Cardiometabolic Chronicle

LIFE IN THE TRENCHES: A Clinical Perspective On Cardiometabolics

I work in the trenches. I am not an academic physician, I do not do research, and I spend all my time in patient care. I am an internist in a busy office as part of an outpatient setting of a large hospital network. My father2 and mentor, an internist and keen diagnostician, made my focus in approaching each patient very easy. He said “whenever you see a patient, narrow down your approach to one question. What variable can you change that will improve the quality or length of his/her life?” He also said, “Be careful, every 7 years, half of what you know will change… However, you do not know which half”.

This led me to the study of cardiometabolics. I realized that unfortunately many patients were being treated as if time stood still in medicine. Cardiologist were treating cholesterol, endocrinologist were treating sugars, and exercise was “going for a walk”. Lipid issues were treated with the advice, “watch your diet” and many patients were told “be careful you have borderline diabetes”. Unfortunately, death rates, though modestly improved, were still unacceptably high. High-profile people were getting ill and dying with traditional care. Tim Russert’s death at 58 years old of a myocardial infarction with an LDL less than 70 mg/dL and a normal stress test 6 weeks earlier is a prime example, as well as Bill Clinton’s bypass and subsequent stenting 2 years later. Both of these men had metabolic issues which should have initiated a full cardiometabolic work-up today.

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REFERENCES:

References:

  1. John C Sciales, MD – Internal Medicine – New York Presbyterian Medical Group Queens NY
  2. William J. Sciales MD 1930-2016, SUNY Downstate 1956, Internist: Flushing, NY
  3. Holman, Rury R., et al. “10-year follow-up of intensive glucose control in type 2 diabetes.” New England Journal of Medicine 359.15 (2008): 1577-1589.
  4. Action to Control Cardiovascular Risk in Diabetes Study Group. “Effects of intensive glucose lowering in type 2 diabetes.” New England Journal of Medicine 358.24 (2008): 2545-2559.
  5. ADVANCE Collaborative Group. “Intensive blood glucose control and vascular outcomes in patients with type 2 diabetes.” New England Journal of Medicine 358.24 (2008): 2560-2572.
  6. Duckworth, William, et al. “Glucose control and vascular complications in veterans with type 2 diabetes.” New England Journal of Medicine 360.2 (2009): 129-139.
  7. Kosiborod, Mikhail, et al. “Lower risk of heart failure and death in patients initiated on sodium-glucose cotransporter-2 inhibitors versus other glucose-lowering drugs: the CVD-REAL study (comparative effectiveness of cardiovascular outcomes in new users of sodium-glucose cotransporter-2 inhibitors).” Circulation 136.3 (2017): 249-259.
  8. Zinman, Bernard, et al. “Empagliflozin, cardiovascular outcomes, and mortality in type 2 diabetes.” New England Journal of Medicine 373.22 (2015): 2117-2128.
  9. Neal, Bruce, et al. “Canagliflozin and cardiovascular and renal events in type 2 diabetes.” New England Journal of Medicine 377.7 (2017): 644-657
  10. Wiviott, Stephen D., et al. “Dapagliflozin and cardiovascular outcomes in type 2 diabetes.” New England Journal of Medicine 380.4 (2019): 347-357.
  11. Marso, Steven P., et al. “Liraglutide and cardiovascular outcomes in type 2 diabetes.” New England Journal of Medicine 375.4 (2016): 311-322.
  12. Marso, Steven P., et al. “Semaglutide and cardiovascular outcomes in patients with type 2 diabetes.” New England Journal of Medicine 375.19 (2016): 1834-1844.
  13. Cannon, Christopher P., et al. “Ezetimibe added to statin therapy after acute coronary syndromes.” New England Journal of Medicine 372.25 (2015): 2387-2397.
  14. Bhatt, Deepak L., et al. “Cardiovascular risk reduction with icosapent ethyl for hypertriglyceridemia.” New England Journal of Medicine 380.1 (2019): 11-22.
  15. DeFronzo, Ralph A. “Bromocriptine: a sympatholytic, D2-dopamine agonist for the treatment of type 2 diabetes.” Diabetes Care 34.4 (2011): 789-794.
  16. Jesús, M., et al. “Real incidence of diabetes mellitus in a coronary disease population.” The American Journal of Cardiology 111.3 (2013): 333-338.
  17. Ramos, Joyce S., et al. “Low-volume high-intensity interval training is sufficient to ameliorate the severity of metabolic syndrome.” Metabolic Syndrome and Related Disorders 15.7 (2017): 319-328.
  18. Kernan, Walter N., et al. “Pioglitazone after ischemic stroke or transient ischemic attack.” New England Journal of Medicine 374.14 (2016): 1321-1331.
  19. Robert H.Eckel MD, Univ of Colorado Charles A. Bottcher II Endowed Chair Of Atherosclerosis, Past President of American Heart Association and President Elect of The American Diabetic Association
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