A recent survey of 900 primary care physicians, cardiologists, and endocrinologists rated diabetes as the highest risk factor for cardiovascular disease (CVD). The American Diabetes Association (ADA) and American College of Cardiology (ACC) recently commissioned a study to evaluate physicians' attitudes and practices in managing cardiovascular risk factors in patients with diabetes.
According to survey findings presented at ADA's 62nd Scientific Sessions in San Francisco this past June, physicians ranked diabetes a higher risk factor for CVD than smoking, obesity, high blood pressure, and elevated cholesterol levels. More than 90% of the physicians surveyed felt that people with diabetes are "very" or "extremely" likely to have a cardiovascular event. This is important information considering the fact that of the 17 million Americans with diabetes, approximately 65% will die from a heart attack or stroke. Also, the likelihood of stroke or heart attack in diabetes patients is two to four times higher than in the general population (see box).
Physicians also stated that they routinely discussed with almost all their diabetes patients the need to reduce the risk of cardiovascular disease. Despite educating their patients about the link between diabetes and CVD, these physicians felt their patients were only moderately knowledgeable about the link between the two. Both primary care physicians and cardiologists felt that their diabetes patients perceived blindness and amputation as the greatest risks of diabetes. Only cardiologists felt that patients perceived heart attack as the greatest risk of diabetes. This may be because those diabetes patients under the care of a cardiologist have already experienced a cardiovascular event.
Physician findings confirmed results found in a previous survey of more than 2,000 diabetes patients (ADA/ACA, February 2002): More than 68% of those surveyed indicated that they were not aware of the risk for CVD but were very aware of the risk for amputation and blindness. Many of those surveyed said that their physicians had not told them about the link between diabetes and heart disease.
The good news, said John Buse, M.D., chair of ADA's cardiovascular initiative, titled Make the Link! Diabetes, Heart Disease, and Stroke, is that "this survey showed that physicians recognize the link between diabetes and heart disease. It also confirmed concerns that people with diabetes are not making this link."
According to Buse, who is also division chief, general medicine, and director of the Diabetes Center at the University of North Carolina, Chapel Hill, "In light of these findings, physicians need to be much more aggressive when treating patients with diabetes. Patients need to understand that diabetes is much more than just managing blood glucose levels. It is also about managing blood pressure and cholesterol."
The survey also found that physicians cite "poor compliance" with lifestyle changes and current multiple drug regimens as major barriers toward treating cardiovascular risk factors in patients with diabetes. "In some instances, patients with diabetes are taking up to 10 different drugs each day to treat hy- pertension, diabetes, and high cholesterol and to prevent a first or second heart attack or stroke," said Buse. This further reinforces the complexity of diabetes.
The survey emphasized the need for shared responsibility from both the patient and physician for treating diabetes. Physicians, pharmacists, and other health professionals need to heighten the awareness among diabetes patients and even among those prone to developing diabetes about lifestyle modifications that can reduce CVD factors, including high cholesterol, hypertension, lack of exercise, and obesity. Patients, with the help of pharmacists and other healthcare professionals, can learn to incorporate lifestyle modifications and live longer and healthier lives. Medical research shows that small decreases in blood glucose, cholesterol, and blood pressure levels will allow patients to live longer and healthier lives.
"Educating patients about the link between diabetes and cardiovascular disease is necessary," said Gwen Twillman, assistant director of the Make the Link initiative. "These surveys have shown us that there needs to be a greater understanding between patients and physicians regarding diabetes management. Physicians, pharmacists, and other health professionals need to help patients with diabetes understand the association between diabetes and CVD, especially in light of the fact that patients thought their physicians did not discuss this link with them," she said.
"This discrepancy may be due to a multitude of factors. Patients may be so overwhelmed with what their physician is telling them about their disease they may be missing vital infor-mation," Twillman continued. "Patients may also feel diabetes and CVD are two separate disease states that are not connected. Physicians may think they are explaining all the risk factors to their patients but may in fact not be giving all the information. This may be due to today's managed care environment and lack of sufficient time devoted to each patient."
Despite the fact that patients have not made the link between diabetes and CVD, they are seeing their healthcare professionals and asking questions. Their knowledge of many of the complications of diabetes is evident, but there is a tremendous need to increase their knowledge about the re-lationship between diabetes and CVD.
Both ADA and ACC are supporting the National Diabetes Education Program's Be Smart About Your Heart: Control the ABCs of Diabetes. The ABCs of diabetes are therapy goals for optimal diabetes management: A is for hemoglobin, B is for blood pressure, and C is for cholesterol (LDL) (see box). Additionally, ADA and ACC are complementing this campaign by focusing education and outreach with the Make the Link initiative. The initiative extends the reach of the ABC message and will help to improve communication and understanding among healthcare professionals and patients.
"Pharmacists are in an ideal position to help patients with diabetes better understand the link between diabetes and heart disease," said Carla B. Frye, Pharm.D., BCPS, scientific affairs associate, professional practice and scientific affairs division, ASHP. "Pharmacists can help educate patients about the importance of medication compliance and provide them with helpful hints for improving compliance as well as discussing the relationship between cholesterol, blood pressure, and diabetes. Many pharmacies offer free blood pressure and cholesterol screenings, which can be used as a tool to educate patients about the link between diabetes and heart disease," she stated.
The Make the Link initiative will make its debut in this fall. Expect a media blitz of public service announcements intended to provide patients with diabetes a wake-up call about their dramatically increased risk for CVD. The initiative will reach physicians with journal advertisements and continuing medical education lessons. Other educational tools include "Top 10 Questions to Ask Your Doctor," a turnkey tool kit designed to help healthcare professionals facilitate discussions with their patients regarding the link between diabetes and CVD. For more information about this program, call 1-800-DIABETES (1-800-342-2383) or visit www.diabetes.org/makethelink.
Elena Haveles. Survey ranks diabetes as No. 1 risk factor for CVD. Drug Topics 2002;24:32s.