Javed Butler Part 3, The Correlation Between Heart Disease and Diabetes

In part 3 of this Exclusive Interview, Javed Butler explains the focus on heart disease versus diabetes as a major cause of mortality in a conversation with Diabetes in Control Publisher Steve Freed.

Javed Butler, MD, MPH, MBA, is a cardiologist, professor, and chairman of medicine at the University of Mississippi Medical Center.

Transcript of this video segment:

Freed: I think it’s curious that when we list the major causes of death in the United States we list heart disease way up there, even though that person had diabetes. So, do we list it as diabetes, heart failure due to diabetes? We don’t have that. We just basically say it’s cardiovascular.

Butler:  So, that’s a very, very complicated question. And the reason why that’s a complicated question is that the CDC reports that come out, they don’t want to double count things, so they don’t want to attribute causes of death to more than one thing. So then, the question is how far back do you go? So for instance, let me just give you one simple example. We all know that patients with heart failure have 10% to 20% risk of dying and only depending on how severe the heart failure is. But by the same token, we say that in the US about 50,000 people die of heart failure annually. If there are 5 million people with heart failure and 50,000 patients died that’s 1% mortality risk. That’s awesome. The problem is that, again, you have 250,000 deaths attributed to chronic ischemic heart disease. Well, what is that? There is, I don’t know, half a million deaths attributed to hypertension. Well, nobody dies of hypertension. They get stroke. They get heart failure. They get myocardial infarction. So, how far back do you go in diabetes, falls exactly in the same realm.

Freed: So, what are the cardiovascular risks in patients with diabetes? Because that’s usually — it’s usually about blood sugars, A1C, we’re not really talking about cardiovascular risk. If we can talk about, you have an increased risk in cardiovascular disease, maybe they’d go for a walk more often.

Butler:  Well, so, cardiovascular disease is all forms of cardiovascular disease. So, vascular part of it is myocardial infarction angina, coronary artery disease, stroke, TIA. And then, once you go sort of beyond that you can have heart failure which could be either related to coronary artery disease or could be primary myocardial dysfunction. And at least I myself think of chronic kidney disease as a form of vascular disease as well, so you can, in my mind, [lump chronic kidney disease as part of the spectrum of cardiovascular diseases as well.

Freed: Is there a high risk of developing heart failure with diabetes?

Butler:  Oh, absolutely. So, not only is there a particularly high risk of developing heart failure in those people who have diabetes, if you do develop heart failure they almost fall off the cliff, for lack of a better term. So, the risks are very high, so you are at a high risk of developing heart failure and you are at a much higher risk for a worse outcome once you have both diseases together. And it’s a bidirectional relationship because most likely both of these things are related to insulin resistance. So, the actual prevalence of diabetes in heart failure population is about 30% to 40% but another 30%-40% have pre-diabetes. So, this is a pretty tight link. So, if you have heart failure and you don’t have diabetes, you’re at a high risk of developing diabetes. If you have diabetes and you don’t have heart failure, you’re at a high risk of developing heart failure. And once you have both, your prognosis is considerably worse than if you were to have either of the two of them.

Freed: Are you saying that those people with heart disease or heart failure and diabetes are going to have worse outcomes?

Butler:  By far. By far.

Freed: And how do you explain that to a patient?

Butler:  So, the way I would sort of explain it to the patient is that we know quite a lot in terms of biology of how that risk occurs. Now, we are not only talking about theoretical risk in biology but we have therapies that improve outcomes. So, let me just rephrase it a different way. If you have a patient who comes to your clinic, is completely asymptomatic and is doing great and their blood pressure is 180 systolic, are we going to leave them alone? No, right? Because you’re trying to prevent future adverse outcomes. If their hemoglobin A1C is 12, will you leave them alone? No, because you treat glucose, because you’re trying to lower microvascular neuropathy, nephropathy, whatever, risk. So, I think we need to just broaden that horizon that in the very same spectrum we also now need to give therapies that can reduce the major cardiovascular events as well.

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