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Simple Strategies to Prevent Cardiovascular Complications in T2D

Sep 19, 2020
 
Editor: David L. Joffe, BSPharm, CDE, FACA

Author: Peter Jay Won, Pharm.D. Candidate, University of South Florida, Taneja College of Pharmacy 

Explore three methods to prevent future acute myocardial infarction with diabetes as an underlying agent.  

The Centers for Disease Control and Prevention predicts that one-third of Americans will be diagnosed with diabetes by 2050. Without decreasing the onset, if the trend continues, it is on course to jeopardize the United States healthcare economy. Diabetes-related expenditures cost Americans $760 billion in 2019 alone, with a projection to increase above $845 billion by 2045, annually. Globally, one-half of people with type 2 diabetes are undiagnosed. The most massive increase was seen in low to middle-income nations. Similar to the 1918 flu pandemic, the Coronavirus disease 2019 (COVID-19) continues to devastate healthcare facilities while imploding global economies. Patients with hypertension and dysglycemia are at high risk of contracting COVID-19. Current studies reveal that there is an underlying increase in risk in mortality for patients with these comorbid conditions. A study conducted by Dr. Giulia Ferrannin, a specialist in internal medicine at Karolinska Institute in Stockholm, Sweden, et. al., revealed that with proper measures, diabetes-related cardiovascular diseases could be prevented by relatively simple and affordable steps.  

The Glucose Tolerance in Patients with Acute Myocardial Infarction (GAMI) study revealed that patients that suffered an acute myocardial infarction, a cardiovascular complication, also had common underlying glucose abnormalities. The study compared 168 patients with diabetes and a history of myocardial infarction (MI) to the 185 patients in control: no history of diabetes or myocardial infarction. All participants were subjected to an oral glucose tolerance test (OGTT) to identify their glucose metabolism.  

“An OGTT is presently the only method that can detect both impaired glucose tolerance (IGT) and diabetes. The use of fasting glucose, and especially of HbA1c alone, is insufficient since a negative result does not rule out dysglycemia,” Dr. Ferrannin declares, “which might prolong the time until the dysglycemic condition is discovered, thereby postponing the establishment of preventive strategies to forestall complications.”  

Only 33% of 366 enrolled participants metabolized glucose normally. Another 33% of the participants showed type 2 diabetes metabolism, while 34% of the participants recorded an impaired glucose tolerance. The control recorded a different outcome; 65% maintained normal glucose levels, 11% of the participants metabolized glucose similar to a patient with type 2 diabetes, and 24% of the participants sustained an impaired glucose tolerance. Similar studies globally support that diabetes is the underlying risk factor that is linked with widespread atherosclerotic vascular disease, especially MI.  

Once the link between poor glucose management and MI was established, the research addressed two common concerns in establishing proper preventive strategies. Inadequate screening and management were the most common hurdle when addressing prevention management. European Action on Secondary and Primary Prevention by Intervention to Reduce Events (EUROASPIRE) V revealed that over 70% of 4,440 patients without known diabetes were diagnosed with dysglycemia when an OGTT was performed. Dr. Ferrannin expressed that low interest in diabetes among cardiologists may be the reason why there is a high proportion of undetected dysglycemia in patients with cardiovascular disease. Furthermore, the Swedish Diabetes Registry reported that patients with type 2 diabetes appeared to have little to no additional risk of developing MI, stroke, and death compared to the general population if all five risk factors were managed within the target: increased levels of Low-Density Lipid cholesterol, decreased levels of High-Density Lipid cholesterol, hyperglycemia, high blood pressure, and smoking. 

There are three solutions to help manage dysglycemia and decrease its risk of causing a future cardiovascular complication: 1)Better communication among various health care providers and nurses following the same guideline is critical. 2)Early detection in people at risk to prevent or postpone type 2 diabetes development.3)Identify and screen patients that present three out of five of the following indications: increased waist circumference, triglyceride levels, blood pressure, and fasting plasma glucose or reduced HDL cholesterol.  

Advancement in diabetes screening technology is pivotal in prevention. The Homeostatic Model Assessment (HOMA) index is designed to diagnose glucose perturbations more precisely than the current HbA1c, fasting, and post-load glucose.  

It is estimated that over one-half of the global population with type 2 diabetes are unaware of their disease until it is too late. Increasing diabetes awareness is the most cost-effective way to prevent future development of diabetes-related complications. Future research demands a more sensitive marker to detect early-onset insulin resistance compared to the HOMA index, the best predictor of future development of cardiovascular complications in patients with type 2 diabetes. As COVID-19 is currently siphoning all scarce resources in health care and the global economy, it is more pivotal now to implement more ways to detect, to prevent, and to save.  

Practice Pearls: 

  • Global capability to properly screen and manage type 2 diabetes is limited and desperately needs improvements to prevent future cardiovascular complications with diabetes as an underlying issue.   
  • Advancement in modern communication and monitoring technology can help with early detection for missed dysglycemic complications worldwide. 
  • Globally, half of the people with dysglycemic issues do not know they have them. Increasing awareness to be screened, backed by good community support, will help encourage more people to get engaged, perhaps take responsibility for their glucose management: potentially saving trillions of dollars worldwide, but more importantly, human lives.  

 

Ferrannini, G. et al. “Is Coronary Artery Disease Inevitable in Type 2 Diabetes? From a Glucocentric to a Holistic View on Patient Management“. Diabetes Care 2020;43:2001–2009 | https://doi.org/10.2337/dci20-0002 

Mahajan K, et al. “Cardiovascular comorbidities and complications associated with coronavirus disease 2019“. Elsevier: Medical Journal Armed Forces India 78 (2020) 253-260. https://doi.org/10.1016/j.mjafi.2020.05.004 

Weir, H. et al. “Heart Disease and Cancer Deaths- Trends and Projections in the United States, 1959-2020“. ME ACTIVITY — Volume 13 — November 17, 2016, http://dx.doi.org/10.5888/pcd13.160211 

Ryden L. “GAMI: Glucose abnormalities in patients with myocardial infarction—prevalence, diagnosis, and prognostic implications.” Paper presented at the European Society of Cardiology Congress 2004, 29 August-1 September, Munich, Germany. 

 

Peter Jay Won, Pharm.D. Candidate, University of South Florida, Taneja College of Pharmacy