Diabetes and Cardiovascular Health: A Review of the Updated Guidelines

Podcast Transcript

Announcer:

Welcome to Cleveland Clinic Cardiac Consult, brought to you by the Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute at Cleveland Clinic.

Natalie Salvatore, MSN, MBA, RN, CCRN:

Hello, my name is Natalie Salvatore. I'm a registered nurse at the Cleveland Clinic in the Heart, Vascular and Thoracic Institute.

Dennis Bruemmer, MD, PhD:

Natalie, thank you for having me. My name is Dr. Dennis Bruemmer. I'm a staff cardiologist in the Heart, Vascular and Thoracic Institute, and I direct the Center for Cardiometabolic Health at Cleveland Clinic.

Natalie Salvatore, MSN, MBA, RN, CCRN:

Well thank you so much for joining me. I wanted to talk a little bit today, I know there are new guidelines out for managing diabetes and heart health. Can you explain a little bit about some of these guideline updates?

Dennis Bruemmer, MD, PhD:

Absolutely, Natalie. So, the American Diabetes Association publishes actually every year updated treatment recommendations, the so-called standard of care for the management of diabetes and associated complications. These are updated annually, in the summer follows actually a new update. And this January comes the 2023 guidelines of which I'm involved in some of the development in these guidelines. And they're important because they look at the current evidence. That's all the trials, all the new findings that have come in over the year. And then based on this new evidence, actually revise the guidelines to provide treatment recommendations, which are the standards we would call them, sort of what treatment of care is expected for what kind of patients in which stage and which complication of diabetes that patient may be in.

Natalie Salvatore, MSN, MBA, RN, CCRN:

Okay. Can you talk a little bit about any of the specific updates or highlights through the updates?

Dennis Bruemmer, MD, PhD:

So when we talk, and I will focus on the cardiovascular aspect of these guidelines because they're so important in terms of patients having ultimately cardiovascular disease as a complication of diabetes. And looking at the risk factors that lead to adverse cardiovascular outcomes in patients with both type 1 and type 2 diabetes, these risk factors are, A, very common, B, frequently insufficiently treated, and C, now we have revised them actually to look again at some of the earlier evidence on our treatment or on our guideline committee and say, what are important changes that we would like to make?

The first change is related to the blood pressure treatment target that has been lowered from systolic 140/90 previously to now, 130/80 millimeter mercury, so that is the new blood pressure treatment recommended target for patients with diabetes. So that is certainly lower. And that target is based on review of previous evidence, a new trial that was published within the past year. And we believe that this is a very appropriate recommendation. If blood pressure can be safely achieved at 130/80 millimeter mercury that is a recommended treatment goal. That's one change.

Dennis Bruemmer, MD, PhD:

The second change that we have made is for the treatment of hypercholesterolemia, mostly LDL cholesterol target, and statin treatment and non-statin treatment recommendations for dyslipidemia in a patient with type 2 diabetes. Now, cholesterol elevation plays a major role in the development and progression of cardiovascular disease, obviously in patients with diabetes. So we have lowered the treatment recommendation. We have what I think simplified it, because now the LDL cholesterol goal for a patient with diabetes without overt cardiovascular disease, but additional risk factors, the LDL should be less than 70 milligrams per deciliter.

Dennis Bruemmer, MD, PhD:

And that is based on the fact that we haven't really ever achieved a lower threshold for LDL cholesterol lowering at which there's no benefit. Patients with diabetes do confer, obviously increased cardiovascular risk, and the patient with diabetes has about equal this risk as a patient who had a previous history of myocardial infarction. And for those patients, the goal is less than 70. So we've set the goal similar. So for a patient without cardiovascular disease, a diagnosis of diabetes and additional risk factors, the LDL cholesterol goal is less than 70 milligrams per deciliter. That is a new recommendation.

Dennis Bruemmer, MD, PhD:

The second new recommendation for LDL cholesterol relates to those patients who have a diagnosis of type 2 diabetes and have now established cardiovascular disease. For those patients, the committee recommends an LDL cholesterol target of less than 55 milligrams per deciliter. And that evidence comes from three main areas of research, the so-called PCSK9 inhibitor trials, the combination statin and ezetimibe combination trials, which have clearly shown that patients with diabetes and established cardiovascular disease benefit most from more aggressive LDL cholesterol lowering. And that target is less than 55 milligrams per deciliter. Now, if a patient is treated with statin as a primary treatment approach for LDL cholesterol lowering therapy and cannot achieve that goal, we recommend additional treatment with non-statin therapy, PCSK9 inhibitor therapy or ezetimibe condition therapy to achieve those targets.

Dennis Bruemmer, MD, PhD:

So those are the risk factor related changes for blood pressure and hypercholesterolemia. We have also revised some of the treatment recommendation for the type 2 diabetes aspect and the treatment because there are new medications which are beneficial for patients with type 2 diabetes. So in patients with type 2 diabetes and established cardiovascular disease or cardiovascular risk factors or diabetic kidney disease or established heart failure, we recommend a class of SGLT2 inhibitors as primary treatment recommendation. If a patient has diabetes and established cardiovascular disease, we can combine those with, for example, GLP-1 receptor agonist therapy. So those two classes of medications are the primary classes of medications that we recommend, depending again on whether a patient has cardiovascular disease, diabetic kidney disease or heart failure. But those would be the primary two treatment approaches and this recommendation is irrespective of whether a patient is already receiving metformin.

Dennis Bruemmer, MD, PhD:

So this was quite a bit of information. I encourage the listener to review those guidelines, which will come out, and focus on the cardiovascular aspect with your cardiologist or interested in cardiovascular outcomes and those guidelines as they relate to cardiovascular disease.

Natalie Salvatore, MSN, MBA, RN, CCRN:

Now, how many or what percentage of our patients would you say are meeting these guidelines?

Dennis Bruemmer, MD, PhD:

That's a very good question with a pretty grim answer. Currently, if we look at the treatment targets for cholesterol, blood pressure, hemoglobin A1C, not smoking, those are the main risk factors for heart disease. If you look at what percentage of patients with diabetes meet those treatment recommendations, it's actually just about less than 20 percent. So, the vast majority of patients need help for a number of reasons. There's a number of barriers we can go all in detail, but the vast majority of patients is not treated to go. And if we then add in the recommended medical treatment, for example, with ACE inhibitor or angiotensin receptor blockers in patients with diabetic kidney disease, you add in the aforementioned SGLT2 inhibitors or GLP-1 receptor agonists as proven cardiovascular beneficial medications, which are recommended. So now we add to the A1C, the LDL, the blood pressure, the smoking, we add those medication classes, which are proven beneficial, it's actually about 5 percent of patients which meet the treatment recommendations for targets and which meet the treatment recommendations for ACE inhibitor, ARB treatment, statin treatment, SGLT2 inhibitor treatment, GLP-1 receptor agonist treatment. So, it's actually a vast minority of patients. So, there's a lot of opportunity and a lot of care that we need to expand to the broader community of patients with diabetes.

Natalie Salvatore, MSN, MBA, RN, CCRN:

And what would you say are some of the strategies that we're implementing to try and improve the number of patients who are going to be meeting those guidelines?

Dennis Bruemmer, MD, PhD:

Yeah, so I think the most important evidence that we have to make an impact on cardiovascular risk reduction in patients with diabetes is trying to provide a comprehensive approach to the care, meaning treating for high blood sugar, the hemoglobin A1C, treating for hypertension, blood pressure, treating for LDL cholesterol, goal, and using medications with proven cardiovascular benefit. And this is sort of a comprehensive program, and I think when providers see a patient with diabetes, this is the question you need to ask yourself every single time, what's the A1C? What's the LDL? What's the blood pressure? Is the patient on the right medications? And this has been proven in clinical trials that this provides the best outcome for the patient. So a comprehensive approach looking at all the risk factors and managing all the risk factors. Now, this is sometimes obviously difficult. There are a number of barriers wherever we try to look. There's patient barriers, there's barriers on physician, there's healthcare cost barriers, there's access to healthcare. But that's a completely different question that goes beyond what we're going to discuss. But I think certainly every provider seeing patients with diabetes can try to look at those and say, okay, this is where we are. And if a patient needs additional help can refer the patient to endocrinology or to us or to cardiology with whom we collaborate and manage comprehensively these risk factors in our section.

Natalie Salvatore, MSN, MBA, RN, CCRN:

Excellent. Well, thank you so much for taking the time to review those guidelines and go over all of the updates and recommendations with us.

Dennis Bruemmer, MD, PhD:

Thank you very much for having me.

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