Complications of Diabetes Mellitus

AHA 2019: Specialists Talk Diabetes and Multi-Organ Dysfunction

PHILADELPHIA—A panel of 5 experts gave compelling presentations of the latest research and advancements in diabetes and multi-organ disease at the American Heart Association (AHA) 2019 Scientific Sessions.

Moderated by Mercedes Carnethon, PhD, vice chair and chief of Epidemiology in the Department of Preventive Medicine at Northwestern University’s Feinberg School of Medicine, the session consisted of talks on diabetes and comorbid atherosclerotic cardiovascular disease (ASCVD), heart failure (HF), chronic kidney disease (CKD), peripheral artery disease (PAD), and more.

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ASCVD Risk in Diabetes

In his presentation, “Diabetes and ASCVD: How and How Much?” cardiologist Peter Wilson, MD, professor of medicine and director of Epidemiology and Genomic Medicine at Emory School of Medicine, reviewed risk factors for CVD in diabetes.

Dr Wilson began by noting that CVD risk in patients with diabetes is 2- to 3-fold compared with those without diabetes. Patients with type 2 diabetes tend to experience cardiometabolic risk factors, including hypertriglyceridemia; low high-density lipoprotein cholesterol (HDL-C); small, dense low-density lipoprotein cholesterol; hypertension; insulin resistance; central obesity; family history of atherosclerosis, and cigarette smoking, he explained. In patients with type 1 diabetes, risk factors for future CVD often include glucose-related complications.

Lipid extremes are common in the context of diabetes, Dr Wilson said. Low HDL-C, high or moderately high triglycerides, or a combination of these are common and tend to be worse in women, often leading to CVD.

He reminded attendees that patients often pass through “the side door” and develop diabetes before developing CVD, underscoring the importance of assessing for type 2 diabetes risk factors in addition to CVD risk factors.

A target of less than 130/80 mm Hg is appropriate for blood pressure control in diabetes, in accordance with 2017 guidelines from the AHA and American College of Cardiology, said Dr Wilson. He also noted the importance of various pharmacologic therapies in patients with diabetes, including angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers for renin-angiotensin-aldosterone system blockade, calcium channel blockers, appropriate diuretics for renal protection.

Prevention of Multi-Organ Dysfunction in Diabetes

Neha Pagidipati, MD, cardiologist and assistant professor of medicine at Duke University School of Medicine, discussed the prevention of multi-organ dysfunction in patients with diabetes. During her talk, she overviewed evidence for the role of various interventions in preventing microvascular and macrovascular complications of diabetes, as well as mortality.

Notable interventions with evidence to support their role in diabetes management included exercise, which is especially beneficial for macrovascular disease, and ACE inhibitors and ARBs, particularly in patients with hypertension, she said.

Although it is not clear whether metformin use offers a cardiovascular benefit, it has a known mortality benefit, Dr Pagidipati said. Sodium glucose co-transporter 2 (SGLT2) inhibitors have clear ASCVD, HF, renal, and mortality benefits, she added.

Dr Pagidipati concluded her talk by naming interventions that are underused in diabetes, including:

  • Bariatric surgery (less than 1% of eligible US patients)
  • Statin therapy (75% of eligible US patients, of whom half receive the recommended statin intensity)
  • ACE inhibitors and ARBs (80% of eligible US patients)
  • SGLT2 inhibitors (5.2% of eligible US patients)
  • Glucagon-like peptide-1 receptor agonists (6.0% of eligible US patients)


Next Page: Clinical Manifestations of HF in Diabetes, and More

Clinical Manifestations of HF in Diabetes

Cardiologist Eldrin Lewis, MD, associate physician at Brigham and Women’s Hospital and associate professor of medicine at Harvard Medical School, began his talk with the overlapping epidemiology of diabetes and HF. HF is one of the most impactful complication of diabetes, and the prevalence of both conditions are increasing in the United States, he said.

Diabetes and HF share several comorbidities, Dr Lewis explained, including hypertension, coronary artery disease/myocardial infarction, PAD, stroke, CKD, obesity, inflammation, and dyslipidemia.

A number of signs and symptoms also overlap in diabetes and HF, including cardiorenal interactions, cardiohepatic abnormalities, coagulopathy, fatigue, peripheral edema, pleural effusions, and holosystolic murmur, among others.

Several studies, including the Framingham Heart Study, Cardiovascular Health Study, Heart and Soul, Multi-Ethnic Study of Atherosclerosis, and National Health and Nutrition Examination Survey, have shown that diabetes is a key predictor of HF. Dr Lewis discussed the pathophysiology from diabetes to HF, which begins with hyperglycemia, insulin resistance, and hyperinsulinemia in diabetes and often progresses all the way down to ischemic cardiomyopathy or diabetic cardiomyopathy prior to HF.

Dr Lewis reminded attendees that the optimal management of diabetes and concomitant CVD, “takes a village,” requiring a multidisciplinary team of endocrinologists/diabetologists, cardiologists, nephrologists, registered dietitian nutritionists, and primary care clinicians.

Appropriate hemoglobin A1c targets often vary in this patient population based on a patient’s clinical/functional status, capacity for self-management, social support, medication costs and adverse effects, treatment burden, and hypoglycemia risks, he noted.

Dr Lewis concluded his session with several key takeaways, including:

  • Diabetes and HF often coexist and increase health risks in patients with both conditions.
  • Diabetes treatments may have variable effects on risk of developing HF.
  • HF should be a part of the primary endpoint in clinical trials, because it often is not, despite data showing that the mortality rate from HF as a complication of diabetes is high.
  • Further research is needed to determine the impact of glucose-lowering therapy in patients with established HF.
  • A multidisciplinary approach is an important part of improving outcomes in patients with diabetes and HF.
     

Pathophysiology and Presentation of CKD in Diabetes

Nephrologist Jennie Lin, MD, discussed diabetic kidney disease, the pathophysiology and presentation of CKD in patients with diabetes, and promising agents for slowing kidney disease progression in this patient population. Click here to read our coverage of her talk.

Diabetes and PAD

Internist Mary McDermott, MD, discussed the impact of diabetes in patients with PAD, associated health risks, and appropriate management and treatment options in this patient population. Click here to read our coverage of her talk.

—Christina Vogt

References:

  1. Wilson P. Diabetes and ASCVD: how and how much? Presented at: American Heart Association 2019 Scientific Sessions; November 16-18, 2019; Philadelphia, PA.
  2. Pagidipati N. How to prevent multi-organ dysfunction in diabetes? Presented at: American Heart Association 2019 Scientific Sessions; November 16-18, 2019; Philadelphia, PA.
  3. Lewis E. Diabetes and clinical manifestations of heart failure. Presented at: American Heart Association 2019 Scientific Sessions; November 16-18, 2019; Philadelphia, PA.
  4. Lin J. Diabetes and chronic kidney disease: pathophysiology and presentation. Presented at: American Heart Association 2019 Scientific Sessions; November 16-18, 2019; Philadelphia, PA.
  5. McDermott MM. Diabetes and peripheral arterial disease. Presented at: American Heart Association 2019 Scientific Sessions; November 16-18, 2019; Philadelphia, PA.