The lack of recognition of the cardiometabolic syndrome has led to a failure of clinicians in looking at metabolic variables in heart disease as opposed to just “aggressive” statin lowering. An example of this is when one of my surgical colleagues, a 67-year-old non-smoker African-American male of above average physical condition and shape had chest pain and had a CABG x4 as well as a carotid endarterectomy. Triglycerides were 90 mg/dL, LDL was 86 mg/dL and HDL was 48 mg/ dL. His coronary angiogram demonstrated at least 8 separate 90% stenotic lesions. He had a strong family history of cardiovascular disease. When he returned back to work, I was shocked to find out he was prescribed 10 mg of atorvastatin because his cholesterol was “fine”. That was the dose that he had prior to his cardiac event! As a friend, I took control and I called the cardiac surgeon. I asked if his heart appeared to be a diabetic or inflammatory type of heart and he said definitely yes. As a matter of fact, he commented over the past 10 years the bypass surgical cases were becoming more complex as there were less discrete lesions and a lot more inflammatory type lesions. I ordered a 2-hour glucose tolerance test which revealed a 2-hour of 108 mg/ dL with an average insulin response. His advanced lipid testing was significant for considerably reduced large HDL. Because of this, I started my friend on rosuvastatin 40 mg as obviously he did require a high intensity statin, icosapent ethyl 2 g twice daily as per the data from the REDUCE-IT trial, and pioglitazone 30 mg based on the IRIS trial18. There was no recognition of the metabolic state by his internist, cardiologist, vascular surgeon, cardiac surgeon or the hospital team taking care of him. Unfortunately, this is the rule rather than the exception. Prior to his diagnosis of advanced atherosclerosis, he was on atorvastatin 10 which was his discharge dose! Obviously, no one thought of changing a variable to prevent it from happening again.
I see 25-30 patients daily and I try to keep my focus simple–change variables to improve outcomes. Like most physicians, I use EMR and barely have time to take a deep breath. However, as Jack Nicholson said in the movie A Few Good Men “…you need me on that wall…protecting you. I have a greater responsibility”. I feel I must be constantly vigilant in my role as a physician and coordinator of my patients’ care. I am wary of the cardiologist who ignores metabolic issues in cardiovascular risk reduction, as well as the endocrinologist whose main focus is glucose lowering ignoring the metabolic issues related to insulin resistance and cardiovascular disease. Cardiometabolic issues involve not only lipids and diabetes but exercise, obesity, nutrition, brain health, inflammation, kidney disease, and even cancer. This list I am sure is not complete. Treating variables is easy but recognizing which ones to change is the difficult task. As Robert Eckel19 told me “…the more we learn the more we realize what we do not know! “. Never lose focus and never stop learning as patient lives are in our hands.
