Diabetes is not about sugars alone. In fact, glucose is the fourth variable I will look at with diabetes. The first is overall cardiometabolic health including percent body fat, exercise patterns, and fitness. The second is evidence of cardiovascular disease. The third is lipid patterns, especially the triglyceride to HDL ratio indicating atherogenicity. Last is the hemoglobin A1C level. Why is so much attention paid to glucose when other variables predict morbidity and mortality to a great extent? Unfortunately, many patients were told that if they did not improve their sugars, they would have a heart attack or stroke. This was proven wrong by the UKPDS3, ACCORD4, ADVANCE5 and VADT6 trials. In fact, overall mortality increased slightly! CVD-real7, EMPA- reg8, CANVAS9, DECLARE10, LEADER11 and SUSTAIN-612 trials, to name a few, have all changed our “goal” when treating diabetes mellitus. The goal should not be hemoglobin A1C, but reducing the cardiovascular morbidity. Most clinicians do not know that the definition of diabetes with a hemoglobin A1C of 6.5% was defined based on diabetic retinopathy and not the associated cardiovascular disease.
Cardiologists must now remove their blinders when it comes to cardiovascular prevention. Lowering a diabetic’s LDL from 90 to 70 mg/ dL after a cardiovascular event with ezetimibe as in the IMPROVE-IT trial13, resulted in a 2% absolute risk difference after 7 years and is minimal compared with the risk reduction of discontinuing the sulfonylurea, adding an SGLT-2 inhibitor as well as a GLP-1 agonist and considering pioglitazone when appropriate. Additionally, as most patients with type 2 diabetes have elevated triglycerides, adding icosapent ethyl has been associated with a 25% to 30% risk reduction14. Bromocriptine, in its safety study15 has been associated with a decreased cardiovascular composite endpoint by 40%, although further large-scale studies need to be undertaken. In statin intolerant patients or those not at LDL goal, a PCSK–9 inhibitor should be added. When a patient has progression of atherosclerosis, one has to change a variable besides mechanically opening up the vessel to prevent it from happening again. Frequently, this is not done especially if the lipid levels are “within normal limits”. Einstein said it best with his definition of insanity, which is doing the same thing multiple times and expecting a different result.
