The Link Between Diabetes and Coronary Artery Disease

Aug 18, 2023

The Link Between Diabetes and Coronary Artery Disease

In December 2021, Get With The Guidelines®-Coronary Artery Disease (GWTG-CAD) enhanced data collection and monitoring of care for patients with diabetes. Learn about the science behind these changes, and to take a closer look at the link between diabetes and coronary artery disease. The webinar will feature distinguished speaker Tracy Yu-Ping Wang, MD, MHS, MSc, FAHA, FACC, Professor of Medicine in Cardiology at Duke University.

Content

5.1 -> - [Renee] On behalf of the American Heart Association

7.22 -> and Know Diabetes by Heart,

9.34 -> I would like to welcome you to today's webinar,

11.94 -> Know Diabetes by Heart Presents,

13.88 -> The Link Between Diabetes and Coronary Artery Disease.

17.69 -> My name is Renee Sednew and I am

19.67 -> a Program Development Manager

21.68 -> for Quality Outcomes Research and Analytics

23.96 -> at the American Heart Association.

26.29 -> I'm joined by my AHA Research

29.01 -> and Analytics Colleague, Jeanne Rash.

33.56 -> Before we begin, I would like to quickly review

35.89 -> how to use this webinar platform for today's event.

39.18 -> If you'd like a copy of today's presentation,

41.47 -> you can download a PDF in the Handout section

44.69 -> of your attendee control panel.

48.67 -> If you experience any technical difficulties,

51.48 -> most issues can be resolved by refreshing your browser.

55.36 -> If that does not work, please contact

57.56 -> the GoTo Webinar customer service team,

60.26 -> found in your confirmation and reminder e-mail.

63.82 -> If you require live closed captioning services during

67.85 -> the webinar, please visit the link in the audience chat

72.28 -> and you view on the chat, from your control panel,

74.98 -> you may need to click the down arrow to see the content.

83.96 -> At the conclusion of today's presentation,

86.13 -> you will receive a link to access the recording,

89.15 -> as well as an invitation to complete our feedback survey.

93.13 -> You will have an opportunity to submit text questions

96.76 -> to today's presenters in the question section

99.56 -> and you can submit these questions at any time,

102.15 -> and we will review them during the Q&A

103.84 -> at the end of the presentation as time permits.

106.77 -> We will also answer any questions by text

109.15 -> that we can during the presentation.

113.79 -> We will begin today's program with a brief overview

116.42 -> of the Know Diabetes by Heart initiative

118.98 -> and the Target Type 2 Diabetes Recognition program.

123.43 -> Then we will welcome guest speaker

124.98 -> Dr. Tracy Wang for her presentation,

127.6 -> Diabetes and Cardiovascular Disease, Making an Impact.

131.71 -> We'll then take some time to review the recent changes,

134.81 -> to get what the guidelines,

136.36 -> Coronary Artery Disease, CAD Data Elements

139.61 -> and Reports related to diabetes care.

143.15 -> As a reminder, these changes were made in December of 2021

148.04 -> and reviewed during a webinar held

150.97 -> on December 1 and distributed via,

154.15 -> the Get With the Guidelines CAD Release Notes

157.05 -> also in December and we have a link

159.77 -> to that recording in the slide deck as well

162.55 -> and feel free to contact your local

165.06 -> Get With The Guidelines representative or myself,

168.59 -> my contact information [email protected]

173.18 -> is in your confirmation e-mail, if you have any questions.

177.27 -> Finally, we'll end with the Q&A.

183.18 -> So, an overview for today, I think many of you know,

187.44 -> part of this call, cardiovascular disease

189.67 -> is the leading cause of death

191.62 -> and a major cause of heart attacks, strokes and disability,

195 -> for people living with type 2 diabetes.

197.76 -> The American Heart Association

199.23 -> and the American Diabetes Association,

201.77 -> along with industry leaders have proudly launched

205.18 -> the groundbreaking collaborative initiative,

207.84 -> known as Know Diabetes by Heart,

210.81 -> to reduce cardiovascular disease, deaths,

213.32 -> heart attacks and strokes for those living with diabetes.

217.83 -> The Know Diabetes by Heart initiative supports

220.71 -> quality improvement efforts by engaging directly

223.31 -> with hospitals and outpatient clinics

225.96 -> to provide long term support to their teams

228.72 -> of professionals as they redesign healthcare

230.93 -> to better serve patients with,

233.5 -> both diabetes and cardiovascular disease.

238.46 -> AHA's Target Type 2 Diabetes Honor Roll

242.33 -> is a component of this broader initiative

244.34 -> that aims to ensure that parents with type 2 diabetes,

247.72 -> receive the most up-to-date evidence-based care.

252.64 -> To bring attention to this critical high-risk population,

256.52 -> American heart Association has established

258.7 -> the Target Type 2 Diabetes Honor Roll

261.22 -> recognition opportunity currently available

264.32 -> for hospital participants

266.48 -> of Get With The Guidelines Heart Failure

268.259 -> and Get With The Guidelines Stroke.

271.8 -> Hospitals that meet specific measure thresholds

274.71 -> may be eligible for recognition

276.48 -> in the Target Type 2 Diabetes Honor Roll,

279.92 -> alongside their existing awards.

283.58 -> To learn more about this program,

285 -> we encourage you to visit our

286.86 -> Target Type 2 Diabetes Honor Roll website,

289.83 -> shown at the bottom right hand of this slide,

293.74 -> where you can also view additional resources.

297.25 -> As well as we encourage you

298.42 -> to visit knowdiabetesbyheart.org

301.27 -> for past webinars, podcasts, latest guidelines and more.

307.97 -> It is now my pleasure to introduce

310.43 -> our distinguished speaker Tracy Wang.

317.19 -> Dr. Wang is a professor of Medicine

319.39 -> and Cardiology at Duke University.

324.81 -> She received her MD from Harvard Medical School

327.82 -> and also holds a Master of Science degree

330.73 -> in Molecular Biochemistry, Biophysics from Yale University

334.89 -> and an MHS degree in Clinical Research from Duke University.

340.23 -> Dr. Wang is a Health Services Researcher

342.5 -> with expertise in implementation science

344.78 -> and pragmatic clinical trials.

347.1 -> She has led several cardiovascular clinical trials

350.289 -> and registries at the Duke Clinical research Institute

354.12 -> that have focused on comparative effectiveness

356.29 -> and safety, health disparities,

358.46 -> care quality assessment and quality improvement.

361.96 -> Dr. Wang currently chairs the Council Operations Committee

364.95 -> at the American Heart Association,

367.19 -> and served as the chair of AHA's Quality of Care

369.92 -> and Outcomes Research Council from 2017 to 2019,

374.55 -> as well as many taskforce committees,

377.04 -> and writing groups for the American Heart Association,

380.34 -> American College of Cardiology,

382.28 -> and American College of Physicians.

384.98 -> Most recently, she served on the Steering Committee

387.97 -> for the AHA's COVID-19 Cardiovascular Disease Registry.

392.97 -> She is an Associate Editor

394.71 -> of the JAMA Internal Medicine Journal,

397.05 -> and is the Director of Health Services and Outcome Research

400.24 -> at the Duke Clinical Research Institute.

403.48 -> Lastly, she actively practices as a non-invasive cardiology

407.73 -> with both inpatient and outpatient responsibilities.

411.21 -> Welcome Dr. Wang, it's such a pleasure

413.59 -> to have you, the floor is yours.

416.8 -> - Thank you so very much, Renee.

418.88 -> I hope you guys can all hear me well.

421.37 -> I'm going to speak for the next 40 or so minutes

425.631 -> on the topic of diabetes in cardiovascular disease.

429.45 -> And let's get started, let's go to the next slide.

433.97 -> All right, some disclosures.

435.8 -> First, I do have research grants both from industry

439.41 -> as well as foundational and governmental sources.

443.21 -> And I do a little bit of consulting as well

445.12 -> as you can see on the slide here.

447.88 -> I usually like to start my talk with a bit of a case.

450.94 -> So this may sound familiar to you as you're taking care

454.82 -> of patients or looking at medical charts.

457.58 -> This is very similar to a patient that I saw,

461.56 -> just rounding on services last week.

466.19 -> So this is a 76-year-old gentleman.

468.67 -> He comes in with chest discomfort, shortness of breath

472.47 -> and was ultimately diagnosed with a non ST elevation MI.

476.87 -> He has a history of type two diabetes,

479.69 -> he has hypertension, he lives alone,

482.28 -> and he also had a bout of pancreatitis not too long ago.

486.4 -> When he came into the hospital his medications

489.06 -> included Metformin, ramipril,

492.03 -> hydrochlorothiazide and atorvastatin.

495.8 -> And on exam on first admission,

498.42 -> he was noted to be obese with a BMI of 30.

502.07 -> Slightly hypertensive, not atypical for someone presenting

505.51 -> with a non STEMI, pulse was 72.

509.27 -> And during his hospitalization,

511.24 -> here are some labs, he's got an EGFR 69.

515.08 -> He's got an A1C of 8.6%, an LDL of 122,

519.717 -> and a triglyceride of 124 and with his non STEMI,

524.1 -> he underwent a cardiac catheterization

527.25 -> and was noted to have a mid LAD lesion

529.9 -> that was treated with a drug eluting stent.

532.49 -> His EF did take a little hit from this

534.88 -> and it was 40% at the end of his hospitalization.

539.59 -> So this is the type of patient that

541.99 -> we're confronted with quite frequently, I would say,

545.08 -> patients with diabetes probably make up

547.6 -> at least a third if not half of the patients

551.61 -> that we see in hospital with an acute MI.

556.21 -> So let's talk about the prevalence of diabetes.

559.02 -> Unfortunately, it is on the rise.

561.48 -> As you can see, this is a timeline starting

564.45 -> from the 1950s when we started to sample households,

568.59 -> to look at the prevalence of diabetes

572.16 -> and then going all the way, this slide is a little old now,

574.79 -> but it goes all the way to 2006

576.897 -> and we have not seen this curve plateau out.

580.49 -> In fact, if anything else, it looks like it's continuing

583.13 -> to climb at a higher rate than

586.13 -> in the early days of the survey.

589.44 -> In part this is because we've got an aging US population

593.07 -> and in part I think many people know this,

595.03 -> but we've got a growing number of overweight

597.66 -> and physically inactive individuals,

600.23 -> that are all contributing to the higher prevalence

602.98 -> of diabetes in our society here.

607.06 -> Unfortunately, a diagnosis of diabetes

611.1 -> is kind of like the tip of the iceberg here,

613.31 -> because we know that it does take several years

615.49 -> in onset and some folks think of that stage

618.3 -> as a pre-diabetic stage before a diagnosis

624.05 -> can often be made late and sometimes

626.51 -> as many of you know, diagnosis of diabetes

628.8 -> are made or hospitalizations that are often

632.03 -> the result of complications of diabetes like an MRI.

636.4 -> But even before diagnosis many of the micro

639.5 -> and macrovascular complications as you can see

641.77 -> on the slide have already started.

644.21 -> So one of the key things here

646.403 -> with diabetes is early diagnosis,

650.07 -> so that we can implement healthy lifestyle changes,

653.9 -> as well as medication changes if needed to try to stave off

658.66 -> the complications related to diabetes.

663.27 -> Because once patients develop diabetes,

666.85 -> unfortunately, the risks climb to much higher levels.

671.97 -> So this is a graphic looking at the risk

675.46 -> of cardiovascular deaths, so this is typically deaths

678.58 -> from either sudden cardiac death,

681.53 -> or MI or a stroke or heart failure

684.33 -> or other cardiovascular reasons and what you see here

689.14 -> is our clusters of bars on the bottom.

692.83 -> And you can see that CHD, CVD mortality,

696.47 -> really track in the same way.

699.2 -> I want you to focus on the yellow bars,

701.42 -> the yellow bars are those who are patients with diabetes.

705.96 -> And then you focus on the blue bar,

708.68 -> those light blue bar at the end and those are the patients

712.5 -> who have what I call the double whammy.

715.01 -> They have diabetes and cardiovascular disease,

717.54 -> you see this group of patients,

718.88 -> they're more likely to die than if they had the red bar,

722.327 -> which is just cardiovascular disease alone,

725.664 -> but certainly having diabetes puts patients

729.47 -> at much higher risk of cardiovascular death

732.9 -> than the green bars which are patients who are healthy

736.01 -> with neither cardiovascular disease, nor diabetes,

739.82 -> or any risk factors such as metabolic syndrome

742.979 -> that could predispose to these.

746.21 -> So when we're talking about a very hard outcome

749.91 -> like cardiovascular disease we know that the risk

752.79 -> is much higher in patients with diabetes.

755.77 -> You combine that with cardiovascular disease,

758.57 -> and it really skyrockets here.

760.79 -> So this is a very important risk factor

764.09 -> to think about modifying here.

768.44 -> When we look at distribution of mortality causes

772.8 -> in patients with type two diabetes we see that about half

777.01 -> of these patients die a cardiovascular death.

780.12 -> So it does make up a significant contribution

784.17 -> to mortality in this population.

788.01 -> And then on the right hand side of the slide,

790.16 -> what you see is a breakdown of cardiovascular death.

793.33 -> And you find that the scary ones, sudden cardiac death,

797.18 -> makes up a good chunk of that.

799.401 -> And then the ones that might be more treatable

802.22 -> if we catch them in time, like acute MI,

804.84 -> stroke and heart failure, probably make up about

807.95 -> a third of these cardiovascular deaths.

811.81 -> And then there's another bucket of deaths

813.68 -> that are sort of a miscellaneous group of patients here.

817.68 -> So this is a group again,

819.91 -> emphasizing high cardiovascular risk

822.36 -> and these are data from the TICO's trial

824.41 -> that are shown here on the slide.

829.05 -> The duration of diabetes makes the difference.

832 -> So this is the Nurses Health Study,

834.33 -> which looked at women aged 30 to 55

837.4 -> and followed them for 20 years,

839.6 -> is a large population of women.

841.993 -> And on the very right hand side of this slide,

845.16 -> I'm gonna have you pay one attention

847.03 -> to those two bars that I've circled in red here.

850.787 -> That light gray bar on the right hand side,

854.7 -> these are patients with diabetes,

856.9 -> but who never had heart coronary artery disease before,

862.15 -> but they've had diabetes for 15 plus years

865.92 -> and you compare that to the dark gray bar

868.63 -> on the left side of this slide,

870.01 -> these are patients without diabetes,

872.73 -> but who have cardiovascular disease,

874.55 -> you see that the heights of these columns

877.06 -> are quite similar, which basically says,

880.11 -> even in the absence of coronary artery disease,

884.42 -> if you have diabetes for 15 plus years,

887.536 -> you're basically at the same risk

890.57 -> of someone who doesn't have diabetes

893.44 -> but has coronary artery disease.

895.59 -> And now if you compare that to the last column

898.08 -> on the right, you can see that if you combine these,

900.8 -> so long duration of diabetes plus heart disease,

904.92 -> then your relative risk of fatal cardiovascular disease

909.77 -> is 30%, pretty high here.

915.82 -> Here's another slide related to life expectancy

919.48 -> with diabetes that's referenced to patients

921.79 -> without diabetes, that's the very last row.

924.95 -> But as you can see just by having diabetes doubles,

928.73 -> you're at risk of having lower life expectancy,

932.55 -> you add a cardiovascular disease condition to that,

936.18 -> that doubles it again to about four-fold hazard ratio here.

941.02 -> And then if you've got diabetes stroke,

943.62 -> and have had a heart attack,

945.36 -> you've now increased your risk seven-fold.

948.53 -> So the amount of life to be expected in patients

953.5 -> with diabetes is in fact much shorter,

956 -> which is also the reason why we need to be very intensive

960.392 -> with our prevention efforts for these patients.

966.36 -> Okay, so risk of MI in patients with diabetes,

970.61 -> and it really doesn't matter if you are a man or a woman,

977.47 -> if you have diabetes, you go into the top two curves,

980.98 -> which means your risk of MI is higher

985.5 -> with diabetes regardless of gender or sex,

991.3 -> than if you did not have diabetes, okay?

994.33 -> so diabetes is a factor that's independent of gender.

999.34 -> And then if you look comparing men versus women,

1002.68 -> currently, we do see that men are at higher risk

1006.22 -> of MI in an age matched fashion than women,

1010.968 -> regardless of diabetes status as well.

1013.75 -> So the absolute risk of MI is higher

1016.76 -> in people with diabetes and in an aged match fashion

1021.29 -> is slightly higher for men than for women.

1026.16 -> And there are of course a number of reasons

1028.47 -> why diabetes can lead to coronary disease.

1032.87 -> In part, there's a proclivity towards thrombosis.

1036.72 -> In part, there are lots of risk factors

1038.83 -> that make the diagnosis worse, so dyslipidemia,

1043.09 -> insulin resistance, hyperglycemia.

1046.32 -> And then there are physiologic changes to the blood vessels

1052.01 -> to the cells that also predispose

1055.54 -> to progression of atherosclerotic disease here,

1058.15 -> so increased inflammatory markers

1060.18 -> on the left hand side of the slide as well.

1062.77 -> So lots and lots of reasons for why diabetes,

1066.88 -> can lead to coronary disease and also,

1069.31 -> these are the targets of many of the novel therapies

1072.27 -> that we're thinking about to try

1074.02 -> to reduce risk in patients with diabetes.

1076.85 -> But first of all, trying to prevent diabetes

1079.81 -> would obviously be the most effective way

1083.27 -> to avoid all of those which is why in my patients

1087.4 -> who are mostly primary prevention,

1090.11 -> I'm often very strongly encouraging lifestyle changes

1094.24 -> and dietary changes to try to reduce

1096.83 -> the risk of diabetes at all.

1100.12 -> Now, you're probably seeing a lot of patients

1103.17 -> who are in the hospital with an acute MI.

1106.19 -> And it may be a new diagnosis of diabetes,

1110.59 -> or no prior diagnosis of diabetes,

1114.37 -> or an old diagnosis of diabetes.

1116.7 -> And this is a very nice prospective observational study

1121.36 -> that looks at the risk of subsequent events

1124.056 -> in these patients and clearly, the patients with diabetes,

1128.26 -> who've just had a heart attack do the worst,

1131.37 -> compared to those who have not had diabetes nor an MI.

1136.13 -> So you can see each of these factors,

1139 -> in and of themselves, add risk to prognosis here.

1143.76 -> So now we're dealing with this group of patients

1146.57 -> at the very lowest curve here where the risk

1149.68 -> is actually quite high for the remaining

1154.85 -> for developing another event.

1159.45 -> So on the inpatient side, in many ways,

1165.28 -> the patient is a captive audience

1168.27 -> but this is the time where we sort of try

1171.09 -> to get patients on the right track.

1172.98 -> So first is trying to come up with

1175.81 -> a diagnosis and detect it if it's there.

1178.72 -> So as I said, many patients can show up

1181.22 -> to their MI without knowing that they're a diabetic,

1184.07 -> the MI is there heralding event.

1186.9 -> And so in these patients, the recommendation is to think

1191.03 -> about doing an A1C measurement,

1194.3 -> if they've never been tested before,

1197.61 -> to help them understand how what their risks are.

1201.74 -> And then patients who already have a diagnosis of diabetes,

1204.84 -> if they've not had an A1C measured in the last three months,

1208.5 -> we wanna help them look at their glycemic control

1211.67 -> over the last three months to be able

1213.07 -> to counsel them on the next steps.

1216.57 -> In terms of intensity of in-hospital glycemic management,

1221.37 -> when someone's critically ill,

1223.53 -> so usually in the ICU setting this is where a lot of times

1226.55 -> I'm seeing a lot of these patients,

1228.92 -> we tend to be a little bit looser with our treatment goal,

1234 -> we're not aiming for perfect control,

1236.167 -> but we're aiming for good control.

1238.64 -> So we want blood sugars that are in the range of 140 to 180.

1243.41 -> And as they transition to the general wards,

1245.72 -> and are getting ready to hopefully approach discharge,

1249.33 -> we start tightening things up a little bit

1251.69 -> and trying to get them to a level that is tolerable,

1257.45 -> keeping in mind, though, that their diets

1260.49 -> in the hospital may be quite different

1263.21 -> from their diets outside of the hospital.

1265.59 -> So we do need to look at how well

1267.67 -> we can achieve these targets safely

1270.4 -> And this is also always a good time

1273.12 -> to evaluate patients lifestyle and provide counseling,

1277.88 -> if they don't have a habit of checking their blood sugar,

1281.85 -> we need to sort of inculcate that behavior into them.

1285.58 -> Remember, these patients are captive audiences

1287.67 -> in the hospital, they have nothing more to do

1290.44 -> than to listen to us nag them or teach them about things.

1294.01 -> So we try to leverage that and most of them

1297.57 -> are receptive to this, especially in the setting

1301.1 -> of an acute MI, this is the time where I think

1303.81 -> a lot of patients are very motivated to understand

1306.86 -> how they can avoid another MI or another hospitalization.

1313.78 -> This is a good time to be thinking

1315.5 -> about what medications they should be on.

1319.51 -> And there have been a number of large,

1322.5 -> randomized clinical trials that have compared ACE inhibitors

1327.52 -> to placebo in both the primary prevention setting,

1331.051 -> as well as the secondary prevention setting.

1334.58 -> And most of these show a survival

1339.53 -> or a cardiovascular benefit to ACE inhibitors over placebo.

1346.16 -> These days, a lot of that data has also been translated

1349.21 -> to ARB's, so for many of our patients,

1354.269 -> I consider ACE inhibitors or ARB's

1356.18 -> are an essential vitamin, particularly,

1359.24 -> in patients with diabetes, someone really needs

1361.43 -> to give me a strong reason,

1363.21 -> a strong contraindication to use,

1365.98 -> but most of my patients do leave the hospital

1368.92 -> with either an ACE inhibitor or an ARB,

1372.57 -> unless they're allergic or unless they have other reasons

1376.13 -> such as hyperkalemia or a very borderline renal dysfunction,

1383.61 -> that's hovering on end-stage renal disease,

1385.9 -> that makes me concerned about their safety

1388.33 -> of using these therapies outside of the hospital.

1392.22 -> This is generally one of those therapies I initiate

1394.48 -> pretty early as soon as they're hemodynamically stable.

1399.41 -> When we you look at beta blockers after acute MI

1402.69 -> and you divide the patients up into those

1405.483 -> with diabetes and those without diabetes,

1408.18 -> and it doesn't matter if they're diabetes

1409.88 -> are treated with insulin or not with insulin.

1414.72 -> This is a retrospective analysis but it's one of many,

1418.12 -> that seems to show a one-year benefit

1422 -> in mortality that might be associated with beta blocker use.

1427.43 -> And that certainly makes sense in someone

1429.5 -> who already has a diagnosis of diabetes.

1434.066 -> This study really didn't show much difference,

1436.16 -> there was no interaction P value that was significant

1440.74 -> between diabetes and no diabetes.

1443.24 -> But this is certainly something that we think of

1445.69 -> as well as a guideline recommended treatment,

1450.11 -> post acute MI that does not differentiate

1452.68 -> based on diabetes status but knowing

1455.6 -> that diabetic patients have a higher risk

1458.42 -> of subsequent cardiovascular mortality.

1461.08 -> This is definitely one of those risk reduction therapies

1465.26 -> that you should be thinking about.

1469.65 -> When you're thinking about blood pressure management

1472.55 -> in patients with diabetes, there are some really great

1476.12 -> guidelines that are out there.

1478.23 -> So if you look at this one,

1479.56 -> these are the 2022 ADA guidelines here.

1485.03 -> If the blood pressure is above 140 but less than 160,

1488.82 -> you think about starting one agent.

1491.32 -> If their blood pressure is greater than 160,

1493.807 -> you think about two or more agents.

1496.57 -> Look at the middle column, having CAD,

1500.72 -> and MI counts of CAD makes you lean heavily

1504.49 -> towards an ACE or an ARB as your first line

1508.05 -> of therapy for these patients that you can also choose

1511.63 -> from calcium-channel blockers or diuretics,

1514.08 -> particularly if ACEs are ARBs are contraindicated,

1517.61 -> or as additive therapy if you're not

1519.67 -> reaching goal with your ACE and ARB.

1523.37 -> As you continue down that pathway,

1525.365 -> and this is now someone who is transitioning out

1528.58 -> of the hospital into clinic,

1530.66 -> we are monitoring patient's blood pressures very carefully

1534.23 -> and especially in the post MI setting,

1536.75 -> we often see that blood pressures are either

1539.02 -> very high or very low during the hospitalization.

1542.5 -> Once they transition home and start to recover,

1545.148 -> we do see some blood pressure changes,

1547.37 -> so in that first visit, post MI discharge,

1551.38 -> one of the key things many of us,

1553.052 -> as clinicians pay attention to is what kind

1556 -> of blood pressure are we looking at?

1557.98 -> Should we be titrating medications

1560.61 -> to get under better control and again,

1563.35 -> we still have that list of ACE, ARB,

1565.13 -> calcium-channel blockers and diuretics to be thinking about.

1569.48 -> This is really much more for an outpatient population

1572.95 -> in the hospital post MI setting,

1574.78 -> we've got beta blockers in the mix as well.

1577.34 -> But there are also other things to think about,

1580.06 -> so you can see the last box on the bottom here

1583.96 -> is if you're really hot dealing

1585.49 -> with refractory hypertension, you could be thinking

1588.99 -> about mineralocorticoid receptor antagonists

1592.16 -> such as burn a lactone as well

1593.71 -> and this is something I often pull out

1596.24 -> as my third or fourth line drug

1599.16 -> in patients with refractory hypertension.

1603.2 -> I see a lot of patients come out on hydralazine,

1605.837 -> I think this is something that is often easy

1609.43 -> to reach for in the hospital setting.

1612.11 -> But in the outpatient setting,

1615.81 -> hydralazine is really not a great therapy

1619.25 -> for blood pressure management.

1621.4 -> It's often a TID, three times a day medication,

1624.452 -> if not a four times a day medication.

1627.76 -> So not really quite compatible, at least I know for myself,

1631.9 -> it's not quite compatible with life,

1634.569 -> I can barely remember to take my once a day medications,

1637.39 -> let alone something three times a day.

1639.66 -> So this is often something I see a lot

1641.693 -> when patients who present to me after

1643.9 -> their hospitalization, I see hydralazine.

1646.54 -> And I started looking to replace that with something

1649.05 -> that's perhaps a little bit easier

1650.73 -> to take as an outpatient.

1653.42 -> So many of the drugs that are listed

1655.64 -> on this slide can do the trick here

1658.12 -> without having to resort to hydralazine.

1662.82 -> Statin therapy, I don't think there's any data

1666.71 -> that refutes the benefit of statin therapy

1669.17 -> in patients with prior ASCVD and that applies

1672.52 -> to patients with an MI in the hospital as well.

1676.33 -> That's the very first box you see here.

1679.34 -> This is a therapy that has been shown to be quite effective.

1682.63 -> These are pretty old data from a heart protection study.

1686.92 -> There have been a lot of recent trials

1689.07 -> and one of the more recent ones is ezetimibe.

1692.81 -> This is on a background of statin therapy

1695.44 -> but in patients who might require

1697.78 -> a little bit more intensive lipid lowering,

1701.653 -> you can see the grouping of diabetes patients on top.

1705.35 -> This is the IMPROVE-IT trial,

1706.84 -> this is a secondary analysis of the IMPROVE-IT trial.

1710.15 -> You see that benefit of ezetimibe,

1712.56 -> particularly in the patients with diabetes

1716.04 -> as opposed to the patients without diabetes.

1718.87 -> Again, speaking to the fact that this is a high risk group.

1723.24 -> And when you're thinking of a treatment

1727.11 -> that has modest cardiovascular benefit

1731.367 -> and that would probably characterize ezetimibe

1734.78 -> very well here, this is a chiras population of patients,

1739.05 -> these diabetic patients for whom this therapy

1742.11 -> can be especially effective in lowering

1745.35 -> their risk of subsequent death from a cardiovascular cause,

1749.99 -> MI or even preventing unstable angina

1753.09 -> requiring hospitalizations or strokes

1756.15 -> or downstream coronary revascularization.

1759.21 -> So when you have someone in the hospital setting,

1762.903 -> I think of ezetimibe when someone comes

1765.76 -> in already on a statin, their LDL is still

1769.33 -> not quite where we needed to be.

1771.7 -> Now we know that there are some instability

1773.83 -> in LDL levels during an acute MI,

1776.7 -> but I tend to be pretty European in my LDL appreciation.

1781.56 -> So in the outpatient space, I often apply a threshold of 55,

1787.81 -> US guidelines to go 70, so I'm trying

1791.01 -> to get that LDL as low as possible.

1793.74 -> So in the in-hospital setting,

1796.06 -> when someone's already on a statin,

1798.53 -> their LDL's not quite at where they need to be,

1802.93 -> I intensify that statin to a high intensity statin

1805.92 -> where I can and if they're already

1807.92 -> on a high intensity statin and it looks like

1810.45 -> they're not going to be able to achieve target,

1813.38 -> and that's generally, a high intensity statin

1815.97 -> should be able to reduce LDL by another 30 to 50%.

1821.61 -> And if I think that they're still not going to get

1823.75 -> to where I think they really should get to,

1826.25 -> I would think about adding ezetimibe

1828.09 -> in that setting as well.

1831.11 -> Keep in mind that the therapies you start

1833.34 -> in the hospital are very likely to be

1836.31 -> the therapies that the patients continue on.

1839.07 -> There is a bit of a therapeutic inertia,

1841.64 -> if you wait to start as an outpatient,

1843.52 -> there is a good chance that that therapy

1845.52 -> doesn't get started or it gets started quite late.

1849.72 -> So the patient is a captive audience,

1851.7 -> use that timeframe to really try to optimize them.

1857.69 -> There is very little data on in-hospital PCSK9 inhibitor

1863.187 -> and I think that data should be evolving,

1865.93 -> as we're speaking here, but in the outpatient space,

1870.13 -> you can see the curves for PCSK9 inhibitors,

1873.09 -> compared with placebo, this is for evolocumab

1876.05 -> that you see on the slide here

1878.44 -> and there is definitely benefit in patients

1881.11 -> both with and without diabetes.

1883.816 -> But as you can see on the left hand side of this slide,

1886.64 -> the curves diverge fairly early,

1889.79 -> within a year after starting the therapy

1892.93 -> and then continue to diverge over the time.

1895.89 -> So the number needed to treat there is about 37.

1900.32 -> So again, this is not just, at least in my practice,

1903.79 -> I don't think of PCSK9 inhibitor

1905.93 -> as my first line therapy, but in my diabetic patients,

1910.84 -> I am very intensive with lipid lowering in these patients,

1916.18 -> I do pursue the goal of trying to get at least below 70

1920.67 -> and ideally, if you wanna go by the European guidelines,

1923.88 -> below 55, so if they are on maximally tolerated statin

1929.73 -> and there is still not a goal,

1931.65 -> this is a group of patients that I am happy

1935.22 -> to fill out the paperwork and to do the teaching,

1938.35 -> in order to be able to get them to take a PCSK9 inhibitor.

1945.72 -> So there are some other recommendations here.

1948.486 -> Really, cardiologists don't practice in a vacuum,

1952.2 -> we need to be coordinating care

1953.77 -> with a patient's primary care physician.

1956.32 -> Many of the patients that I discharged

1958.13 -> from the hospital usually see we have

1961.27 -> a follow up appointment with a cardiologist

1963.16 -> and with a primary care physician within the next two weeks

1966.99 -> to four weeks so that we can tighten this

1969.75 -> and to do modifications.

1971.79 -> It's not just about medications.

1973.67 -> It's also counseling about lifestyle modifications,

1976.9 -> including physical activity, weight management,

1980.5 -> cardiac rehab for me is a must in a post MI patient,

1984.5 -> so if they have access to cardiac rehab,

1988.13 -> and nowadays with some virtual cardiac rehab options,

1991.54 -> there really isn't an excuse

1993.25 -> for someone not to do cardiac rehab.

1997.31 -> But I do know that there are

1998.56 -> some financial barriers to that,

2000.24 -> but I think that is quite helpful in making sure

2005.47 -> that the lifestyle modifications you're counseling patients

2008.73 -> are sustained over time and provides

2011.84 -> another set of eyes to be looking

2013.61 -> at blood pressure control and lipid management.

2016.86 -> Here our cardiac rehab is excellent.

2018.94 -> I have technicians reaching out to me sometimes,

2021.82 -> giving me notes about how their heart rate

2023.83 -> and their blood pressures are behaving

2025.43 -> while they're exercising which allows me an opportunity

2028.62 -> to be able to do some gentle titration

2030.67 -> of medications in a way that gets them

2033.38 -> to target blood pressure's up very quickly here.

2037.79 -> Metformin is a 2A recommendation,

2040.43 -> it's often considered the first line of pharmacotherapy

2043.79 -> and often useful if not contraindicated,

2046.08 -> we usually wait about 48 hours after contrast exposure

2050.9 -> to get them back on their Metformin,

2053.47 -> to get them started on their Metformin,

2055.33 -> so sometimes since the average length of stay

2057.55 -> is about two to three days, this is something

2060.38 -> that we instruct them they would resume or start

2065.21 -> after they leave the hospital.

2067.44 -> And we try to get their A1Cs

2070.7 -> as close to seven as possible

2072.52 -> and that's a 2B recommendation there as well.

2077.17 -> And knowing about cardiologists,

2078.88 -> it's kind of I'm a cardiologist by by training.

2081.77 -> I see patients in our cardiac intensive care unit,

2085.596 -> in our regular wards and I also see

2087.88 -> many cardiovascular patients in my cardiology clinic.

2091.11 -> And 10 years ago, I would not have giving

2093.84 -> this talk because I always thought that,

2096.29 -> this would have been the domain of someone

2098.48 -> who I would collaborate With

2100.43 -> on the primary care side or the endocrine side,

2102.96 -> but many of us are now on the frontlines too.

2105.7 -> And in part, it's because many

2107.97 -> of our patients with ASCVD have diabetes

2111.22 -> and unfortunately after they leave the hospital,

2114.22 -> after an MI, most of them see us in clinic,

2117.6 -> but very few of these patients will see an endocrinologist.

2122.86 -> So I think that's one reason why cardiologists

2126.26 -> are very much on the front lines these days as well.

2129.7 -> But also because there are some newer therapies

2132.14 -> that are "for diabetes" or listed as diabetes drugs,

2136.26 -> but aren't really not just Diabetes drugs anymore.

2138.83 -> These are often used for cardiovascular disease prevention,

2142.68 -> even for renal prevention and certainly,

2144.83 -> if you're a heart failure doc,

2146.591 -> these are now considered part

2149.13 -> of our heart failure regimen as well.

2150.98 -> So many of these therapies we're starting

2153.67 -> to get to know very well and know how to manage,

2158.77 -> I would say that there are still some areas

2161.12 -> where we do need to make sure we ask for help.

2164.45 -> So for someone who's on a very complex insulin regimen,

2168.6 -> I tend not to manage that on my own

2170.61 -> that really needs to be done in concert

2172.5 -> with a diabetes care specialist,

2174.09 -> whether that person is a primary care physician

2175.99 -> or an endocrinologist.

2177.77 -> If there are multiple medications,

2179.63 -> I often or if they have an A1C that is quite elevated,

2184.31 -> I feel much more comfortable getting

2185.91 -> my endocrinologist involved 'cause these patients

2188.06 -> really need as many pairs of eyes managing

2192.01 -> their regimen as much as possible.

2194.47 -> I get a little nervous when patients

2195.87 -> have an EGFR that's less than 30,

2199.02 -> it certainly helps to have a diabetes care specialist

2203.13 -> involved help me think about picking medications.

2206.89 -> And if they have complications of diabetes,

2210.06 -> such as DKA or hyperglycemia,

2213.247 -> or extensive micro and macrovascular complications,

2219.87 -> I think this is one of those situations where we want

2223.26 -> to make sure we've got a great group of specialists

2226.61 -> that is comprehensively evaluating these patients.

2230.11 -> So I do involve many of these individuals.

2235.77 -> Let's talk a little bit about SGLT2 inhibitors and GLP-1s.

2241.01 -> These are now becoming quite commonly applied

2245.21 -> in the cardiologist's office.

2247.63 -> So this is a nice meta analysis

2249.82 -> that's looking at SGLT2 inhibitors and its risk,

2253.57 -> and a MACE associated with that.

2255.99 -> If you look at the top grouping over here,

2258.19 -> you can see that in patients

2259.68 -> with atherosclerotic cardiovascular disease,

2263.08 -> this is a class of therapy that has definitely been shown

2266.87 -> to improve risk of major adverse cardiovascular events.

2271.03 -> So typically CV death, MI and stroke.

2275.41 -> In patients without ASCVD, perhaps that benefit

2278.34 -> is a little less obvious here.

2283.24 -> The other piece that has really emerged

2286.04 -> over the last five years is the risk

2288.64 -> of heart failure hospitalization.

2291 -> So diabetes and heart failure

2293.26 -> actually go together quite often.

2295.75 -> I would say that more than 50%

2299.27 -> of our heart failure patients have diabetes.

2303.05 -> The ratio is a little lower among diabetic patients,

2305.87 -> but perhaps higher in diabetic patients who are of older age

2310.08 -> but in patients with cardiovascular disease,

2313.3 -> again, in that top clustering of point estimates here,

2316.3 -> everything's well to the left of the line of unity.

2320.2 -> So there is a heart failure prevention benefit

2324.76 -> to the use of SGLT2 inhibitors in these patients,

2328.64 -> and it doesn't matter if you're thinking

2330.11 -> about empagliflozin, canagliflozin or dapagliflozin.

2333.71 -> All of these are associated with improvements

2337.603 -> in heart failure in patients with ASCVD.

2344.01 -> And may also be true even in the absence of diabetes.

2349.77 -> So let's see if I can get to the next slide.

2352.63 -> There you go, so, if you look at dapagliflozin on the left,

2357.7 -> you have diabetes patients on the right,

2359.731 -> you have patients without diabetes

2362.28 -> and you're comparing dapagliflozin to placebo.

2365.91 -> You see that the hazard ratio is pretty similar, 0.75.

2370.18 -> There seems to be benefit even in patients without diabetes,

2374.43 -> which is why these SGLT2s have really entered

2378.24 -> the armamentarium for patients with heart failure.

2383.19 -> This is very interesting, it's certainly an area

2386.265 -> of a lot of research as we think about,

2391.38 -> which steps do we take before we start reaching

2393.73 -> for an SGLT2 inhibitor in patients with heart failure.

2397.46 -> Do I do it before or after we use something

2400.07 -> like entresto or spironolactone.

2405.47 -> But certainly this is a nice addition

2409.53 -> to our ability to optimize heart failure

2413.17 -> and that's often the case in patients who are post MI.

2417.53 -> There are a couple of trials that are ongoing right now,

2420.51 -> that are recruiting patients in the acute MI stage

2423.24 -> to think about when we should be thinking

2425.05 -> about starting these therapies as well.

2431.79 -> Even in all patients those with and without diabetes,

2435.13 -> you can look at the A1C measurements.

2438.53 -> So on the left hand side, on the X-axis,

2440.84 -> you see A1C measures going all the way from five up to 12.

2444.92 -> And then the gray, a lot of the gray set of lines here,

2448.36 -> you see the 95% confidence interval

2451.24 -> for the hazard ratio here and it basically confirms

2456.541 -> what the previous slide shows which is,

2460.5 -> the amount of glycemic control doesn't matter

2463.59 -> in both heart failure patients,

2467.285 -> sorry, in both diabetes patients

2468.61 -> and patients without diabetes,

2471.49 -> we do see a benefit to using SGLT2.

2475.51 -> People often wonder about adverse events,

2477.91 -> particularly the non-diabetic patients,

2480.38 -> so either their hypoglycemic or other events

2482.78 -> that could cause a study drug discontinuation

2485.91 -> and this trial really showed that

2488.43 -> there was no significant difference

2491.498 -> in the patients treated with placebo or dapa.

2496.039 -> If you look at the second row,

2497.06 -> this is the no diabetes group, it's 4.5% versus 5.3%,

2501.803 -> numerically slightly higher in the dapa group

2504.68 -> but again not reaching statistical

2506.75 -> significance here as well.

2508.22 -> So again, lots of research being done about how we implement

2512.58 -> drugs like dapagliflozin in patients without diabetes,

2516.42 -> but who are at risk of heart failure here.

2520.1 -> And then finally, we'll talk a little bit

2522.53 -> about the impact of renal disease and again,

2525.33 -> in patients with atherosclerotic cardiovascular disease,

2528.59 -> this slide is very much like the other slides,

2531.76 -> there is benefit, we can slow down progression

2534.67 -> to end-stage renal disease in these patients.

2537.66 -> And that may also be true in patients

2540.51 -> even without cardiovascular risk factors as well

2543.85 -> as you can see in the CANVAS program

2545.347 -> and the DECLARE program, there seems to be a hint

2548.223 -> for a renal protection even

2550.39 -> in the absence of ASCVD here as well.

2553.44 -> So I think that nephrologists are getting

2555.56 -> as excited as the cardiologists and the heart failure docs

2558.75 -> about the use of this therapy

2560.695 -> in patients with chronic kidney disease.

2565.83 -> Let's spend a minute and talk about GLP-1 receptor agonists.

2569.56 -> These tend to be mostly injectables,

2571.94 -> although there are some oral forms available.

2575.094 -> There does seem to be a predictive effect as you think

2578.57 -> about major adverse cardiovascular effects.

2581.21 -> This is the meta analysis here,

2584.3 -> where you've got a hazard ratio of 0.88,

2586.96 -> a number needed to treat of 75.

2589.91 -> For cardiovascular death, again,

2591.83 -> you do seem to see some benefit here

2594.03 -> for this class of therapies here,

2596.21 -> again, with a hazard ratio of 0.88,

2598.64 -> but a slightly higher number needed to treat here,

2600.81 -> the confidence intervals are a little bit wider,

2603.31 -> 'cause this is a rare event here.

2605.87 -> So also something to think about

2607.563 -> and I tend to think a little bit about

2609.67 -> GLP-1 receptor agonists particularly

2612.24 -> in patients with a high BMI because many of these therapies

2615.96 -> Do you have a BMI lowering benefit

2619.76 -> as well as associated with that.

2622.4 -> I will confess this is not an easy class

2624.93 -> of medication for me to reach for,

2626.92 -> in part because it is mostly an injectable,

2629.62 -> whereas SGLT2s are orals, so something I would say that,

2635.17 -> personally, I tend to reach for SGLT2s a little bit faster.

2642.54 -> And so I think that's also the reality,

2645.8 -> you know, on the left hand side,

2646.9 -> you've got the algorithm that is put out

2650.06 -> by the professional societies here,

2653.29 -> but which class for which patients,

2654.79 -> I think the reality is many of our cardiologists

2658.6 -> are going to think about an SGLT2 inhibitor first,

2663.25 -> because this is something that they're comfortable with.

2666.61 -> We know that 14 to 36% of MI patients ultimately

2670.944 -> will develop heart failure and so as a classic therapy

2674.44 -> that tends to reduce heart failure hospitalization,

2678.27 -> this is something that could have benefit in that.

2682.45 -> Half of these patients also have ASCVD, also have CKD,

2686.49 -> and so trying to slow down progression to renal failure

2691.84 -> is something that is very attractive there as well.

2695.99 -> Other attractive features, it's oral,

2698.3 -> it's much easier to think about teaching someone

2700.71 -> to use if they've never been on an injectable before.

2704.095 -> These are once a day dosing,

2706.2 -> there's really not a whole lot

2707.43 -> of dose titration that goes on,

2709.88 -> and not a lot of monitoring that needs

2712.34 -> to be done other than glycaemic monitoring.

2715.57 -> Although there are some side effects that really need

2717.73 -> to be known about these therapies,

2719.42 -> particularly the risk of fungal infections in these people.

2725.83 -> So the things that I generally think about

2728.85 -> when I start this class of therapies,

2732.539 -> the blood pressure does tend to go down in part,

2735.2 -> there is a diuretic effect for the SGLT2 inhibitors.

2740.62 -> It can also reduce the A1C by a little bit,

2743.53 -> it can reduce weight also a little bit,

2745.61 -> but there is a three to fourfold risk

2747.91 -> of fungal infections and some people

2749.78 -> could get orthostatic symptoms from the initiation

2753.98 -> of these therapies as well as an uncommon

2758.45 -> but clearly dangerous risk of euglycemic DKAs.

2761.96 -> So things we think about most I think in the early days

2765.3 -> of me using these therapies, I often would CC

2769.1 -> the primary care physician to say,

2771.02 -> hey, this is the therapy that I'm starting here,

2774.19 -> I'm going to see the patient back a little bit earlier,

2777.04 -> it'd be great if you could also see

2778.41 -> the patient back a little earlier as well,

2780.71 -> just so that we're keeping

2782.01 -> an eye out for these therapies here.

2787.41 -> I don't talk about general hygiene too much in my clinic,

2790.64 -> but I do tell people that there is a risk

2793.38 -> of UTIs and vaginal infections in my female patients.

2799.48 -> So I asked them to watch for that.

2801.54 -> I do ask them to monitor the diabetic patients

2804.79 -> to monitor their blood pressure and their blood sugar

2807.32 -> is at least a little bit more intensively

2809.16 -> in the first two weeks, starting these therapies here.

2813.611 -> Other things that cardiologists we need to know,

2816.05 -> we do have to think about this a little bit

2818.38 -> more carefully in patients who previously

2820.77 -> had DKA or in patients who have renal dysfunction.

2824.47 -> And so these are patients I still make sure

2826.61 -> that I talk to the patient's primary care physicians about,

2830.73 -> when I started just to give them a heads up about that.

2833.96 -> This may also require some insulin

2835.83 -> dosing adjustments if needed to.

2838.78 -> When I see patients in the hospital, they're on an SGLT2

2842.24 -> I make it a routine practice to just pause SGLT2

2845.22 -> at least in the first 24 hours,

2847.78 -> until I get a better handle on what's going on.

2850.38 -> I don't think there is any downside to stopping

2852.62 -> those therapies for a day or two and then we're watching

2856.11 -> for that you euglycemic DKA as well,

2859 -> particularly when someone's in critical care.

2864.47 -> So let's go back to our case.

2866.032 -> Just to quickly remind you, this is a gentleman,

2869.01 -> a slightly older gentleman with type two diabetes

2871.24 -> for a while now, hypertension,

2872.87 -> he now just got an LAD stent, has a history of pancreatitis.

2877.25 -> What are some of the things

2878.19 -> we're thinking about for this person, his GFR is okay at 69.

2883.12 -> So this is someone, cardiac things first,

2886.414 -> we would make sure we have adequate stent protection

2890.63 -> and cardiovascular risk production.

2893.04 -> So aspirin and dual antiplatelet therapy with aspirin

2896.4 -> is pretty key in this patient.

2897.97 -> So either clopidogrel or ticagrelor for this patient,

2901.46 -> and I tend to use a little less prasugrel

2904.111 -> in the population who are 75 years of age or older.

2908.88 -> This is someone I would switch their dosing

2912.98 -> or their a statin to a higher intensity.

2915.4 -> So that would be atorvastatin 40 or 80,

2918.35 -> or rosuvastatin 20 to 40, just to make sure that,

2922.997 -> and this person's LDL was still low on the high side.

2926.05 -> So if there's an opportunity to intensify the statin, I do.

2929.67 -> If there's not much of an opportunity to intensify

2931.653 -> the statin this is someone I would

2933.41 -> think about ezetimibe for.

2936.09 -> They are already on an ACE inhibitor for diabetes,

2938.7 -> primary prevention, I would think about adding

2940.66 -> a beta blocker mostly trying to target

2942.81 -> blood pressures lower than 130 over 85.

2947.3 -> Two days after their cath I would

2949.09 -> have them resume their metformin.

2952.51 -> Thinking about an SGLT2 versus a GLP-1 receptor agonist,

2956.14 -> I would favor the SGLT2 inhibitor,

2958.561 -> in part because the GLP-1 receptor agonist

2961.43 -> does have some concern in patients

2965.82 -> who've previously had pancreatitis,

2967.78 -> so I tend to stay away from that class of therapies

2970.42 -> in someone who's had prior pancreatitis before.

2974.52 -> I strongly counsel this patient to attend cardiac rehab

2977.99 -> and set a weight goal for the cardiac rehab,

2980.38 -> as well an exercise goal that they should reach eventually,

2985.251 -> from a lifestyle modification standpoint.

2988.67 -> And then I make sure that this is a patient

2991.21 -> who leaves the hospital with an appointment in hand.

2994.88 -> So for example, if it's a Friday

2996.66 -> and they're discharging over the weekend,

2998.32 -> I call and get the appointment Friday afternoon

3000.74 -> before the office is closed because this is someone

3003.47 -> who's going to need very careful fall,

3005.77 -> definitely not someone you wanna

3008.19 -> let fall through the cracks here.

3011.06 -> And since their EF is 40%, it might be worth getting

3014.2 -> another echocardiogram down the road,

3017.199 -> maybe about six to eight weeks to make sure

3019.72 -> that there is some EF recovery, if not,

3021.69 -> we may be thinking about other therapies that could help

3025.57 -> reduce the cardiovascular risk such as an ICD.

3030.738 -> So this is a bit of a whirlwind tour of what I tend to think

3034.69 -> about when I'm treating patients in the hospital

3037.48 -> with acute MI who have diabetes.

3039.98 -> There was a very, very nice,

3042.18 -> recently published scientific statement,

3045.74 -> talking about management of cardiovascular risk factors

3049.5 -> for adults with type two diabetes,

3051.21 -> that if you have a chance to read, you should.

3054.8 -> I put the scientific statement on the slide

3058.09 -> and our staff can also circulate that PDF if interested.

3065.02 -> So I wanna thank you all very much for listening to us

3068.42 -> and I'm going to turn it back over to Renee.

3072.87 -> - [Renee] Thank you so much Dr. Wang

3074.26 -> for that wonderful presentation and really emphasizing

3077.59 -> the opportunity that we have,

3079.69 -> for immediate and long term impact

3082.15 -> while these patients are in the hospital.

3085.09 -> As a reminder, you can submit questions

3086.939 -> at any time in the Questions pane.

3088.66 -> I see some are coming in and we'll review

3091.46 -> them in just a few minutes.

3093.72 -> After we review some of the changes that we've made

3096.87 -> in Get With The Guidelines in CAD.

3099.043 -> I'd now like to turn the presentation over

3101 -> to my colleague, Jeanne Rash.

3104.29 -> Jeanne The floor is yours and you

3107.07 -> can advance the slide, thank you.

3112.41 -> - [Jeanne] Great, thanks, Renee.

3117.19 -> I'm waiting to advance the slide.

3122.67 -> You may need to assist me with that.

3127.987 -> - [Renee] Okay, you should be able to go ahead.

3136.447 -> The first one takes just a moment,

3138.92 -> so that you click the next.

3147.54 -> - [Jeanne] I'm not having any luck, Renee, sorry.

3150.15 -> - [Renee] That's okay, I'll go ahead

3151.21 -> and advance for you, go ahead.

3153.84 -> - [Jeanne] Okay, so good afternoon everyone.

3156.86 -> Sorry for that slight delay, I will be brief here.

3161.25 -> I wanted to review with you the changes

3164.39 -> that we've actually done to the,

3165.59 -> Get With The Guideline CAD registry

3169 -> that aligns with all the information

3172.67 -> that was just presented to you.

3175.15 -> As mentioned at the start of the webinar,

3178.5 -> the changes to the registry

3181.48 -> actually occurred back in December.

3184.54 -> So you should have access to the changes

3187.35 -> that are on the data collection form

3189.87 -> and also the new measures that are available to you.

3194.94 -> There should be some written release notes

3197.95 -> about these updates in the library

3201.4 -> of online resources within the registry.

3207.37 -> Next slide, please.

3210 -> So on just a couple of updates to the data collection.

3214.11 -> Here, there are two of them on the Pre-Hospital Arrival tab.

3220.35 -> One of them is in the medical history section

3223.35 -> that provides some added detail to the type

3226.88 -> of diabetes that's in the patient's medical history

3230.81 -> and for those patients who come into the hospital

3233.42 -> who don't have a previous medical history of diabetes,

3236.46 -> but are newly diagnosed during the episode of care,

3239.593 -> their status can be documented in a new element

3244.64 -> than a new diagnosis during this admission.

3249.91 -> Next slide, please.

3253.773 -> And then there's a one additional update

3256.18 -> on the Discharge tab in the Discharge Medication section

3259.72 -> and that's a few elements for recording

3264.29 -> any anti-hyperglycemic medication

3267.02 -> that was prescribed at discharge.

3269.92 -> There are up to four different classes

3272.18 -> and medications that can be recorded here.

3275.86 -> If you're unfamiliar with the medication classes,

3281.11 -> there is a table within the coding instructions

3286.16 -> that will indicate which class

3289.56 -> certain medications belong to.

3294.18 -> and if an SGLT2 inhibitor was not prescribed

3298.37 -> during this episode of care,

3302.36 -> there'll be an additional message asking,

3304.39 -> was there a documented reason.

3307.04 -> This will give us all opportunity to assess

3311.87 -> some of the risk reduction treatments

3314.73 -> that are being prescribed and allow us to calculate

3319.26 -> new measures that have been added into the tool, next slide.

3325.07 -> So, the measures set that have been added,

3328.97 -> will probably look somewhat familiar to you.

3332.67 -> A lot of these are already in

3336.24 -> the Get With The Guidelines CAD registry.

3340.49 -> Many of these measures have been

3343.25 -> adapted specifically for patients with diabetes.

3349.921 -> So although it is similar risk reduction measurement,

3354.55 -> we are focusing strictly on the diabetic patients.

3359.14 -> So those are patients with either

3360.68 -> medical history or newly diagnosed

3363.33 -> and then something to also note here is,

3367.79 -> unlike our other Get With The Guideline measures

3372.64 -> that are separated by STEMI and NSTEMI populations,

3377.79 -> for the diabetes measures, all AMIs are included.

3384.82 -> So you'll see it's four AMIs and then,

3388.36 -> we have a composite measure that is an accumulation

3391.99 -> of all those measures and we have one reporting measure

3394.863 -> that's looking at the anti hyperglycemic medication

3400.09 -> with the proven CVD benefit that Dr. Wang

3403.95 -> was just reviewing, next slide.

3407.76 -> So this is just meant to illustrate, again,

3411.27 -> the difference in the patient population.

3413.94 -> So the initial population could be

3417.703 -> a STEMI yes or STEMI no, but there would be

3421.05 -> positive cardio biomarkers indicating an AMI,

3424.71 -> so those patients would be included and then,

3429.65 -> the medical history or new diagnosis of diabetes.

3434.17 -> So this is for the nine measures that

3437.17 -> are looking at the risk reduction therapies

3440.64 -> and the population for the reporting measure

3444.047 -> for the SCLT2 medication is outlined on the next screen

3451.7 -> and that is slightly different.

3454.21 -> It also includes both types of MIs,

3459.371 -> but we're looking at the diabetes type

3462.26 -> of type two only with these metrics.

3466.42 -> These full measure description documents

3469.52 -> are available to you in the library of online resources.

3475.41 -> So you can take a closer look at those to better understand

3479.94 -> exactly how the measures are being calculated.

3485.03 -> - [Renee] Thank you, Jeanne and I just wanna take one moment

3488.883 -> so that we could have time for questions,

3491.61 -> just to share with everyone this roadmap

3494.621 -> for including these diabetes measures.

3498.98 -> This was also shared back in December

3502.17 -> and I just want to emphasize that 2022 awards

3505.77 -> that are based on 2021 calendar year data

3508.33 -> will not be impacted by these changes.

3511.14 -> And you can see here in the roadmap,

3513.07 -> we started data collection in late December

3515.61 -> and this is the time all of the CAD hospitals have access

3519.3 -> to these data elements and reports

3521.65 -> that Jeanne just reviewed and we will take time during 2022

3526.467 -> for our national volunteer committees to review

3530.09 -> and analyze the data that's coming in,

3532.06 -> and then make a decision if it's appropriate or not

3536.76 -> to update the Target Type 2 Diabetes Honor Roll Awards,

3540.91 -> for the next round of awards in 2023.

3545.11 -> And I know we're at the top of the hour but Dr. Wang,

3547.93 -> I just wanted to bring up one question

3551.168 -> that came up from the audience.

3554.81 -> Are non-diabetic patients generally reluctant

3557.94 -> to start SGLT2s in your clinical practice?

3561.21 -> If so, are there general education points

3563.63 -> you discuss with them to encourage starting them?

3566.6 -> Also, is it becoming more

3568.06 -> common practice for you to prescribe,

3569.87 -> just discuss this class of meds in your practice.

3574.55 -> - [Tracy] Yeah, a very good question.

3579.75 -> I have not encountered resistance to thinking about

3583.92 -> SGLT2 inhibitors in non diabetic patients in my practice.

3588.53 -> In part because this is a little tongue in cheek

3591.19 -> but people don't always know that this is a drug

3594.84 -> that was originally developed for diabetes.

3597.91 -> I think the biggest resistance to these therapies

3600.92 -> is often in the form of cost.

3604.01 -> None of these therapies are generic,

3607.53 -> just as there are no generic SGLT2 inhibitors yet.

3611.69 -> So this is often a therapy that can cost

3617.75 -> a bit in terms of out of pocket costs

3621.33 -> or co-payments and things like that.

3624.52 -> This may especially be through in patients,

3627.7 -> who also on another non-generic heart failure medication.

3631.7 -> So things like sacubitril-valsartan or entresto,

3635.96 -> is also not generic yet and so I think the cost piece,

3642.44 -> I think, is probably one of the bigger barriers

3645.69 -> to be thinking about when we're starting these therapies.

3649.78 -> And we hope that that's actually a situation that'll change

3653.1 -> a little bit once the evidence-based

3654.9 -> for these therapies build up a little bit more.

3660.9 -> But yeah, the short answer is, non-diabetes versus diabetes,

3666.04 -> there's not a whole lot of resistance starting these.

3668.33 -> These are conversations we're now starting

3670.24 -> to have a lot in our clinic.

3674.22 -> I would say in the majority, I'd say out of five patients

3677.11 -> that I started SGLT2 inhibitor on,

3680.06 -> four of them are probably diabetic.

3682.61 -> And then the final piece of things I would say is,

3687.09 -> because SGLT2 is an oral oral drug in many ways,

3691.41 -> patients think of it very similar to many

3693.64 -> of the other oral drugs that they were taking,

3695.56 -> like ACE inhibitors, beta blockers, since we're all active.

3701.05 -> - [Renee] Thank you, Dr. Wang and thank you

3702.47 -> to everyone for submitting your questions.

3704.57 -> I will we will review those that we didn't have a chance

3707.48 -> to answer and I wanna thank everyone for staying

3710.29 -> on a couple minutes past the hour.

3713.77 -> So thank you also Jeanne Rash,

3716.67 -> for being part of today's webinar.

3718.86 -> And for all of you, all of your participation.

3722.21 -> Just a reminder after today's event ends,

3725.2 -> you will receive a follow up email

3727.22 -> with a survey on the presentation

3729.3 -> and you'll also receive a recording from today.

3734.33 -> This concludes our today's presentation.

3737.3 -> Thank you so much and have a wonderful afternoon.

Source: https://www.youtube.com/watch?v=f6YKm0WePTo