Reducing cardiovascular risk in diabetes
Old friends, colleagues and compatriots, Professors Stefano del Prato and Antonio Ceriello join forces once again to examine the current state of play in the perennial struggle against cardiovascular disease in people with diabetes.
For time immemorial, the inter-relationship of heart disease and diabetes has been the object of determined clinical effort and the subject of vigorous debate. In 1979, the American Heart Association even went so far as to define diabetes as a cardiovascular disease (CVD).
Of course, things have moved on considerably since 1979. But despite all the efforts made over these years - including the project initiated by the Steno study, to systematically set about reducing all the individual CVD risk factors – CVD remains a huge problem for people with diabetes. Indeed, as Stefano del Prato and Antonio Ceriello remind us in their presentation for the latest installment of ‘The long and the short of it’, even today as many as 80% of people with diabetes die from cardiovascular events.
These bleak statistics apply to both type 1 and 2 diabetes, as Antonio is careful to emphasise. We need, he insists, to attend to cardiovascular risk in type 1 diabetes, not just type 2. After all, the cluster of risk factors underpinning the pathogenesis of CVD in diabetes – hyperglycaemia, hypertension, dyslipidaemia, propensity to thrombosis - are to be found in both conditions.
Nowadays, though, new classes of drugs present us with new opportunities for preventing CVD – in particular the GLP-1 receptor agonists and the SGLT-2 inhibitors. Again, Antonio insists type 1 diabetes should be included in our consideration of these advances. His personal belief, as he describes it, is that the benefits for preventing cardiovascular events in people with type 2 diabetes will also be seen in people with type 1.
The problem this presentation identifies lies not with what’s in our toolkit but our readiness to use it. In brief, the true culprit is clinical inertia. In Antonio’s opinion, these drugs are not being given early enough to maximise their potential for reducing cardiovascular risk. Rather than waiting to exhaust other treatments or for patients with diabetes to present with actual cardiovascular events, they need to be prescribed much more widely and at a much earlier stage in an individual’s diabetes journey. “I’m not saying everyone with diabetes,” says Antonio, “but I honestly believe a huge number of people stand to benefit from the early use of these two compounds.”
This is a sometimes provocative and always thought-provoking discussion, which makes along the way some fascinating observations about recent international guidelines, the value of combination therapy, the relationship between micro- and macrovascular complications, and a wider discussion on the definitions of secondary and primary prevention commonly used in this area.
For more on the topics raised in this presentation, why not enroll on the following EASD e-Learning courses:
Watch out for our new ‘Therapeutic inertia’ module, launching later this year.