Diabetes & Cardiovascular Disease: Comprehensive Care
JUNE 12, 2019
MD Magazine Staff
Keith C. Ferdinand, MD, FACC, FAHA, FASH, FNLA: Melissa, tell us what you do with the SGLT2 [sodium-glucose cotransporter 2] inhibitors and GLP-1 [glucagon-like peptide-1] agonists. When do you start to intervene in patients who come to you, and when do you refer them to the diabetes specialist?
Melissa L. Magwire, RN, MSN, CDE: I’m in a fortunate position in that we have actually started a Comprehensive Cardiac Center–certified cardiometabolic center of excellence. We have a cardiologist and me who are taking on patients, who have already had either an event or been diagnosed with ASCVD [atherosclerotic cardiovascular disease] or heart failure and type 2 diabetes. We have a couple of different pathways. We work hand in hand with the endocrinologist. If a patient does not already have an endo [endocrinologist] on board, and we feel that the patient needs to advance to insulin or to, let’s say, an insulin pump, that’s an automatic referral to the endocrinologist.
Keith C. Ferdinand, MD, FACC, FAHA, FASH, FNLA: So you probably can handle it, because I know you’re certified.
Melissa L. Magwire, RN, MSN, CDE: Yes.
Keith C. Ferdinand, MD, FACC, FAHA, FASH, FNLA: But in general, in that setting, that cardiovascular center that you have, once they go to high-dose insulin or an insulin pump, you do refer them on.
Melissa L. Magwire, RN, MSN, CDE: Yes, because we do want to continue this as a team effort. I’ve been kind of excited to be pulling cardiology into it and kind of breaking down some of these silos that we’ve been practicing in. We need to be very aware of keeping everyone on the team informed and realizing that we’re not asking cardiologists to actually start managing glucose. Our cardiologists are looking at the risk reductions that we can get from some of these medications. But at the time that we really need to start looking at insulin doses and really manipulating, that’s probably when they need an endo [endocrinologist] or a diabetologist or a well-versed primary care. We’ve actually built in pathways to ensure that we actually have the right team member with the right patient and that we’re not excluding anybody from the team.
Keith C. Ferdinand, MD, FACC, FAHA, FASH, FNLA: Now, you don’t have a PharmD on your particular team.
Melissa L. Magwire, RN, MSN, CDE: We are working on that, though. That is next. We will have PharmD because of the polypharmacy and because of some of the really complex medication regimens that we have these patients on. We feel a PharmD would be a really integral part of this program.
Keith C. Ferdinand, MD, FACC, FAHA, FASH, FNLA: Anyone works with PharmDs?
Christopher P. Cannon, MD: Well, we have a PharmD for the very complex prior authorization.
Melissa L. Magwire, RN, MSN, CDE: Yes.
Keith C. Ferdinand, MD, FACC, FAHA, FASH, FNLA: To treat the paper.
Christopher P. Cannon, MD: No joke. Obviously, also helping choose because there’s renal adjustment and there are different factors. We talked about barriers, but that’s the barrier. And Seth, you’ve been really spearheading this on PCSK9, but the same is true to some extent. And so having experience of simply going through and getting in the routine of, “Oh, yeah, here’s the information the company will need,” to then get access. And we’re able to use the classes of drugs.
Keith C. Ferdinand, MD, FACC, FAHA, FASH, FNLA: All the patients who you see have already had an event, a documented ASCVD? Or do you see some who are just high risk?
Christopher P. Cannon, MD: Full spectrum, from healthy people who have heard about a calcium score to a very advanced patient with diabetes and who had a heart attack 3 weeks ago. And so there, having the support as we learn and try to integrate into the polypharmacy, it is important to have other people on the team.
Keith C. Ferdinand, MD, FACC, FAHA, FASH, FNLA: The coronary artery calcium scoring was seen as an additional risk enhancer in the guidelines from the American Heart Association and the American College of Cardiology. You used it more than once. You’ve talked about calcium score. It sounds like you think that really helps.
Christopher P. Cannon, MD: In the right setting. And so very often in younger patients, …the risk calculator comes out at 1% or 2% because they’re young, but they have multiple risk factors. So they’re more often they’re presenting with metabolic syndrome or prediabetes, and they’re a little hypertensive. Very often a big family history is what brings them to a cardiologist to get a consult. And that, I have found, is the perfect setting for a calcium score to say if atherosclerosis has started or not. And it’s remarkable; there are a fair number of 0s. Thankfully women more often, I’ve found, have a risk factor or a family history but will come up with a 0. But then sometimes there’s the converse. One guy had an 1100 out of the blue. And we got him now. His LDL [low-density lipoprotein] is really low but on antiplatelet therapy. So it really gives the full spectrum. As opposed to, oh, primary prevention, in which we need to have you exercise and do the standard things, it allows tailoring of intensity.
Keith C. Ferdinand, MD, FACC, FAHA, FASH, FNLA: We’re going to finish in a few minutes to talk about the whole patient. There’s another term that you’ve brought up more than once, and that’s family history. That’s not in the guidelines. You don’t have to do a family history for ASCVD risk calculation.
Christopher P. Cannon, MD: You know, it’s true, and that is something that the patients come bring to me most often. They will recite, “Oh, my uncle and my extended family.” They’ll have seen the pattern and worry about that, and then that generates, then, the comprehensive look at, well, what are the lipids and what is the blood pressure?
Keith C. Ferdinand, MD, FACC, FAHA, FASH, FNLA: So you think it’s important.
Christopher P. Cannon, MD: It’s tremendous. It’s a key factor.
Keith C. Ferdinand, MD, FACC, FAHA, FASH, FNLA: In the Framingham Offspring Study, family history did come through. But in the original Framingham risk calculator, family history is not part of it.
Christopher P. Cannon, MD: Paul Ridker of Brigham and Women’s Hospital in Boston, Massachusetts, did a risk calculator that ended up including family history, because in his analysis and data set that he derived from, that was a factor: the Reynolds Risk Score for Cardiovascular Risk in Women. And I think it’s the top of the list on the risk enhancers in the guideline. All these factors are important because patients come with all sorts of prior history, and we want to try to integrate all that and then match our treatment plan to that.
Transcript edited for clarity.