Diabetes & The Heart: An Individualized Risk-Reduction Program

While the connection between diabetes and heart disease has been known for more than 40 years, there’s been little guidance on how to care for people who have both conditions until recently.

Miami Cardiac & Vascular Institute is responding to the need for a more comprehensive approach to this patient population with the launch of its Cardiometabolic Disorder and Prevention program in 2021.

Jonathan Fialkow, M.D., deputy medical director, chief of cardiology at Miami Cardiac & Vascular Institute and chief population health officer for Baptist Health South Florida.

“This will be a coordinated, individualized approach to patients at risk for, or with cardiovascular conditions, who will benefit from a more holistic and complete approach to their risk reduction,” said Jonathan Fialkow, M.D., deputy medical director, chief of cardiology at Miami Cardiac & Vascular Institute and chief population health officer for Baptist Health South Florida.

Dr. Fialkow sat down with the Resource news team to explain the link between diabetes and heart disease. In his words: “It’s more than the sugar.”

Q: How strong is the link between diabetes and cardiovascular disease?

Dr. Fialkow: “Diabetes and pre-diabetes, a metabolic disorder that precedes true diabetes diagnosis, are both significant risk factors for cardiovascular disease illnesses and death.”

Q: Can you give us an idea of the size of the impact these diseases have on our healthcare system?

Dr. Fialkow: “Diabetics are two- to four-times more likely to suffer heart disease, stroke and death. Nearly 70% of people over 65 who have diabetes die from some form of heart disease, including heart attacks and heart failure, and 16% die of stroke. Billions of dollars are spent on treating the consequences of this poorly controlled disease.”

Q: When we think of treating diabetes, we think of controlling blood sugar. Does a person’s blood sugar influence their risk of developing heart disease?

Dr. Fialkow: “Diabetics often have other metabolic disturbances such as hypertension, dyslipidmia, (a condition involving abnormal cholesterol particles and elevated triglycerides), obesity, obstructive sleep apnea, fatty liver disease and more. Adding up of all these metabolic disturbances contributes to the high rates of cardiovascular disease and death in a diabetic.

“If we just concentrate on glucose control and ignore all these other components, we have not shown that we have been able to decrease cardiac illness and death in diabetics. It’s more than the sugar.”

Q: What does the term cardiometabolic disorder mean?

Dr. Fialkow: “This is now the term we use for the metabolic conditions that lead to cardiovascular disease and death including heart attacks, heart failure and strokes. The same conditions also lead to kidney disease and an increased risk to need dialysis. It is not a single condition, like hypertension. The metabolic disturbances have been well-recognized and assessments and treatments are now available that are proven to decrease cardiovascular illness and death.”  

Q: Can you explain how medications originally designed for other purposes, such as lowering blood sugar, also provide benefits to heart health?

Dr. Fialkow: “Cardiometabolic Disorder has many components. As a medication is developed to treat one component, not infrequently we find a benefit related to a different component.”

Q: What role can these medications play in prevention of cardiovascular disease in diabetic patients? Is their use limited to those with diabetes?

Dr. Fialkow: “Many of the new, relatively safe therapies originally developed for diabetics to lower blood sugar are being shown to decrease cardiovascular death, heart failure and heart attacks and are also shown to decrease renal failure and hospitalizations. We are now seeing benefits in patients who are at high risk for cardiac conditions and not diabetic, again, showing the multiple pathways that metabolic conditions lead to disability and death.

“It should be noted that it is believed that less than 10% of diabetics are currently receiving treatment for all of the conditions that lead to cardiovascular disease and death.”

Q: Patients with high blood pressure or high triglycerides may have no bothersome symptoms. How do you get someone who feels well to say, “Oh, I understand. And I will take this medication that may cost me money, or might have side effects?”

Dr. Fialkow: “The entire concept of ‘prevention’ is assessing someone when they feel well to see if there is any evidence of something going on that can lead to something bad in the future that is preventable.

“First, we have to identify the patients with markers of high cardiovascular risk, like high blood pressure, high triglycerides, low HDL cholesterol, obstructive sleep apnea, etc. Even things like abdominal obesity, low testosterone, fatty liver disease, mild kidney dysfunction and more are markers of increased risk. Then, we make a good assessment of what may be contributing to these in the person’s medical status and lifestyle. An individualized treatment plan which includes diet, exercise, sleep pattern assessments and recommendations is necessary, followed by medications that have been shown to prevent the bad outcomes.

“Ultimately there is data that diabetes can be avoided and even reversed and medications for other conditions can be discontinued with proper dietary considerations.”

Q: What is the role of the Miami Cardiac & Vascular Institute Cardiometabolic Disorder and Prevention program?

Dr. Fialkow: “There are many community-focused education and support programs, all of great value, but not reaching many people who will benefit.

“Miami Cardiac & Vascular Institute is one of five founder members of a national Cardiometabolic Center Alliance where we will be participating in creating national standards of care for this condition, sharing best practices with other large Centers and consolidating our data as we learn more about this important condition. We expect to lead in educating our community and medical providers on the importance of recognizing this condition and its components and intervening early to avoid bad cardiac outcomes.”

Q: What are the benefits of this approach to the community?

Dr. Fialkow: “Many people who have Cardiometabolic disease or are on their way to developing this condition are either unaware of it or too busy to have it taken care of. Many patients and doctors focus on one element and don’t have the time for full education, assessment and treatment. The program will provide an organized way for the patient to have these components addressed, using in-office visits and telemedicine visits in full support of the primary care doctors and other specialists in the community. Similar programs are showing the impact of getting people treated appropriately and avoiding bad medical outcomes.”