Fitfab.Club recently spoke to endocrinologist Dr Ben Ng and cardiologist Dr Nandakumar Ramasami from Arden Cardio Metabolic Clinic to learn more about why it makes sense to treat diabetes and heart disease together rather than separately.
Q: What is the likelihood of diabetes patients also suffering from heart disease, hypertension and high cholesterol?
Dr Ben Ng: There is a very strong relationship between heart disease and diabetes. People who have diabetes have a two to four-fold increased risk of developing heart disease and stroke whilst almost 70% of people with diabetes will inevitably suffer from some form of heart disease.
Dr Nandakumar Ramasami: Approximately 25% of patients referred for a coronary angiogram (an X-ray to see if arteries are clear or blocked) have diabetes and conversely 75% of those with diabetes will have underlying heart disease. In fact, two-thirds of those with diabetes have hypertension. In diabetes there is also a characteristic increase in bad cholesterol (LDL and triglycerides) and lower level of good cholesterol (HDL). Since the changes in these three components are characteristic of diabetes they are called the “diabetic triad”.
Q: What is the current mode of treatment for patients with (a) heart disease who also have diabetes?
Dr Nanda: Diabetic heart disease (DHD) refers to heart disease that develops in people who have diabetes. Compared with non-diabetics, diabetics are at higher risk for heart disease, tend to have additional risk factors, develop heart disease at a younger age, and have more severe heart disease. In addition, those with DHD respond less favourably to treatments such as stents (coronary angioplasty) and bypass surgery compared to non-diabetics.
In 2017, 30% of the total number of deaths in Singapore was due to cardiovascular disease and of these, 18.5% was due to coronary heart disease and 6.3 % due to stroke.
The current mode of therapy for diabetic heart disease is no different to those who do not have diabetes. However the emphasis is on the control of blood sugar, as poorly controlled hyperglycemia causes damage to the various organs in diabetes. It is therefore very important to know your numbers ie “A, B, C” (where A = HbA1c, the blood test showing the three-month average for blood glucose , B = blood pressure and C = cholesterol)
Multiple risk factors usually co-exist in the same patient – i.e., poor lifestyle and stress with a familial/ genetic predisposition is the common bond leading to many metabolic disorders such as abdominal obesity, fatty liver, hypertension, diabetes and raised lipids. Therapy should therefore be directed at these risk factors which are multiplicative. Moderate elevation of multiple risk factors in fact can be more dangerous than a single elevated risk factor.
Q: What are patients’ challenges in managing their heart disease and diabetes?
Dr Ng: The essential problem is that both conditions are chronic and have varying degrees of complexity. Very often, the advice and treatment recommended by both the heart specialist and diabetes specialist may differ slightly, and patients essentially get confused as to which treatment is the best and whether medications prescribed by one doctor can interact with medication prescribed by the other and/or with other supplements and medications that they may be taking.
Dr Nanda: In earlier stages of diabetes there are no symptoms and therefore diabetes may go untreated or under-treated as patients feel well. By the time symptoms start to manifest, the organs are usually damaged and this is usually irreversible.
Also heart disease symptoms may be masked and are sometimes atypical, resulting in missed treatment such as timely intervention for a heart attack – which can be debilitating to the patient.
As with any chronic disease, making lifestyle changes and adhering to them may be quite challenging for some patients. Patients can go through periods of despondency with poor or non-compliance to therapy which has to be sensitively managed.
There may also be periods of increased stress related to external socio-economic factors which may worsen the control of diabetes and progression of heart disease.
Q: What are specialists’ challenges in helping their patients with heart disease and diabetes?
Dr Ng: Currently, the treatment of diabetes and heart disease in a patient can be complicated. Very often, patients require several different kinds of medication to keep blood sugars under control and also to treat blood pressure and cholesterol. Parallel to this, both lifestyle and dietary changes are recommended in a bid to improve patient’s health. The main challenge that many patients face is to integrate all this information together.
For instance, very often, patients with diabetes would be encouraged to exercise more regularly and to reduce the overall sugar intake. However, in contrast, patients who have heart disease may be asked to restrict the amount physical activity they can do (particularly following a recent heart attack) as well as foods which may be low in sugar are high in fat and cholesterol. This makes things very often confusing for patients as they may receive forms of advice from different doctors who are dealing with different parts of the body and different diseases.
It is therefore essential that a holistic approach is employed for patients with heart disease and diabetes. The specialists involved in the care have to meet up to discuss the best treatment and intervention for each individual patient. They have to ensure that the correct lifestyle intervention and recommendations are given to the patient and to ensure that all medications prescribed are correct and do not have any interactions which may be detrimental for the health of the patient.
Dr Ng: Arden Cardio Metabolic Clinic’s integrative model ensures that investigations of the patient’s condition are tailored to the cardio-metabolic syndrome as a whole as the effects produced by these related diseases are closely interlinked. In diabetes,
the core underlying factor is the abnormal levels of glucose, leading to the poor function of cells especially the vasculature which affects both small and large blood vessels. The effects of damage on small vessels are seen in the eyes and kidneys for instance, whereas larger vessels would include the brain, limbs and heart etc.
In the integrated model, all screening for the various organs are performed in the clinic along with blood tests, urinalysis and other tests. This one-stop approach makes it more convenient for the patient and enhances compliance to regular screening in the long term. This is followed by a combined assessment by the endocrinologist, cardiologist and nephrologist working together to form a single integrated care plan that aims to achieve the best possible therapeutic goal for the patient as a single entity.