T2D and CV Risk Reduction: Treating the Whole Patient
JUNE 12, 2019
MD Magazine Staff
Keith C. Ferdinand, MD, FACC, FAHA, FASH, FNLA: Before we conclude to talk about the whole patient, I’m going to ask just about that family history, and then you can do it at the same time: Tell me about the whole patient. Peter, and then we’ll go with Seth, go back to Chris, and we’ll end with Melissa because she’s the one who probably does a better job than we do in treating these patients. Family history and treating the whole patient.
Peter McCullough, MD, MPH, FACC, FACP, FAHA, FCCP, FNKF: Sure. Well, family history is the foundation of identifying premature coronary heart disease risk. So I follow an earlier AHA [American Heart Association] definition of a first-degree family member: mom, dad, brother, or sister, male before 45 or a female before age 55, with a cardiovascular event or revascularization, as having a positive premature history of cardiovascular disease. The other thing I’m going to ask about is lipid levels. Because I think if family history is this core foundation of identifying patients with heterozygous FH, familial hypercholesterolemia. It’s important.
Keith C. Ferdinand, MD, FACC, FAHA, FASH, FNLA: Yeah, that’s true.
Peter McCullough, MD, MPH, FACC, FACP, FAHA, FCCP, FNKF: Keep in mind that family history for type 2 diabetes plays a role, particularly in certain ethnic groups: Hispanics, African Americans, American Indians. That’s important. A lot of people don’t realize that even in renal disease, believe it or not, a family history of somebody being on dialysis is a very strong risk factor for that individual to be at risk for progressive kidney disease.
Keith C. Ferdinand, MD, FACC, FAHA, FASH, FNLA: So give us your closing remarks on treating the whole patient. And then Chris, you’re going to be next, treating the whole patient.
Peter McCullough, MD, MPH, FACC, FACP, FAHA, FCCP, FNKF: Treating the whole patient involves a comprehensive assessment of cardiovascular risk, and because we’ll have many opportunities to see a patient over time, we don’t have to tackle it all in 1 office visit. I think we really—patients give us lots of opportunity, and we work on this multifactorial risk reduction. I think if I was going to leave a final point, it is that coronary heart disease, and now it looks like heart failure, is enormously preventable. We don’t have much in the way of preventing pancreatic cancer or what have you, but coronary heart disease and heart disease in general, accounting for 40% of the deaths in the United States, has a great aspect of prevention. And this is a goal that we should all universally pursue in ourselves personally, our family members, and our patients.
Keith C. Ferdinand, MD, FACC, FAHA, FASH, FNLA: Well stated.
Christopher P. Cannon, MD: I think I’ll turn to a practical sense of treating the whole patient, that very often people come with a chief complaint, and often for me high cholesterol will be 1. And I have to force myself to ask the questions: Should they be on aspirin, or should they stop the aspirin that they’ve already been taking? What about their diabetes risk? Do they have prediabetes? How is the blood pressure? And I make sort of separate paragraphs in my summary and conclusion to not lose track of the various factors that may need observation in patients. So then when I see them back 3 or 6 months later, I can remember, “Oh wait, I have to look at how this is evolving.” So it’s important to move beyond sort of the 1 thing. Someone was sent to you as a specialist, to remember how all these things interrelate, and I have to force myself to do it. But that’s how I do it.
Keith C. Ferdinand, MD, FACC, FAHA, FASH, FNLA: It kind of keeps us on our toes. Just when we thought we had this medicine thing down pat, something else comes up.
Christopher P. Cannon, MD: What exciting times, obviously, to have so many modifiable things. I was reflecting on the kidney disease. There are things that can affect that. So before it was sort of, “Oh yeah, the kidney is just getting worse.” But now we can really intervene with probably 2 classes of drugs. And so that, then, calls more attention to monitoring and doing things differently.
Keith C. Ferdinand, MD, FACC, FAHA, FASH, FNLA: Before I go to Seth, I would say I was being facetious. It’s actually good that we have a lot of things we can do for our patients. It may make us have to read a little bit more and keep up, but it’s good for the patient.
Christopher P. Cannon, MD: Yeah.
Keith C. Ferdinand, MD, FACC, FAHA, FASH, FNLA: Seth, what do you do with the whole patient?
Seth J. Baum, MD, FACC, FACPM, FAHA, FNLA, FASPC: I’m definitely in favor of looking at the whole patient, I’ll say that. As someone who has a large number of FH patients in my practice, I do start with the family history, and I take a very extensive family history. And in this age of burgeoning genetics—in which we now understand the genetic connection in diabetes, and the genetic connection in lipids, and the genetic connection in rhythm disturbances and sudden cardiac death, and on and on and on—I think a family history is a very valuable part of the assessment. In terms of the whole patient, I have the Chris Cannon approach. I’m sitting there with my notepad like this and writing down every single thing all over the page and flipping it over. And then I go and construct my note, which has different aspects of the plan involving every system. So even though I’m a cardiologist, I agree with you. I think it’s dangerous to relinquish everything that we seem to have wanted to relinquish now, because I think we’re going to end up with a very small, and too narrowly focused, and ineffective approach. So yes, I’m a fan of the whole person.
Keith C. Ferdinand, MD, FACC, FAHA, FASH, FNLA: Melissa, you have the last comments, and you have time. I’m not trying to cut you short. What do you do with the whole patient?
Melissa L. Magwire, RN, MSN, CDE: I think the whole patient takes a whole team, and I’m kind of excited about the direction things are going. And I echo what my peers said, that we are all each responsible for the whole patient, but I do think it’s challenging us in the way we practice and really looking at building a team. Because 1 practitioner alone can’t handle all that in 1 visit. Just as you said, it doesn’t have to be all tackled at 1 time, but I think we all need to be held accountable to that whole patient. And so I think it’s going to be very interesting to see how these teams grow over the next couple of years, how we’re merging diabetes and cardiology into 1 practice essentially in some ways. And actually improving our communication across the team, I think, is going to be key—not only the team peer to peer but provider to patient as well.
Keith C. Ferdinand, MD, FACC, FAHA, FASH, FNLA: Do you have a checkbox for all of these ABCs?
Melissa L. Magwire, RN, MSN, CDE: We do have a checkbox. But as I said, it takes more than 1 person. It does take building that team and having the specialist—the cardiologist, the endocrinologist, the diabetologist, the pharmacologist, the educator—and really making sure we are educating ourselves as well as our patients, and really looking at the whole picture and not just each of our subspecialties.
Keith C. Ferdinand, MD, FACC, FAHA, FASH, FNLA: Do you use handouts and do your handouts have different cultural aspects?
Melissa L. Magwire, RN, MSN, CDE: We do.
Keith C. Ferdinand, MD, FACC, FAHA, FASH, FNLA: I think patients need literacy-level-appropriate handouts. If you give them these little small fonts that look like an encyclopedia, it might make us feel really good that we gave them comprehensive materials, but they can’t read all that stuff.
Melissa L. Magwire, RN, MSN, CDE: We do, and that’s something that I’ve actually helped with, for the American Association of Diabetes Educators to come up with some of these handouts. But 1 of the driving forces we have in my health care system is to ensure that if you get handed an education form in the endocrinology office, it might be the same one that you get handed in a cardiologist’s office and the same message coming from me.
Keith C. Ferdinand, MD, FACC, FAHA, FASH, FNLA: So you’re trying to integrate those.
Melissa L. Magwire, RN, MSN, CDE: We’re trying to integrate that, so that we’re all on the same team and we’re all giving the patient the same message.
Keith C. Ferdinand, MD, FACC, FAHA, FASH, FNLA: This has been a wonderful panel. We’ve had a lot of information about type 2 diabetes, prediabetes, and cardiovascular risk. We’ve been looking at it not just from a heart point of view. We’ve also looked at the kidney, and not just the heart attacks and angina. We also looked at heart failure and protection against progression of end-stage renal disease. We’ve heard a lot about lipids, blood pressure, and the multiple factors that make the person with diabetes a person who’s at increased risk.
Thank you all for your contributions—Chris, Peter, Seth, and Melissa. This has been a very valuable program. On behalf of our panel, we thank you all for joining us, and we hope that you found this Peer Exchange® discussion to be useful and informative.
Transcript edited for clarity.