to include regular exercise, keeping one's weight under control, proper diet, avoiding highly processed or refined foods. But what we really want to impress upon the listeners is that diabetes is not just a sugar disorder. It's a cardiac and vascular disorder. And the components that decrease that cardiac and vascular risk are ultimately beyond just lowering one's sugar.

Dr. Fialkow:

We've got lots of weapons available. We've got lots of expertise. Talk to your primary care doctor. Make sure you're having this assessed appropriately. And our Cardiometabolic Center and Prevention Program will be able to make sure our patients have that holistic approach to their problems sensitive towards what the individual patient wants and is comfortable with. Thanks again, and to our listeners, as usual, if you have any thoughts, ideas for future podcasts, any other comments, please email us at baptisthealthtalk@baptisthealth.net. That's baptisthealthtalk@baptisthealth.net. Thanks again, everyone, and stay safe.

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