Cardiodiabetes – is a joint approach the way forward?

Br J Cardiol 2008;15(Suppl 2):S8-S10 Leave a comment
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Sponsorship Statement: Merck Sharp & Dohme Limited and Schering-Plough Limited sponsored the faculty and discussants to attend the Cardiodiabetes Forum, and also the medical writing and publication of the supplement. Editorial input and control remains entirely with the faculty and The British Journal of Cardiology.

Diabetes is a known, independent, risk factor for cardiovascular disease and since diabetes and serious cardiovascular disease are frequently observed together, the term ‘cardiodiabetes’ is increasingly applied to describe the convergence of these conditions.

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The European Society of Cardiology – European Association for the Study of Diabetes (ESC-EASD) Task Force guidelines of 2007 acknowledge the inter-relationship between diabetes and cardiovascular disease and call for an early, multidisciplinary approach to the recognition and intensive management of all cardiodiabetes risk factors.1 The evidence that diabetes is a key factor in cardiovascular disease is also highlighted by the National Institute for Health and Clinical Excellence (NICE) clinical guidelines on lipid modification and type 2 diabetes, which recommend treatment of serum lipids in patients with type 2 diabetes mellitus and those with established cardiovascular disease (CVD).2,3

‘Prevention of cardiovascular disease must focus equally on patients with established atherosclerotic disease and on people with diabetes’

Traditionally, cardiologists and diabetologists have played parallel roles in managing cardiovascular risks in their patient populations. The emergence of cardiodiabetes as a term poses a number of questions with implications for optimal and effective, collaborative management of patients in the UK.

The Group set out to summarise current consensus on the appropriateness of the term cardiodiabetes, and to consider the practicalities, in the UK, of adopting a revised approach to patient care that successfully bridges specialist disciplinary divides while supporting healthcare for the individual based in primary care.

Is the term cardiodiabetes really meaningful?

A number of terms are used to describe the convergence of cardiovascular disease and type 2 diabetes in a patient. While there is an increasingly prevalent view that diabetes should be viewed from the outset as a vascular disease, the consensus view of the Group was that use of hybrid terms to acknowledge the concurrent diseases and risks at play is useful for both clinicians and for patients.

The term cardiodiabetes was preferred by the Group over the word ‘cardiobetes’, which was considered too truncated a term. In recognition that many patients with diabetes and cardiovascular disease may be obese, ‘cardiodiabesity’ was suggested as an appropriate catch-all term. Further, the high risk for renal complications in patients with convergent diabetes and cardiovascular disease led to the suggestion of ‘cardiorenaldiabetes’ as another descriptor.

“The term ‘cardiodiabetes’ is a useful reminder for clinicians to assess multiple risk factors’

Table 1. Cardiodiabetes – what’s in a name?
Table 1. Cardiodiabetes – what’s in a name?

The term of cardiodiabetes was viewed as most useful for clinicians (table 1), serving to remind diabetologists of the need to assess blood pressure and lipid parameters in addition to weight and glucose management, and similarly serving to prompt cardiologists to consider diabetes-related risk factors in patient assessment and management. For patients too, the combined term is meaningful, and the addition of the ‘cardio’ prefix to diabetes adds impact to the overall descriptor.

‘Physicians must communicate and collaborate to combine the best of specialist experience with primary care expertise’

The rising tide of global obesity was recognised by the Group to be a major driver of diabetes and a contributor to the burden of cardiovascular disease. While the term metabolic syndrome is useful for prompting consideration of the aetiology of a host of risk factors that may collectively increase a patient’s cardiovascular risk profile,4 the Group considered that this term has a different application to the term cardiodiabetes. The metabolic syndrome may be more useful when considering prevention of the continuum from obesity through diabetes to cardiovascular disease, whereas the term cardiodiabetes is more applicable to the particular spectrum of cardiovascular disease, plus more diffuse peripheral vascular and renal disease, that is associated with diabetes.

The practicalities of collaborative management of two separate risks

Cardiodiabetes is a useful term to describe a particular group of patients but leads to the question of who should manage such patients – one particular speciality, or a care team in which the primary care physician plays the key role?

The Group felt that diabetologists, cardiologists, lipidologists and renal physicians all have experience and knowledge that must be included and shared as part of patient management. Diverse approaches to patient management which span both primary and secondary care are employed currently in the UK. A patient may be seen by both diabetes and cardiology specialists (arguably with some duplication of assessments, advice and consultation costs) or, more rarely, may be seen at joint specialist clinics run at hospital centres, or may be managed through Primary Care Trust (PCT) one-stop clinics.

Supporting primary care

There is no single model for the provision of care services to patients who fit the cardiodiabetes description and no real consensus on whether the care of such patients needs the creation of a cardiodiabetes specialist or specialist team. Rather than developing a new speciality, more could be done to encourage experience sharing between specialities, and to support GPs with a special interest (GPwSI) in diabetes and cardiovascular disease.

Communication and experience sharing are also essential to prevent hospitals becoming the place of last resort in disease management and to ensure that patients have early and appropriate access to clinical expertise that could affect the direction of disease management and, ultimately, prognosis and outcome.

While there is scope for more hospital-based joint-clinic management of cardiodiabetes, the Group considered that current healthcare policy and commissioning of services place the GP in a key position as a major point of patient care.

Balancing national drives with patient care can present dilemmas. Quality and Outcomes Framework (QOF) programmes encourage GPs to manage chronic diseases, such as diabetes, to specific set targets. QOF initiatives, although highly laudable, work to surrogate end points and pre-set targets do not always deliver the optimal treatment goal for a given patient. Taking too rigid an approach to patient care can mean that aspects of a patient’s total risk profile and clinical needs are overlooked. Studies such as the United Kingdom Prospective Diabetes Study (UKPDS) and the Anglo-Scandinavian Cardiac Outcomes Trial (ASCOT) provide the evidence and support the view that treatment strategies to reduce diabetes and cardiovascular disease should be based on assessment of all risk factors, rather than based only on numerical thresholds for individual risk factors.5,6,7

The evidence for aggressive management of the multiple risk factors associated with CVD and diabetes is summarised in the form of existing practice guidelines such as those of the JBS 28 and ESC-EASD.1 GPs should be encouraged by the clinical evidence and by guidelines to aim for higher rates of patient control for glycaemia, blood pressure and lipid targets. Local specialist champions in diabetes and cardiovascular disease can play an educational and skill-support role in helping GPs to work to targets appropriate to a patient’s overall risk profile.

There may be scope for creation of multidisciplinary teams with a focus on cardiodiabetes, particularly for the referral of cases that require specialist appraisal, treatment or care services.

Collaborative care: the barriers

Issues over infrastructure can affect the optimal management of one-stop clinics at hospital and primary care level. Time, efficiency and resource limitations are affected as much by politics and policy as by clinical factors or a disease label. In addition, some specialists have professional resistance to being drawn into primary care and away from hospital-based practice.

On the positive side, one-stop clinics in the community, where a specialist physician together with a team of nurses provide protocol-based evaluations and management, can streamline the process of patient review and can work well if the attending specialist and the primary care team have opportunities to communicate and share case experiences. On the negative side, such clinics run the risk of offering too rigid an approach to patient assessments and may fail to tap into the wider range of clinical expertise and services that can be offered at specialist centres.

The Group agreed that communication is key to breaking down barriers that prevent collaborative approaches to patient care.

The clinical evidence – cardiovascular risk factors in patients with diabetes

Clinical evidence that patients with diabetes have multiple risk factors for cardiovascular disease is undeniable (a full review of the evidence is outside the scope of this report). Current practice guidelines from the Joint British Societies identify the risk faced by patients with diabetes and provide a framework for managing those risks in order to improve patient outlook.8

Patients are increasingly interested in understanding their disease. The Group recommended that they should be encouraged to know the nature and the levels of their modifiable risk factors and the targets set for reducing these risks.

‘GPs are key to the delivery of cardiodiabetes patient care and more support should be given to those with a special interest in diabetes and cardiovascular disease’

More still needs to be done to promote public health messages based on known cardiovascular risk factors. Campaigns to encourage healthy lifestyles and to discourage obesity are the responsibility of government but can be supported by physicians and their professional societies. At a more localised level, a combined approach to managing diabetes and cardiovascular disease risk factors offers a way forward in reducing cardiovascular events and deaths.

Conclusions

Cardiodiabetes acknowledges the inter-relationship between diabetes and cardiovascular disease and the term creates a meaningful label for both physicians and patients. It also denotes a need to consider risk factors beyond glycaemic control and weight management. Collaborative care must be offered to cardiodiabetes patients, founded on clinical evidence and drawing on both specialist expertise and primary care skills. Communication and experience exchange are key elements for its success.

Discussion

Q: Would the Group advocate an ‘umbrella’ speciality to deal with cardiodiabetes?

A: We debated this at length. While there is some justification for taking a single-stop approach to patient care, we believe that specialist knowledge still has a key place in ensuring that patients are referred for particular expert investigations and consultations. We think that common approaches across the specialities, taking heed of guidelines such as those provided by NICE and JBS 2, are the way to ensure optimal patient care.

Q: There is no doubt that different specialities are already influenced by an awareness of the need to think beyond their own disciplines when managing patients with diabetes. How do you see the role of GPs?

A: Today’s GP has a key role in the day-to-day management of the patient and in helping with disease prevention. We consider a good GP with a well-trained team to be essential. The Primary Care Cardiovascular Society is going from strength to strength and good GPs can help to keep patients out of hospital. What we need to facilitate are means of ensuring that the hospital and specialists do not become the last resort but that they add value to community-based care and can identify and deal with complex cases.

References

  1. Ryden L, Standl E, Bartnik M et al. Guidelines on diabetes, pre-diabetes, and cardiovascular diseases: executive summary. The Task Force on Diabetes and Cardiovascular Diseases of the European Society of Cardiology (ESC) and of the European Association for the Study of Diabetes (EASD). Eur Heart J 2007;28:88–136.
  2. National Institute for Health and Clinical Excellence. Clinical Guideline 67. Lipid Modification. Cardiovascular risk assessment and the modification of blood lipids for the primary and secondary prevention of cardiovascular disease. May 2008.
  3. National Institute for Health and Clinical Excellence. Clinical Guideline 66. Type 2 diabetes. May 2008.
  4. Grundy SM, Brewer HB, Cleeman JI et al. Definition of metabolic syndrome: report of the National Heart, Lung and Blood Institute/American Heart Association Conference on scientific issues related to definition. Circulation 2004;109:433–8.
  5. Stratton I, Adler A, Neil HA et al. Association of glycaemia with macrovascular and microvascular complications of type 2 diabetes (UKPDS 35): prospective observational study on behalf of the UK Prospective Diabetes Study Group. BMJ 2000;321:405-12.
  6. Sever PS. Lipid-lowering therapy and the patient with multiple risk factors: what have we learned from the Anglo-Scandinavian Cardiac Outcomes Trial (ASCOT)? Am J Med 2005;118(Suppl 12A):3–9.
  7. Sever PS, Poulter NR, Dahlof B et al. Reduction in cardiovascular events with atorvastatin in 2,532 patients with type 2 diabetes: Anglo-Scandinavian Cardiac Outcomes Trial–lipid-lowering arm (ASCOT-LLA). Diabetes Care 2005;28:1151–7.
  8. JBS 2: Joint British Societies’ guidelines on prevention of cardiovascular disease in clinical practice. Heart 2005;91(Suppl V):v1–v52.
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