Coronary Artery Disease in Diabetes: What Nashville Patients Need to Know
Introduction
I am William Conway, a general internist in Nashville, Tennessee. In this series of YouTubes and blog posts, I will share with you current treatment options for common, serious medical problems. I will speak to you directly, drawing on advanced courses I have taken on the complications of diabetes.
I speak to you as I speak to my patients. I will be brief. I will be clear. I will provide take-home ideas for your decision-making. I will provide take-home practices that will benefit you.
Diabetes is common. Diabetes is serious. Diabetes is complicated. Here, we will focus on the relationship between diabetes and heart disease.
Executive Summary
- Diabetes places you at risk for heart disease.
- Diabetes is a coronary artery disease equivalent.
- Common, inexpensive medications can be used to protect you against the risk of having a heart attack.
- We have new drugs to protect your heart in diabetes. These are remarkable but expensive. Now, you must explicitly evaluate potential benefits versus present costs.
Statement of Problem
Diabetes, while common, has always been complicated and unpredictable. Diabetes is associated with serious, life-altering complications.
Diabetes is the most common cause of blindness, kidney failure, and amputations in the United States. Here in Tennessee, we have a well-deserved reputation for being more prone to diabetes due to our diet and lifestyle; this is true throughout the South. Ignoring diabetes can lead to severe complications.
Treatment of diabetes has always involved difficult trade-offs. In the past you had to choose between ignoring your blood sugar and doing multiple daily finger sticks. Did you choose to inconvenience yourself to better manage your blood sugar? Or did you choose convenience and take a greater risk of kidney failure or heart attack? Every choice has trade-offs.
Treatment of diabetes has always been complicated. However, the level of complexity in treatment decisions has increased tremendously.
We now have powerful, new choices in treatment. These new choices in treatment come at a significant increase in price. Financial planning is now important if you have diabetes. 
What Does it Mean to be a Coronary Artery Disease Equivalent
If you have had a myocardial infarction (heart attack) in the past, we know you have coronary artery disease. A coronary artery disease equivalent means that patients who have diabetes carry the same risk of having a future heart attack as patients who have had a previous heart attack.
I speak to patients daily about their decisions. I have noted that patients become much more serious about treatment after having had a heart attack. Patients who were previously less attentive about treating their blood pressure before their heart attack are now more motivated to treat their blood pressure.
This is what we mean about diabetes as a coronary artery disease equivalent. You have serious heart disease already, even if you have not had a heart attack. Factor this knowledge into your executive decision making. Is it now worth taking your medications daily? What is your budget to reduce the risk of a future heart attack?
That’s why, in my clinic at Nashville Concierge Medicines, I treat diabetes as both a metabolic problem and a heart problem.
The Medications That Save Lives: Mother’s Milk in Diabetes
For decades, we have known that certain drugs are beneficial in reducing cholesterol levels.
Statins
Drugs called statins are effective, inexpensive, and well-tolerated. While most patients do not experience significant side effects, some may develop muscle aches or liver enzyme changes. The statins have been a cornerstone of protecting the heart in diabetes. Current guidelines recommend that most adults with diabetes benefit from at least moderate-intensity statin treatment.
Blood Pressure Medicines
Drugs in the category of ACE inhibitors are a cornerstone in heart protection in diabetes. These commonly used drugs are inexpensive and well-tolerated. The only common complication of ACE inhibitors is a nagging cough. IF you experience a nagging, chronic cough, then your physician may recommend switching to ARB medications. ARBs are equally effective and equally inexpensive.
It is well known that keeping your blood pressure lower than commonly accepted blood pressure targets will provide you with benefits.
Newer Diabetes Medications with Heart Benefits
This is one of the biggest breakthroughs of the last decade.
High-Priced Medications
The SGLT2 inhibitors (empagliflozin, dapagliflozin, canagliflozin) have remarkable, additional benefits, including:
- Reducing hospitalizations for heart failure.
- Lowering the risk of cardiovascular death.
- Protecting kidney function.
The new weight loss drugs, GLP-1 receptor agonists (semaglutide, liraglutide, dulaglutide), all have additional benefits, including:
- Reducing heart attacks and strokes.
- Achieving and maintaining a healthy weight.
- Improving long-term outcomes even in people without prior heart disease.
Your Choices
If you do not have diabetes, you should live as though you have diabetes. You have significant daily choices, including whether or not to:
- Quit smoking– smoking is a poison to the heart and blood vessels.
- Take the medications which protect your heart.
- Manage your blood sugar levels.
- Exercise regularly.
- Eat healthily.
- Achieve and maintain a healthy weight.
The Budget
A big challenge in Nashville and nationwide is cost. Many patients who come into my concierge medicine clinic here in Nashville have questions (which I answer). Consider the following:
- Statins and ACE inhibitors are generic and inexpensive.
- SGLT2 inhibitors cost around $500/month without insurance.
- GLP-1 receptor agonists (Ozempic, Wegovy, Trulicity) run $1,000–$1,200/month.
- Icosapent ethyl (Vascepa) costs several hundred dollars a month.
The monthly cost of medications to prevent complications of diabetes and to achieve and maintain a healthy weight can easily run $2,000 to $3,000 per month, or $24,000 to $36,000 per year.
You may have insurance from your work. Everyone has the option to go to HealthCare.gov during the open enrollment period and choose their insurance. In my experience, I have found HealthCare.gov to be a well-organized website which allows you to express your choices about your insurance, as well as choose your monthly premium. You have the option to choose the insurance with the value for you. Look past the sticker price. Look at what you will receive.
Summary
- Diabetes is a coronary artery disease equivalent: Diabetes places you at risk for heart disease.
- Taking your blood pressure medication daily will reduce your risk of heart attack.
- Taking your cholesterol medication daily is critical.
- SGLT2 inhibitors and GLP-1 receptor agonists are remarkable drugs, forcing you to explicitly evaluate potential benefits versus present costs.
- Every choice has trade-offs which you can consider with your physician.
CTA
If you live in Nashville and want care that takes your diabetes and your heart health seriously, I invite you to reach out.
**Call Nashville Concierge Medicines at 615-708-0390.**
References
- Kannel WB, McGee DL. Diabetes and cardiovascular disease. JAMA. 1979;241(19):2035–2038.
- Haffner SM, et al. Mortality from coronary heart disease in subjects with type 2 diabetes and in nondiabetic subjects with and without prior myocardial infarction. N Engl J Med. 1998;339:229–234.
- Young LH, et al. Cardiac outcomes after screening for asymptomatic coronary artery disease in patients with type 2 diabetes (DIAD study). JAMA. 2009;301(15):1547–1555.
- Heart Protection Study Collaborative Group. MRC/BHF Heart Protection Study of cholesterol-lowering with simvastatin in 5963 people with diabetes. Lancet. 2003;361:2005–2016.
- Zinman B, et al. Empagliflozin, cardiovascular outcomes, and mortality in type 2 diabetes. N Engl J Med. 2015;373:2117–2128.
- Marso SP, et al. Semaglutide and cardiovascular outcomes in patients with type 2 diabetes. N Engl J Med. 2016;375:1834–1844.
- Bhatt DL, et al. Cardiovascular risk reduction with icosapent ethyl for hypertriglyceridemia. N Engl J Med. 2019;380:11–22.
