Barriers in Managing Patients With T2D at Risk for CVD
JUNE 12, 2019
MD Magazine Staff
Keith C. Ferdinand, MD, FACC, FAHA, FASH, FNLA: We’re going to go into lipids and intensive treatment of lipids. But before we do that I wanted to ask Melissa; an experience that I have had is, I actually will print out the person’s laboratory results. And I’ve had persons with eGFRs [estimated glomerular filtration rates] in the 40s and the 50s. And I’ll say, “You have chronic kidney disease,” and I’ve seen middle-aged persons almost cry because they said, “Nobody ever told me.”
Melissa L. Magwire, RN, MSN, CDE: Exactly. We see that every day, and I don’t think it’s really a negative on the practitioner, I think we sometimes don’t equate that with that renal disease, if they have a good creatinine level and things are functioning. So we do that in our center as well, and not as a scare tactic but to actually get the patients thinking about the overall disease mechanism that’s going on in their body.
Keith C. Ferdinand, MD, FACC, FAHA, FASH, FNLA: And especially in women, the BUN [blood urea nitrogen]/creatinine ratio can look pretty good.
Melissa L. Magwire, RN, MSN, CDE: Exactly. And so it’s time to act, and I tell people, “Again, not to scare you, but it’s time to take action.” We need to get on this and really give it some emphasis.
Christopher P. Cannon, MD: I wanted to point out that I had the honor to chair the National Kidney Foundation’s Kidney Early Evaluation Program for over a decade. So we had 200,000 patients that we had screened for kidney disease and followed them. Among patients who had stage IV kidney disease, estimated GFR below 30, only 15% of them said that any doctor or care provider mentioned that they had a kidney problem.
Keith C. Ferdinand, MD, FACC, FAHA, FASH, FNLA: Wow.
Christopher P. Cannon, MD: So our awareness on the patient’s side and the clinician communication side for chronic kidney disease is even lower than that of cardiovascular events.
Keith C. Ferdinand, MD, FACC, FAHA, FASH, FNLA: I think we’ve done a great job pointing out the risk of chronic kidney disease and how we need to do more. What about lipids?
Seth J. Baum, MD, FACC, FACPM, FAHA, FNLA, FASPC: Can I ask you one question of you before?
I’m going to go through lipids, but I wanted to bring it back to hypertension just for a moment because we have great hypertension guidelines, but I’ve been hearing that most of us don’t actually take blood pressure appropriately.
Keith C. Ferdinand, MD, FACC, FAHA, FASH, FNLA: Absolutely.
Seth J. Baum, MD, FACC, FACPM, FAHA, FNLA, FASPC: It may be worth going through that.
Keith C. Ferdinand, MD, FACC, FAHA, FASH, FNLA: Absolutely. A working group report, a scientific statement from the American Heart Association, was published just this year. And they’re now suggesting that we have the arm supported, resting 5 to 10 to 15 minutes, no talking, eating, smoking, and we, the clinicians, should get out of the room.
Seth J. Baum, MD, FACC, FACPM, FAHA, FNLA, FASPC: Get out of the room, right.
Keith C. Ferdinand, MD, FACC, FAHA, FASH, FNLA: Get out of the room. Because there’s a little lower arm reaction that happens. The automated cuffs, using it at least 3 times, at best 4 to 5 times, sometimes if you’re doing a clinical trial, 6 times. Discard the first one because it takes time for the cuffs to sit on the blood pressure arm, and then average that out, that’s the true blood pressure. And if you do that particular type of mechanism, it’s called automated office blood pressure, it tends to reproduce what you see, even with an ambulatory blood pressure looking at daytime systolic blood pressures.
Unfortunately, we don’t do that. We need to. We certainly shouldn’t have patients rushing in, sitting on the exam table, arm dangling, soft drink in their hand, just had a cigarette because they were nervous.
Seth J. Baum, MD, FACC, FACPM, FAHA, FNLA, FASPC: On their cell phone.
Keith C. Ferdinand, MD, FACC, FAHA, FASH, FNLA: We’re trying to get them out of the room so we’re coming in, “Are you finished with the blood pressure yet?” We’re going to get elevated blood pressures, which may not be a true biomarker.
Seth J. Baum, MD, FACC, FACPM, FAHA, FNLA, FASPC: Right.
Keith C. Ferdinand, MD, FACC, FAHA, FASH, FNLA: Lipids, what are we going to do with lipids in persons with diabetes?
Seth J. Baum, MD, FACC, FACPM, FAHA, FNLA, FASPC: Obviously we’ve mentioned that diabetes, although we don’t consider it a cardiovascular risk equivalent, we certainly understand how significant cardiovascular disease is among diabetics, two-thirds dying from cardiovascular disease. So we have to take lipids very seriously.In our most recent guidelines the recommendation was for moderate intensity statins unless a patient with diabetes was at higher risk, and that’s greater than 7.5%. And so I think that’s an appropriate way to move forward. I don’t think it’s, personally, inappropriate to continue to use high intensity statins in these patients.
Keith C. Ferdinand, MD, FACC, FAHA, FASH, FNLA: Melissa, what do you do with lipids?
Melissa L. Magwire, RN, MSN, CDE: We do the same thing—the high intensity, we treat it as an overall risk. Even though it’s 7.5%, we’re not going to back down if somebody’s tolerating the high; we do use a lot of PCSK9 [proprotein convertase subtilisin/kexin type 9] inhibitors as well. We screen a lot of patients for FH [familial hypercholesterolemia] and have the FH registry and price was an issue, but that is getting better, thankfully. And you can get those LDLs [high-density lipoproteins] down really appropriately with PCSK9 inhibitors. So I’d be interested to see what everybody else’s take on that is.
Peter McCullough, MD, MPH, FACC, FACP, FAHA, FCCP, FNKF: I would say the change in my practice first has been with the generic availability of ezetimibe. I’m adding a lot of ezetimibe now because it’s just so available and so affordable to patients to moderate or higher intensity statins. And then like others we’re using PCSK9 monoclonal antibodies directed against that molecule. Keep in mind that familial hypercholesterolemia, FH, is independent of diabetes. So a diabetic can also genetically get dialed up for FH. I’m always worried about a diabetic who has something additional. And those are the super high-risk patients we see in the CCU [coronary care unit]. So if we see an untreated LDL cholesterol over 190, or a treated LDL cholesterol over 145, I start to think about familial hypercholesterolemia heterozygous.
Keith C. Ferdinand, MD, FACC, FAHA, FASH, FNLA: Peter, what do you do?
Peter McCullough, MD, MPH, FACC, FACP, FAHA, FCCP, FNKF: Well, certainly lowering cholesterol is good, and as you pointed out, doing the stepwise approach of using the less expensive agents makes total sense. So using more ezetimibe, and it really looks good in patients with diabetes in the IMPROVE-IT study. So good evidence in this population. And then fewer people you need to battle the insurance companies. But this is a very modifiable risk factor that has big impact in patients with diabetes. And way back the CARDS trial had to be stopped 3 years early because it was so positive with statins. So a big winner. But it’s amazing how many patients in all the various trials, in patients with diabetes, aren’t on statins, it’s just amazing.
Transcript edited for clarity.