Cardiovascular Risk Management in Patients With Diabetes - Episode 7
Unmet needs in the management of coronary artery disease and peripheral artery disease, and advice for working with patients and other healthcare professionals to optimize care for patients at high risk for cardiovascular disease.
Manesh R. Patel, MD: In the management of CAD/PAD, there are so many unmet needs still unfortunately. Think about this for peripheral artery disease, we all know that if the left main artery, the main artery to your heart or the lAD and the circumflex disease or the right coronary three vessel disease is present, you do worse. In the peripheral artery system, we do not even have a scoring system we've agreed upon for future limb loss. So just even anatomic criteria that we agree upon and the management of that, is just a first step. But the biggest areas of unmet need, I think for both drug development and patient care is verifiable patient reported outcomes that we can measure in our patients with PAD. And for our CAD/PAD patients, finding ways where we can get proven therapies to them in consistent fashion. So even though it sounds simple, adherence is one of the hardest things we must solve and getting our patients' cholesterol numbers down, getting them chronically on antithrombotic therapy that they can tolerate without bleeding and getting them to get their blood pressure down. Whether it is with drugs or device therapy, are all going to be critical for the future of what we do for our patients of cardiovascular disease. And if we have learned anything from the pandemic, we have learned that we have to all work to bend the curve for cardiovascular disease just as we did with the pandemic, because last year and the year before more people died from cardiovascular disease than almost anything else. And for last year in the pandemic, more people died from cardiovascular disease than even with COVID. It's significant opportunity to improve our patient's health, probably by getting innovative therapies at high adherence to our patients.
You know, I find that as we go through medicine, we continue to potentially relearn things or learn new things that have been done. But one of the reasons I think all of us are in the healthcare field, is to get the joy of having people feel better and live longer, healthier lives. In fact, our biggest challenge now is to find ways to improve the health of our population in an equitable fashion around the world. And the only way to really do that is to get people more engaged in their own health and that does require, in our little episodic ways, in which we care for our patients, thinking about ways to take care of their entire health and finding out what matters to them. And that is some of the fun- most fun things we do. I start a lot of my clinic visits by asking my patients, what do they do on most of their days, what is the average day that- what gives them fun, what is limiting them, how do we make them feel better. In fact, Dr. Caleb was a mentor of mine once in the CIC at Duke taught me that we should only do things for patients that make them live longer, feel better or avoid unpleasant events, and things like being in the hospital or feeling like you can walk or do more of your activities. And really treating the whole patient's health through that lens has helped me throughout my career because I find that when people get to do things that improve their quality of life, they enjoy it and come back to see us and say, hey, thanks, I was able to do this, or I was able to stay on this therapy and be healthier longer. Now, part of prevention or even treating people after we've intervened on them, the hardest part is getting them to recognize that the risk is still high and that taking these therapies reduces their future risk. I would suggest that treating the whole patient is really the only way to have a meaningful and fun long-term career in medicine.
Marc P. Bonaca, MD, MPH: I think many clinicians that see patients with diabetes, patients with atherosclerotic vascular disease or patients with a combination of both, there is a struggle now because there’s so many different therapeutic options and we have a short period of time with our patients. Prevention is challenging because patients do not feel that and what you're trying to prevent like heart attack and stroke, they don’t know that they're not having those events. They’re taking therapy for prevention. I think it is difficult. And there are also a lot of crossovers now between specialties. For example, we have targeted diabetes therapies like the SGLT2 inhibitors, which have benefits in multiple populations that aren’t related to their glucose-lowering ability but are targeted therapies, things like GLP-1s, lipid-lowering, and so on. I think the biggest problem we face is clinical inertia and in some ways paralysis because there’s so many different clinicians in the mix and we’re all thinking about different things. And the patient is already taking a lot of drugs. So how do we improve the provision of care. I think this is the core area where multidisciplinary care teams are really necessary to align on identification of patients at high risk, and systematic adoption of proven therapies to reduce risk. It can’t be sort of willy-nilly in the clinic, today I had enough time to think about it because then we end up with big gaps in care. We know from population data sets that there are a lot of patients, particularly PAD patients that are under-treated that aren’t even getting statins. So multidisciplinary care teams allow us to think about a patient in a holistic fashion. A patient is not a PAD patient or a CAD patient or a diabetes patient. They’re your patient and they have all of those risk factors that you need to manage and then you need to manage that not only hierarchy of risks but then hierarchy of therapies and what provides the broadest, most important net benefit for that patient that you're seeing. And I think a multidisciplinary care approach enables you to think about those patients in a very holistic way. Now that alone may not be enough to really improve the provision of care and I think that implementation science and systems of care guided by multidisciplinary care teams that enable the systems to look at patients broadly across a population, identify high risk, and then you use algorithms to introduce therapies that have broad benefits with the support of pharmacists, nurses, a care team approach can do a much better job at improving the provision of care than a single clinician. And I say that personally because I know many times a patient walks out of my office and they’re probably not on optimal therapy because we didn’t have time, because there are payor issues, because of other things. And it’s very difficult as an individual patient/clinician combination to always get it right. And I think multidisciplinary care models and enhanced systems of care are necessary to really care for these complex patients.
Manesh R. Patel, MD: When I'm taking care of patients with my colleagues in a team-based format, one of the biggest things I enjoy is being able to have the back and forth sort of relationship with the patients and my colleagues as we take care of that patient. For my vascular surgical colleagues, one of the things I enjoy the most about is their innovative ways of getting blood flow to the limb. And often our interaction of learning how to better treat all their arteries. I say this all the time to my patients that I can fix a pothole with a stent, my surgical colleagues can put a bypass around the problem, but we really need therapies that treat all the highway. And so, working with my vascular surgery colleagues or my cardiology colleagues, we often think about systemic therapies for diseases that are chronic and systemic like cardiovascular disease. With my podiatry colleagues, I really appreciate their attention to detail and wound healing, and in identifying patients that have reduced blood flow in their limbs. And understanding that even if we work to get more blood flow to them, then it's not just more blood flow, but chronic antithrombotic therapy, chronic lipid lowering therapy and chronic control of diabetes that will lead to better outcomes for your patients' limbs, toes and obviously all the things that many of us want our patients to stay mobile without morbidity or mortality.
Transcript Edited for Clarity