Peer Review: A New Partnership Examines the Links Between Cardiovascular Disease and Diabetes

By joining with the American Academy of Family Physicians, the American Association of Nurse Practitioners, and the American Academy of Physician Assistants, the Endocrine Society has created an educational coalition to address the challenges of treating patients with both type 2 diabetes and cardiovascular disease.

Together with the American Academy of Family Physicians (AAFP), the American Association of Nurse Practitioners (AANP), and the American Academy of Physician Assistants (AAPA), the Endocrine Society was honored to participate in the interprofessional education program, “Current and Future State of Cardiovascular Disease and Type 2 Diabetes.”

The program envisioned bringing voices together from different clinician trainings and backgrounds to discuss the intimate connections between cardiovascular disease and type 2 diabetes. Surveys have shown that professional societies are the most trusted sources of information for members, who prefer to learn from their peers on how to best apply the science to their specific clinical practice. To enhance learning, the curriculum included multiple interactive case studies developed with the primary care provided treating patients with diabetes in mind.

This educational effort focused on cardiovascular disease (CVD) as the leading cause of death and a major cause of morbidity and mortality for people living with type 2 diabetes. A survey by the American Heart Association and the American Diabetes Association showed that only half of people aged 45 year and older with type 2 diabetes recognize their increased CVD risk or have discussed their risk with a healthcare provider.

Primary care providers, who manage most patients with diabetes, are treating a growing number of patients with established cardiovascular disease. Recent cardiovascular outcomes trials (CVOTs) have demonstrated the cardio-protective effects of new antidiabetic therapies, which create the need for clinicians to consider cardiovascular outcomes data, in addition to achieving glycemic targets, when choosing therapies.

The intersection between these two complicated diseases and their complementary treatment goals makes coordination of care to reduce cardiovascular risk even more important. This complexity also supports the importance of a team-based approach, including all healthcare professionals, to manage the elevated CVD risk in this patient population. Bringing this four-pronged team together, we utilized a variety of training scenarios to review available management approaches to treat patients with diabetes, including stage-specific recommendations for lifestyle, medications, and weight loss surgery.

A survey by the American Heart Association and the American Diabetes Association showed that only half of people aged 45 year and older with type 2 diabetes recognize their increased CVD risk or have discussed their risk with a healthcare provider.

Three open-access, free educational programs were created to follow the progression of cardiovascular disease from early/pre-diabetes to advancing/progressive disease to late stage/managing advanced complications. All three cases can be found at the Resource Center, which includes links to accredited programs for endocrinologists, family physicians, nurse practitioners, and physician assistants, with individually provided links from each association for more education.

The case-based scenarios are outlined below with learning objects discussed throughout. Faculty will you walk you through the cases with interactive panels throughout for a robust discussion.

Case 1: Prediabetes and Cardiovascular Risks: A Primary Call to Action

Meet Lisa, a 31-year-old Hispanic female presenting for her annual exam. She was diagnosed with gestational diabetes seven years ago and both parents have obesity and type 2 diabetes. She had a 12-pound weight gain over the past year and is currently not on any medications. Lisa’s A1C is 6.0% with elevated triglycerides and HDL-C at 234 mg/dL and 31 mg/dL, respectively. She works the overnight shift as a deputy sheriff with excessive soda and takeout consumption but little time for exercise with her two young children.

Join the faculty as they address their collaborative treatment recommendations and lifestyle modifications through the learning objectives below:

• Discuss the epidemiology of prediabetes and diabetes.
• Review risk factors, screening tools and diagnostic criteria for prediabetes and diabetes.
• Describe the pathophysiology and complications of prediabetes.
• Analyze the relationship between prediabetes and cardiovascular disease.
• Develop and implement screening strategies for a patient presenting with prediabetes.
• Formulate an evidence-based treatment plan for patients with prediabetes including lifestyle and pharmacologic interventions.

Case 2: Patient-Centered Management of Diabetes and Prevention of Cardiovascular Disease

Meet Les, a 67-year-old Black male with type 2 diabetes for 12 years in addition to hyperlipidemia, hypertension, and early-stage chronic kidney disease (CKD). He does not always refill his five medications on time and has a high deductible. He frequently dines out and exercise includes golf games where he usually consumes five to six beers.

Join the faculty as they discuss cardiovascular outcome trials (CVOTs) and a team approach to strengthening diabetes self-management through the learning objective below:

• Discuss prevalence and associations of diabetes, cardiovascular disorders (CVD), and diabetic kidney disease (DKD).
• Recognize diabetes as a CVD equivalent and accelerator.
• Review behavioral interventions for mitigating CVD and DKD risk in type 2 diabetes.
• Distinguish major drug classes and outcomes from cardiovascular outcome trials (CVOTs) related to impacts on glycemic control, CVD, and DKD risk reduction in type 2 diabetes.
• Develop clinical strategies using CVOT drug classes to optimize glycemic goals and reduce CVD and DKD risk for patients with type 2 diabetes.
• Implement a team approach to diabetes care encouraging patient-centered diabetes self-management skills, education, and support (DSMES).

Surveys have shown that professional societies are the most trusted sources of information for members, who prefer to learn from their peers on how to best apply the science to their specific clinical practice. To enhance learning, the curriculum included multiple interactive case studies developed with the primary care provided treating patients with diabetes in mind.

Case 3: Managing Macrovascular Complications In Patients with Diabetes

Meet Tony, a 62-year-old white male with diabetes, multivessel coronary artery disease (CAD), DKD with an eGFR of 38 mL/min/1.73m², and Charcot Arthropathy. His A1C is 9.1% with fluctuating pre-prandial blood glucose, LDL is 104 mg/dL, and albumin creatinine ratio (ARC) is 447 mg/gram. Tony has a fair diet and no history of smoking or excessive drinking. However, he has poor medication adherence.

Join the faulty as they discuss macrovascular complications, hypoglycemic prevention and treatment, and increase adherence along with cultural competencies through the learning objectives below:

• Review major risk factors for coronary artery disease, diabetic kidney disease and heart failure in patients with type 2 diabetes.
• Summarize the associations of type 2 diabetes, CVD and DKD, and implications to the progression of cardiorenal syndrome (CRS) and CV mortality.
• Apply CVOT results to provide guidance on appropriate pharmacologic interventions for patients with advanced diabetes related complications.
• Analyze the impact of hypoglycemia in patients with advanced coronary artery disease and discuss techniques for mitigating risk of hypoglycemia.
• Employ tools and techniques to improve adherence and long-term chronic disease outcomes.

We thank the participation of the primary care and specialty organizations in content development, which enabled us to create clinically relevant content for our target audiences, resulting in better cardiovascular risk management for patients with diabetes.

All content can be found on the collaborative Resource Center.

Purnell, professor of medicine at Oregon Health & Science University in Portland, served as chair of the “Current and Future State of Cardiovascular Disease and Type 2 Diabetes” program. Joining him were Angela Thompson, DNP, FNP-C, BC-ADM, CDE, FAANP, Hendricks Endocrinology and Diabetes Youth Foundation of Indiana; Jeffery Unger, MD, FAAFP, FACE, of Unger Primary Care Concierge Medical Group and Catalina Research Institute; and Jonathan Weber, MA, PA-C, FAAPA, of the Yale School of Medicine Physician Associate Program.