Diabetic Care Held Up at Stop Signs on the Prevention Highway

The following article was written by Dr. Alaa Diab as a CardioNerds Conference Scholar for The American Society for Preventive Cardiology 2022 Congress on Cardiovascular Disease Prevention.

Type 2 diabetes mellitus is becoming more prevalent in the United States, with an estimate of 37.3 million Americans living with diabetes according to the 2020 CDC statistics. What’s worrisome about this data? Adults with diabetes are at a greater risk of developing cardiovascular disease (CVD) with rates 2 to 4 times higher than in adults without diabetes.1 In addition patients with diabetes have a 1.8 to 6-fold greater risk of stroke.2 Given the increasing prevalence of diabetes and its inherent CVD risks, we must ask: how are we managing diabetes to prevent CVD, and most importantly how to eliminate disparities in diabetes care?

The STENO-2 study enrolled 160 patients with type 2 diabetes with signs of kidney disease (microalbuminuria) in Denmark and randomly assigned them to either receiving intensive therapy (i.e., tight glucose regulation with the use of renin–angiotensin system blockers, aspirin, and lipid-lowering agents) or conventional diabetic therapy.3 The primary endpoint was time to death from any cause and secondary end points were death from CVD causes and CVD comorbidities, such as stoke and myocardial infarction.

Over a mean follow-up of 13.3 years, 24 patients (30%) in the intensive therapy group died in comparison to 40 patients (50%) in the conventional therapy group, meaning that there was an absolute risk reduction of 20% (P=0.02).3 Intensive therapy was associated with a lower risk of death from cardiovascular causes (hazard ratio, 0.43; 95% CI, 0.19 to 0.94; P=0.04) and of cardiovascular events (hazard ratio, 0.41; 95% CI, 0.25 to 0.67; P<0.001).3 Nowadays, there are more potent drugs for managing diabetes towards CVD prevention, such as the SGLT2-Inhibitors and GLP1-Receptor Agonists.

Erin Michos, MD, MHS Associate Professor of Medicine and Epidemiology in the Department of Medicine and Director of Women’s Cardiovascular Health at the Johns Hopkins School of Medicine highlighted the importance of eliminating disparities in diabetes care at the ASPC 2022. “Disparities exist in their utilization by race, ethnicity, and socioeconomic status, may contribute to worse morbidity and mortality in these populations” said Dr. Michos. “Addressing such disparities will require a multipronged approach; we must address Social Determinants of Health, optimize self-management by free diabetes classes, remove barriers for new therapies by eliminating prior authorizations for diabetic patients, and educate the underrepresented populations on the risk of complications” she added.

 

Diabetic care is being held up at the stop signs on the prevention highway. The road to reducing diabetes-associated CVD morbidity, mortality, and health inequalities is clear if we stand together with a multifaceted systems approach to address known barriers.

References:

  1. Raghavan S, Vassy JL, Ho YL, et al. Diabetes Mellitus-Related All-Cause and Cardiovascular Mortality in a National Cohort of Adults. J Am Heart Assoc. 2019;8(4):e011295. doi:10.1161/JAHA.118.011295
  2. Goldstein LB, Bushnell CD, Adams RJ, et al. Guidelines for the primary prevention of stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association [published correction appears in Stroke. 2011 Feb;42(2):e26]. Stroke. 2011;42(2):517-584. doi:10.1161/STR.0b013e3181fcb238
  3. Gaede P, Lund-Andersen H, Parving HH, Pedersen O. Effect of a multifactorial intervention on mortality in type 2 diabetes. N Engl J Med. 2008;358(6):580-591. doi:10.1056/NEJMoa0706245