Announcer:
Welcome to ReachMD.
This medical industry feature titled, “Role of the Cardiologist in CV Risk Management for Patients With Type 2 Diabetes,” is sponsored by Novo Nordisk.
It was recorded prior to the release of the 2021 Standards of Medical Care in Diabetes and references the 2020 Standards of Medical Care in Diabetes.
Here’s your host, Dr. Charles Turck.
Dr. Turck:
Patients with type 2 diabetes face a higher risk of cardiovascular morbidity and mortality than adults without diabetes. This much is becoming common knowledge across medical disciplines. But how does this understanding specifically affect the way cardiologists manage their patients with type 2 diabetes?
This is ReachMD, and I’m Dr. Charles Turck. Joining me to discuss the cardiologist’s role in cardiovascular risk management among patients with type 2 diabetes is Dr. Joshua Stolker, an interventional cardiologist practicing at Mercy Clinic Heart & Vascular in St. Louis, Missouri. He’s also an Adjunct Associate Professor of Internal Medicine at St. Louis University School of Medicine.
Dr. Stolker, thanks for being here today.
Dr. Stolker:
Thanks for having me.
Dr. Turck:
Let’s begin with a little background on the updated 2020 ACC Expert Consensus Decision Pathway on novel therapies for CV risk reduction in patients with type 2 diabetes and cardiovascular disease. What are some of the main decision points recommended there?
Dr. Stolker:
When we talk about choosing the right medicine from a cardiologist’s standpoint, we’re mainly looking to avoid major adverse cardiovascular events, or MACE. These are things like heart attacks, strokes, cardiovascular death. That’s the main focus of a cardiologist.
So, when we look at the summary graphic from the American College of Cardiology’s Decision Pathway and we talk about the decision points, we need to first look at who are the patients that we’re talking about and what exactly we’re addressing. We’re talking about adults with type 2 diabetes who either have established cardiovascular disease or heart failure or chronic kidney disease or those with significant risk factors for cardiovascular disease.
And from there we need to make sure that we pick the right drug for the right patient, and we need to make sure that we’re not missing contraindications and that we are making ourselves familiar with the safety profiles and the side effects of the drugs. We also need to look at when we need to adjust the other therapies, the antihyperglycemic therapies, or the other cardiovascular therapies, such as their blood pressure or lipid therapies, that our patients might be on.
Dr. Turck:
Now, as I understand it, both the updated Expert Consensus Decision Pathway as well as the 2020 ADA Standards of Medical Care in Diabetes included some major changes. Could you walk us through those updates?
Dr. Stolker:
Sure. So, the 2020 ADA Standards of Medical Care in Diabetes recommend that along with the initiation of comprehensive lifestyle intervention, including weight management and physical activity and metformin as first-line therapy, clinicians should also assess indicators of high-risk or established atherosclerotic cardiovascular disease or chronic kidney disease or heart failure and then consider an initial combination of those therapies with a GLP-1 agonist or an SGLT2 inhibitor with proven cardiovascular benefits, meaning it has a label indication of reducing cardiovascular events. This recommendation should be considered independently of the baseline A1c or of the individualized A1c target.
Meanwhile, the updated 2020 ACC Expert Consensus Decision Pathway, which is also endorsed by the ADA, puts these glucose-lowering agents even closer to the cardiologist’s frame of mind by drawing on evidence showing that GLP-1 agonists and SGLT2 inhibitors can reduce the risk of major adverse cardiovascular events, such as heart attack or stroke or heart failure or cardiovascular death. So, similar to the ADA guidelines, if an adult patient with type 2 diabetes has or is at high risk for atherosclerotic cardiovascular disease or has heart failure or diabetic kidney disease, the ACC Pathway recommends starting a GLP-1 agonist or SGLT2 inhibitor with proven cardiovascular benefit alongside lifestyle changes and optimized guideline-directed medical therapies, and these drug classes are recommended selectively based on patient-specific risk factors and comorbidities.
Dr. Turck:
All right, so with these changes in mind, let’s consider impacts on cardiology practices in general. How do you see clinical strategies or mindsets shifting in the context of these updates, if at all?
Dr. Stolker:
Well, to be clear, this is a complete change in mindset for our cardiologists. The potential of these medications, the GLP-1 agonists, the SGLT2 inhibitors, has created an opportunity for us to reexamine the traditional roles for various medical specialties in the management of type 2 diabetes, and that’s leading to cardiovascular specialists adopting a more active role in prescribing therapies that until now may have been seen only as glucose-lowering therapies, so we are seeing an evolving role based on the need to make our clinical care more collaborative and multidisciplinary as we manage these high-risk patient groups that have multiple comorbidities.
The way I see it, coming back to the 2020 ACC Decision Pathway, we don’t only have an opportunity but we have a responsibility in the cardiology community to encourage and to prescribe and to monitor and to notify our referring doctors to get patients on the right therapies for the right patient, meaning start our patients with type 2 diabetes on cardioprotective diabetes therapies.
Dr. Turck:
So, have the treatment priorities for you and your colleagues changed in response to these updates to the 2020 ACC Expert Consensus Decision Pathway?
Dr. Stolker:
Well, I think a lot of cardiologists, myself included, are starting to pay more attention to these therapies because the updates have opened the door for some of our patients with type 2 diabetes, such as those who have had a prior MI, to get a cardioprotective diabetes therapy on board. We know that most morbidity and mortality in patients with type 2 diabetes comes from cardiovascular events, so this puts the cardiovascular specialist in a key position to optimize care for these patients.
There are a couple of tracks I would think about. First of all, we screen for type 2 diabetes in our patients who either have established cardiovascular disease or are at high risk of cardiovascular disease, and the second thing would be aggressively treating these cardiovascular risk factors, both of which we were doing before. But the third thing is the key new point here, is incorporating glucose-lowering agents that have evidence behind improving cardiovascular outcomes into our routine practice. These are the kinds of roles that I see us adopting more and more to try to make a positive difference for patients with type 2 diabetes and reduce their risk of cardiovascular events.
Dr. Turck:
Now, Dr. Stolker, you mentioned earlier the recommendation to consider glucose-lowering agents, specifically GLP-1 receptor agonists and SGLT2 inhibitors, independent of baseline A1c or individualized A1c targets. So, with that said, how do you envision patient education and counseling strategies evolving beyond A1c?
Dr. Stolker:
Well, let me just say that, as cardiologists, we are not trained to focus on glycemic control. I think it’s our responsibility as cardiovascular clinicians to get the appropriate patient with type 2 diabetes on therapies that are going to reduce their risk of cardiovascular events, like heart attack and stroke and death. I really think that many patients with type 2 diabetes are not aware that they are at higher risk for cardiovascular events versus those without type 2 diabetes, so we have some groundwork to lay down to make sure our patients are aware of that risk. And if we think about that further, especially for patients who have already experienced a heart attack or a stroke in the past, I think we can educate them and help them understand their own risk. And at the end of the day, it’s about selecting the right therapy for the patient and then making whatever adjustments are appropriate to maximize the benefits of type 2 diabetes therapies that have proven cardiovascular benefit in alignment with the goals that have been laid out by the primary care physician or the endocrinologist.
Dr. Turck:
And looking at the ongoing care coordination means for patients, what are your thoughts on integrating these guideline updates into cardiology practices?
Dr. Stolker:
Well, my personal experience is that we start these patients as soon as possible following the diagnosis of their cardiovascular disease in the setting of type 2 diabetes. No matter the setting, whether it’s in the hospital, whether it’s in the clinic, I try to integrate these guidelines into practice by talking with my patients who have diabetes about making sure they are taking appropriate therapies that can protect their hearts and reduce their risk of cardiovascular events. I think, in order to do that better, we need to get more comfortable with understanding and talking about these glucose-lowering agents that have proven cardiovascular benefit. They haven’t historically been in our wheelhouse as cardiologists, but it’s time to make them part of our conversations with our patients that have type 2 diabetes so that we can put cardioprotection at the top of their minds for both the patients and for us as their physicians.
Dr. Turck:
Those are great comments for us to think about as we come to the end of today’s program. I want to thank my guest, Dr. Joshua Stolker, for helping us better understand the emerging roles for cardiologists providing CV risk management for patients with type 2 diabetes. Dr. Stolker, it was great having you on the program.
Dr. Stolker:
Thanks again for having me.
Dr. Turck:
I’m Dr. Charles Turck. Thanks for listening.
Announcer:
This program was sponsored by Novo Nordisk. If you missed any part of this discussion or to find others in this series, visit ReachMD.com/heartoft2d. Be part of the knowledge.
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US20DI00435 February 2021
