Diabetologists and cardiologists are joining forces to address the issue of cardiovascular disease in patients with diabetes.
In North America, new joint guidelines from the American Heart Association (AHA) and the American Diabetes Association (ADA) focus on the primary prevention of cardiovascular disease in patients with diabetes (Circulation 2007;115:114–26; Diabetes Care 2007;30:162–72).
“People with … diabetes are at increased risk for [cardiovascular disease] and have worse outcomes after surviving a CVD event,” wrote coauthor Dr. John Buse, director of the diabetes care center at the University of North Carolina at Chapel Hill, and his colleagues.
And in Europe, the European Association for the Study of Diabetes (EASD) and the European Society of Cardiology (ESC) have issued guidelines on diabetes, prediabetes and cardiovascular diseases (Eur. Heart J. 2007;28:88–136).
Although both the North American and European documents recognize the importance of harmonizing the approaches of cardiologists and diabetologists, they both also focus on specific and different aspects of the diabetes-cardiovascular disease dyad, making them potentially complementary documents. In both documents, special attention is placed on the early stages of disease development, but the European document focuses on the role of prediabetes in early cardiovascular dysfunction, whereas the North American document emphasizes primary prevention of cardiovascular disease in patients with overt diabetes.
The importance of the ADA/AHA document is not so much its content, but rather its existence, suggested Dr. Daniel Einhorn, medical director of the Scripps Whittier Institute for Diabetes, an endocrinologist at the University of California, San Diego, and a spokesperson for the American Association of Clinical Endocrinologists (AACE). “What is new here is that these two organizations are agreeing to a joint statement on primary prevention of cardiovascular disease in diabetes.”
Cooperation between the ADA and AHA is, for both organizations, a hurdle crossed after some much publicized disagreement last year, acknowledged Dr. Buse in an interview. “This paper was an effort to get together and hammer out where the common ground is in the few areas where there were fairly nuanced differences in approach.”
The main issue of contention between the ADA and AHA has been the debate over whether or not metabolic syndrome exists. In the joint statement, they have agreed to disagree: “The AHA and the [National Heart, Lung, and Blood Institute] have issued a statement on management of the metabolic syndrome and maintain that with regard to risk for CVD, the metabolic syndrome and type 2 diabetes can coexist in one person. The ADA, in contrast, contends that once type 2 diabetes is present, the metabolic syndrome no longer pertains because CVD risk factors characteristic of the metabolic syndrome are largely subsumed in the type 2 diabetes syndrome,” they wrote.
Dr. Einhorn said that even with some opposing viewpoints, a single set of guidelines shared by cardiologists and endocrinologists serves not only to clarify clinical practice, but to justify a preventive approach.
“It is important for people in managed care environments to have some validation that it is important to do testing, to prescribe medications, and to follow up on these patients from a cardiovascular standpoint, even when they don't have any known cardiovascular disease yet. It offers some impetus in large medical group settings,” he said.
It was an effort to hammer out the common ground in the few areas in which there were fairly nuanced differences. DR. BUSE
More Aggressive Tactics Recommended
The new joint ADA/AHA guidelines “encourage more aggressive prevention and treatment of risk factors that lead to heart disease” in people with diabetes, according to a press release from the two organizations. “Patients with diabetes have twice the risk of incident myocardial infarction and stroke as that of the general population,” they say. “Furthermore, large numbers of people with diabetes do not survive their first event, and if they do survive, their [mortality] over the subsequent months to years is generally greater than that of the general population. As many as 80% of patients with type 2 diabetes will develop and possibly die of macrovascular disease.”
While continuing to encourage lifestyle changes—such as weight loss, improved nutrition, and physical activity—the joint statement also emphasizes the importance of medical interventions to manage lipids, blood pressure, and blood glucose in this population. The full text of the guidelines can be viewed at