Impressions of a Patient With T2D and CVD
APRIL 15, 2019
MD Magazine Staff
John Anderson, MD: This case is a Mexican woman who is 46 years old, has had type 2 diabetes for 3 years, and comes to see you as a new patient 1 month after having had a heart artery stenting procedure. Now it doesn’t say that she had myocardial infarction. We presume that she just had unstable angina, went to get seen, and had a stent put in. And then she comes to see you and is on all the usual agents, right? She’s on antiplatelet agents, which include clopidogrel and aspirin. She’s on a high-intensity statin, which is Lipitor at 80 mg. And then she’s on a modest dose of metformin and a small dose of a sulfonylurea. But then you see her hemoglobin A1C [glycated hemoglobin] is 8.2%. Now this is a younger patient. Even though she’s had a cardiovascular event at 46 years of age, her goal should be closer to 6.5%. So you’ve got the challenge of, what are we going to do to try to bring her dysglycemia under control? We also have to think: Are there other things we can do while trying to lower her glucose that will also provide cardiovascular benefit?
John B. Buse, MD, PhD: The patient who we’re discussing is a relatively young Mexican American woman with a relatively short history of diabetes associated with the typical comorbidities—obesity, hypertension, hypercholesterolemia. It seems like she probably had not been very well controlled, historically. She recently presented with chest pain and received a stent. Her cardiovascular risk factors are certainly well managed now. She doesn’t really have any other evidence of complications of her diabetes, and the question is, on metformin and a sulfonylurea with inadequate blood sugar control, what should we do next?
The treating doctor is an endocrinologist. This is a pretty frequent presentation. I’d say this patient is a little bit younger. This patient is a woman. We classically think of cardiovascular disease as being a disease of the elderly and more common in males. That’s true. The older you are and based on your gender, the more likely you are to have cardiovascular disease. But the sort of shocking thing in diabetes is that we do have these young women presenting with cardiovascular disease, particularly like this patient with multiple risk factors.
John Anderson, MD: This particular patient is not that uncommon because of what I talked about in terms of the increased risk cardiovascular disease in patients. She’s a little younger than most, but she’s had a long history of hypertension and high cholesterol. She’s obese, with a BMI [body mass index] of 35. She comes from a Hispanic population that’s at increased risk for macrovascular disease and diabetes. And while there is not 1 typical presentation, the combination of macrovascular disease, in a patient like this is, unfortunately, is all too common.
When she presents to us after this heart artery stent 1 month later, there are a lot of things I want to know. I want to know: Is her blood pressure controlled? Is she taking her medication? Is she having any trouble affording her medication? Is she having any trouble with this high-intensity statin? I want to make sure that she’s comfortable with her regimen and that she has a routine for taking it.
But then I want to look at all those parameters that I’m supposed to achieve, right? I want to be sure her blood pressure is controlled. I want to be sure she’s at that target LDL [low-density lipoprotein] for cholesterol lowering, especially for someone who has already had a cardiac event. And then I want to focus on 1 of the glaringly obvious needs, which is to get her hemoglobin A1C out of that 8.2% range and down well under 7%, and hopefully maybe even closer to 6.5%.
Transcript edited for clarity.