Cleveland_Clinic_Host: Welcome Dr. Hoogwerf and thank you for being with us today. Let's begin!

Speaker_-_Dr__Hoogwerf: I am happy to be here today

Metabolic Syndrome

kathleen: Can you explain what is metabolic syndrome? I have heard about this but don't really understand it.

Speaker_-_Dr__Hoogwerf: Metabolic Syndrome is a cluster of risk factors for heart disease including increased waist circumference, high triglycerides, low HDL (good) cholesterol, high blood pressure and high blood sugar.

Speaker_-_Dr__Hoogwerf: If you have any 3 of these you are diagnosed of having the metabolic syndrome. Combinations of these risk factors increase the risk for heart disease. Each of the components is a target for treatment - ie. weight loss, blood pressure control, blood sugar control if you have diabetes, and cholesterol/triglyceride treatment.

lakewatch: Can metabolic syndrome be reversed by weight loss induced by Byetta and exercise?

Speaker_-_Dr__Hoogwerf: Yes, many features of the metabolic syndrome can be favorably affected by exenatide (Byetta). About 85% of all patients on Byetta lose weight. In the top quartile of weight loss in recent studies there were small reductions in blood pressure, marked reductions in triglycerides and increases HDL cholesterol along with improved glucose control.

Diabetes, Pre-diabetes and Heart Disease

rosemarie: I am a 45 year old female diabetic who has a history of heart attack and bypass surgery. Am I at greater risk for the need for future bypass surgery?

Speaker_-_Dr__Hoogwerf: Women who have both diabetes and a history of heart disease as evidenced by CABG are a very high risk for future heart disease. There is compelling evidence that reduction of LDL cholesterol reduces this risk substantially. Blood pressure control and aspirin use also reduce risk. Use of medications like ACE inhibitors have shown reduced risk. Trials are underway to determine whether blood sugar lowering with reduce the risk for future heart disease—although most clinicians believe that reducing blood sugar will help reduce future risk for heart disease or need for future interventions

maryann79: My husband is 45 years old and just had a heart attack. He is very overweight. He had angioplasty and stent after his heart attack to his LAD. He is on medications orally for his diabetes, but his sugar averages about 220. The triglycerides are about 230. He should watch his diet more but I am at a loss for what to do as he will not listen to me. If you could tell me just one thing to focus on, maybe that would help.

Speaker_-_Dr__Hoogwerf: Your husband would be classified as very high risk for future heart disease and stroke and perhaps peripheral arterial disease (blockage of the blood vessels to the legs). The most important risk factor to target is his ldl cholesterol which by NCEP guidelines would be a value under 100 mg/dl and most of us would believe his ldl should be less than 70 mg/dl.

Speaker_-_Dr__Hoogwerf: His triglycerides may come down with improved blood sugar control. A blood sugar average of 220 is typically a hgbA1c of about 9 percent. This is well above the current recommended guidelines. Most patients with patient this high require multiple glucose lowering medications or the need to start insulin. Many endocrinologists would seriously consider the use of exenatide (Byetta) as a part of his regimen. As it may have a favorable effect on weight loss, triglycerides, and blood sugar. Blood pressure also needs to be controlled. I realize this is targeting more than one thing but each of his risk factors should be treated to reduce his risk for future vascular disease.

paul57: I am a 50 year old male that had cabg surgery and have been diagnosed with pre-diabetes. What is that? Do I have to take pills?

Speaker_-_Dr__Hoogwerf: Pre diabetes is a term generally used for people whose blood sugar levels have not yet reached the threshold of diabetes (Fasting blood sugar of 126 or higher). But are elevated typically in the range of 100 - 125. People in this range have an increased risk for heart disease and some increased risk to develop diabetes in the future. Several large studies have shown that diet and exercise (5% loss of body weight and 150 minutes a week of exercise) substantially reduces the risk to develop diabetes.

Speaker_-_Dr__Hoogwerf: Three large studies have looked at pills to reduce the risk to diabetes. One with metformin, rosiglitazone, and one with carbohydrase inhibitor called precose. These trials have not yet resulted in general use of these medications to prevent diabetes.

paulk: What is microvessel disease? Is it more common with diabetes?

Speaker_-_Dr__Hoogwerf: Small blood vessels in the body are damaged by diabetes. Most commonly the abnormalities are associated with diabetic retinopathy (damage to small vessels in the back of the eyes)and nephropathy (damage to small vessels in the kidneys). There is accumulating information that small vessels in the heart and or extremities and brain may be affected by diabetes. How much this contributes to heart disease risk is unknown.

Speaker_-_Dr__Hoogwerf: However, recent studies suggest that it may be more important than previously thought in women with diabetes. There are no good measures to study small vessel disease in the heart however.

newborn2304: Ten months ago I had a heart surgery to by-pass three coronary arteries. Now I have good heath, but my sugar level in the blood is around 110. Is that value a risk factor?

Speaker_-_Dr__Hoogwerf: This value is a risk factor but not necessarily a therapeutic target. Meaning, that other risk factors such as cholesterol, blood pressure, and the need for aspirin may be more important than the blood sugar.

bobw44: I am a 60 year old male with coronary artery disease and diabetes. Is bypass surgery or angioplasty a better option for me if I am offered both?

Speaker_-_Dr__Hoogwerf: The decision about angioplasty vs. CABG is influenced by the nature of what your angiography shows. An older study called BARI did suggest that CABG was better in diabetic patients however the angioplasty techniques were not nearly as sophisticated as they are today. Angioplasty is in many cases simpler and associated with less risk than CABG. Therefore, the benefits vs. the risks need to be individualized and discussed with your treating physicians.

sharon101: I am a 50 year old diabetic woman that was diagnosed with coronary artery disease during a routine physical and stress test. I have good control of my diabetes but read that diabetics do not always feel they are having symptoms of chest pain. I am worried. How will I know if I need to call the doctor or seek emergency help?

Speaker_-_Dr__Hoogwerf: Your question addresses one of the difficult dilemmas that face patients with diabetes and their treating physician.

Speaker_-_Dr__Hoogwerf: Patients with diabetes are less likely to have traditional chest pain and this is especially true in women.

Speaker_-_Dr__Hoogwerf: Attention to changes in exercise tolerance, shortness of breath with exercise, nausea with exercise, may be angina type symptoms. These symptoms should be brought to the attention of your health care provider.

Speaker_-_Dr__Hoogwerf: Many cardiologists recommend regular stress testing in diabetic patients with established coronary artery disease to try to detect "silent" disease before it becomes a problem.

castleman: As a diabetic (Type II) what specific complications are possible with after bypass surgery? I have bypass surgery scheduled in September and I want to know what to expect.

Speaker_-_Dr__Hoogwerf: One of the main concerns in diabetic patients who undergo CABG is an increased risk for sternal wound infections and infections at vein graft sites after the procedure. There is evidence that careful blood sugar control immediately after surgery may reduce this risk. You should inquire about the procedures at your hospital. Diabetic patients may also be at increased risk for closure of bypass grafts. Studies done 10 years ago show that cholesterol lowering may be one of the important ways to reduce this risk.

Diabetes and Medications

sharon101: If I have high blood pressure, I think some of the medications can be bad for diabetes. What should I avoid? Is coreg ok?

Speaker_-_Dr__Hoogwerf: As noted in a previous response, some blood pressure medications may have an effect on blood sugars and the ability to detect low blood sugar reactions. Coreg has less of an effect on blood sugar than some other beta blockers in small comparative trials

richard04: I am nervous about all the information in the news lately about oral diabetes medications. What is the safest medication to take if you have a history of heart disease?

Speaker_-_Dr__Hoogwerf: All diabetes medications have some risks. The safest medications in patients with a history of heart disease is still insulin, which can be used with all sorts of heart related medications, and even in the face of heart failure and kidney problems.

Speaker_-_Dr__Hoogwerf: The recent story about TZDs comes from early clinical trials and suggests some patients there may be some risk for heart disease, However there are several large trials underway that will answer this question more definitively.

Speaker_-_Dr__Hoogwerf: Decisions about avandia use should be discussed with your physician. Other medications that are generally safe in the presence of heart disease is metformin (glucophage) which has been available for several decades. It should not be used if you have reduced kidney function or serious heart failure. The sulfonylureas have also been available for several decades and are among the most commonly used agents in people with heart disease.

Speaker_-_Dr__Hoogwerf: Newer agents including exenatide (Byetta) or the glyptims (Jnuvia) appear to be safe in heart disease although they have not been around as long. Combinations of these agents are often necessary for blood sugar control The best combination for you should be determined by working with your physician.

Speaker_-_Dr__Hoogwerf: There are a number of herbal medications that have been proposed to lower blood sugar. None have the demonstrated efficacy of approved prescription medications. Whereas biological sources of many medications are well known. The variability of herbal medications is such that routine use for sugar control is not recommended.

Speaker_-_Dr__Hoogwerf: Furthermore, although popular opinion may hold that herbal medications are safe, this is not a safe assumption. There may be interactions with other medications used in the treatment of heart disease for example coumadin.

Diabetes and Diagnostic Testing

mattcol552: My mother is a diabetic. She is 80 years old and has an angiogram procedure scheduled next week. Are there risks for diabetics who have to undergo this type of procedure?

Speaker_-_Dr__Hoogwerf: Angiogram procedures for the heart, brain and lower extremities are quite safe in good hands. They are never entirely without risk but generally done in people in which the information is necessary to make decisions about surgery.

rgs52: If your A1C is 7 – what does that mean? What is a normal range?

Speaker_-_Dr__Hoogwerf: Hemoglobin A1c of 7 percent is associated with an elevated blood sugar. In many studies it represents an average of 150 mg/dl. The normal range for most Hg A1c assays is 4 - 6 percent. Some people with established diabetes can have levels within the upper limits of normal. The higher the Hg A1c, the greater the risk for eye and kidney complications of diabetes.

kovacsv: How often should a person screen for Diabetes whether they do or do not have risk factors?

Speaker_-_Dr__Hoogwerf: The American Diabetes Association generally recommends annual screening with a fasting blood sugar in people who are at high risk and every few years in people at low risk. High risk characteristics include a family history in first degree relatives, obesity, or components of the metabolic syndrome. Other diseases associated with risk include depression, hepatitis C, and the use of medications like prednisone.

pat: I see a regular doctor and a cardiologist and now I found out I have diabetes. Do I need to see a special doctor for that or can my regular doctor handle it?

Speaker_-_Dr__Hoogwerf: At least 70 percent of the people with diabetes are managed by their primary care physician. Patients on more complex regimens or with significant complications of diabetes should consider a referral to an endocrinologist. Many cardiologists also feel comfortable managing diabetes.

pamlittle: If I have to fast before my cholesterol test, should I still take my diabetes medications? What happens if they get too low?

Speaker_-_Dr__Hoogwerf: Many of us recommend taking your diabetes medications after you have had your blood test. Some medications do not increase the risk for low blood sugars such as metformin, the TZDs (avandia and actos), or sitigliptin.

Speaker_-_Dr__Hoogwerf: These drugs can generally be taken safely in the fasting state. We often recommend that blood pressure medications can be taken in the fasting state. You should discuss what your treating physician recommends.

Insulin Resistance, Pre Diabetes, Diabetes, and Future Risk for Cardiovascular Disease

canadabob: I was told I am insulin resistant. I am overweight and I have high blood pressure. I try to exercise and I am starting to watch my diet to lose weight. I am on lipitor 40 mg but my LDL is still 120. If I get my blood sugar down, will it help my LDL or do I need to be on more lipid drugs? Can I keep trying diet and exercise to get my blood sugar down? When do you have to start on a medication?

Speaker_-_Dr__Hoogwerf: Insulin resistance refers to the fact that your body requires more insulin to keep blood sugars under control. many people with insulin resistance will develop diabetes. Insulin resistance is often associated with features of the metabolic syndrome.

Speaker_-_Dr__Hoogwerf: Regular exercise and weight loss will improve insulin resistance. Weight loss may also be associated with reduction in LDL cholesterol. Although weight loss may affect blood sugar and LDL, simply lowering blood sugar will not necessarily decrease LDL. If your LDL is above target on your current dose of statin, options include: increasing the dose of your statin or adding another class of medications such as ezetemibe or resins.

Speaker_-_Dr__Hoogwerf: Most physicians suggest adding a medication for blood sugar control when your HgA1c (blood test for blood sugar) is greater than 6.5 or 7 percent

robertl: If you have diabetes and it is in good control are you still at risk for heart disease and stroke. I take glucophage. I am in good control. What else do I need to do to prevent a heart attack. My dad had his first heart attack at 50 years old.

Speaker_-_Dr__Hoogwerf: In general patients with impaired glucose tolerance (pre diabetes) and people with diabetes are at increased risk for heart attacks and strokes in comparison to their nondiabetic counterparts. Whereas increased heart disease risk is associated with increased blood sugar levels, large clinical trials have not yet confirmed that glucose lowering will reduce the risk for heart disease.

Speaker_-_Dr__Hoogwerf: The results of the ACCORD trial addressing this question will be available in 2010. There are multiple clinical trials of LDL cholesterol lowering showing the benefit of this strategy to reduce the risk of heart disease and stroke in diabetic patients. In addition, blood pressure control reduces the risk especially in stroke. Unless there is a contraindication diabetic patients should take low dose aspirin.

Speaker_-_Dr__Hoogwerf: Finally large clinical trials using ace inhibitors have suggested the benefit in diabetic patients to reduce heart attack and strokes beyond the effects on blood pressure control.

Diabetes and Vascular Disease

rgs52: I have diabetes. My A1C is between 6 and 7. Lately I have numbness sometimes in my legs and cramps in my legs if I walk too long. What does that mean? Do I need to get checked?

Speaker_-_Dr__Hoogwerf: Leg cramping can be associated with diabetes. It can also be associated with some of the medications commonly used in diabetic patients, including statins (for cholesterol) or blood pressure medications. Diabetic patients are at increased risk for peripheral vascular disease especially if they have a history of smoking. Screening for peripheral vascular disease can be done with testing called pulse volume recordings or PVRs.

jasonl: My dad had a stroke and they said one of the risk factors is diabetes. I have type 2 diabetes. I am overweight but I am trying to lose weight. What should I look for? What should I do? I am worried.

Speaker_-_Dr__Hoogwerf: You should have regular checks of at least a fasting blood sugar. Because obesity is associated with cholesterol, triglyceride and blood pressure abnormalities - each of these risk factors need to be followed carefully as well. As noted in a prior response, weight loss and regular exercise are the best way to reduce the risk for diabetes. Regular evaluation and treatment of these risk factors is the best way to reduce your risk for future heart disease, stroke and diabetes.

Diabetes and Heart Rhythm

kjf317: Are there some heart rhythm problems that are related to diabetes? I just started having atrial fibrillation. Is that because of my diabetes? Are there medications for the atrial fibrillation that will not be good for my diabetes?

Speaker_-_Dr__Hoogwerf: There does not appear to be rhythm problems that are specific to diabetes however diabetic patients are at increased risk for coronary artery disease, which in turn may be associated with abnormal heart rhythms. Beta blockers are often used in atrial fibrillation. These agents may raise blood sugar and triglycerides. However, if beta blockers are the treatment of choice, they are not contraindicated in patients with diabetes.

Speaker_-_Dr__Hoogwerf: Diabetic patients on insulin may also have difficulty detecting hypoglycemic (low blood sugar) reactions when on beta blockers. Other commonly used agents, including amiodarone do not appear to have an affect in diabetes. Thyroid function tests do need to be followed on all patients on amiodarone.

smithm: I have syncope and I am being evaluated now for treatment. Is there a link between diabetes and syncope?

Speaker_-_Dr__Hoogwerf: Syncope may be associated with low sugar reactions. Syncope may also be associated with abnormal heart rhythms as a result of heart disease in diabetes. Some medications formerly used in diabetes such as cisapride had an affect on the heart's electrical mechanism. These drugs are no longer available in the U.S.

Speaker_-_Dr__Hoogwerf: In general syncope evaluation in diabetic patients is the same as those without diabetes.

Diabetes and Renal Artery Disease

west2az: What is the relationship between diabetes and kidney disease? What does one have to do with the other? Is it caused by high blood pressure or diabetes? I have both and my doctor is watching my kidneys.

Speaker_-_Dr__Hoogwerf: Diabetes increases the risk for kidney disease called diabetic nephropathy. The addition of high blood pressure significantly worsens the risks of diabetic nephropathy. High blood pressure by itself is also a cause of kidney disease. Treatment of diabetic nephropathy with hypertension includes not only intensive glucose control but intensive blood pressure control. The blood pressure regimen should include an ace inhibitor or ARB. Small studies suggest the combination may have additional benefit but also additional risks for potassium related problems.

Cleveland_Clinic_Host: Dr. Hoogwerf thank you again for taking the time to answer our questions today.

Speaker_-_Dr__Hoogwerf: Thank you for having me .

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