Arriving at the Crossroads of Diabetes and Cardiovascular Disease
Melissa Magwire, MSN, RN, CDCES authored the following post as a part of PCNA’s collaboration with the Know Diabetes By Heart TM initiative.
Getting to the Heart of the Issue
The decision to become a cardiovascular nurse occurred at the same time that I decided this noble career was the path I would be taking. An elementary school assignment that had me tracing a drop of blood through the entire circulatory system not only fostered my love of anatomy and physiology but shaped my decision regarding my choice of employment as a graduate nurse. What began thirty-two (32) years ago with me practicing as a Certified Critical Registered Nurse (CCRN) on a Telemetry-ICU step-down unit has in many ways come full circle despite many changes to the path along the way.
Responding to life-threatening arrhythmias, providing life support to patients in crisis, and better yet, recognizing the early signs of cardiac decompensation and avoiding the crisis were what I found as gratifying endeavors early in my career. As challenging as the job was, it was a patient named Jack that changed the way I looked at my role in nursing and started my journey from that of a CCRN to a Certified Diabetes Care and Education Specialist (CDCES) for the next 27 years.
Jack was what those of us on the unit, unfortunately, referred to as a “frequent flyer”. Over the two years that I knew Jack, he had received care on my unit no less than nine times. Jack had been living with known cardiovascular disease for over 10 years with revascularization attempts too numerous to count, impending dialysis, multiple TIAs, one minor stroke, all in the setting of type 2 diabetes. Jack lost his battle with cardiovascular disease during one of my shifts and while it was a massive MI that precipitated his death, the attending Cardiologist correctly informed his family and surrounding nursing team that it was in fact type 2 diabetes that ultimately lead to his death.
Making the Connection but Still Missing the Mark
The realization that it was not solely the large MI that lead to Jack’s death, but the 30 years of type 2 diabetes serving as the catalyst for the next phase of my nursing career as an outpatient CDCES. What better way to prevent other patients from having to fight the losing battle that I had witnessed Jack and his family wage than to focus on one of the biggest contributing factors. While I was fortunate to be taken under the wing of an amazing Endocrinologist who made it his mission to improve the life of our patients, we still lost many to cardiovascular complications. With each new glycemic lowering medication that came to market we thought perhaps now we could better prevent the cardiovascular damage that so many of our patients experienced despite our never-ending push to lower their A1cs.
While the numerous landmark clinical trials in this space and time had shown us that glycemic control could indeed lead to fewer microvascular complications, the picture for prevention of macrovascular complications was still murky and as such, became very glycemic-focused as well. We felt as if we were doing our due diligence as we educated our patients that keeping their A1c in control was the most important thing they could do in order to prevent cardiovascular complications. Conversely, our cardiovascular peers were telling their patients that under their management, blood pressure and cholesterol levels were the keys to avoiding complications. While both of these campaigns waged on, cardiovascular disease continued to lead to morbidity and mortality in our patients.
A New Path Forward
The next fork in the road occurred as a result of the 2008 FDA regulations requiring all new glycemic lowering therapeutics to undergo cardiovascular safety outcome trials. As the results of these trials began reporting out, a new, heightened emphasis on cardiovascular risk and treatment focus in the setting of type 2 diabetes began to take shape. Primary care practitioners, Endocrinologists, and Cardiologists all agreed that there was evidence that these new therapeutic options not only work to lower glucose but provide cardiovascular risk reduction, lower incidents of MIs, Heart Failure, strokes, and cardiovascular death despite A1c levels. The challenge now became who should drive this holistic cardiometabolic approach as it would require providing care outside of the traditional silos of type 2 diabetes and cardiovascular disease.
As my chosen career was focused on improving the lives of those living with diabetes, it seemed like a perfect time to use my skillset in a very nontraditional setting for an outpatient CDCES. Having worked in both the cardiovascular and endocrinology arenas, I was fortunate enough to meet some of the trailblazers in this new Cardiometabolic focused space. I made the leap from a traditional outpatient Endocrinology practice back to Cardiology where I had started so many years before. My next challenge was to assist in the design and implementation of a new and novel approach to care in which type 2 diabetes and cardiovascular disease were treated as Cardiometabolic disease and not as separate disease states. The successes of this approach to care were seen early on and have served as a springboard in building momentum in other sites across the country as health care providers strive to redefine care in the cardiometabolic continuum.
Not only have healthcare professionals changed their approach to care in this space, but professional associations and societies have also made great strides in merging approaches to cardiovascular care in the setting of type 2 diabetes in the attempt to view these two disease states as one that should be looked at as a singular health condition. An example of this collaboration is seen in the Know Diabetes by Heart™ campaign in which the American Heart Association and the American Diabetes Association joined forces with the goal to reduce cardiovascular death, heart attack, stroke, and heart failure in people living with type 2 diabetes.
Call to Action
While the advent of this new focus on viewing type 2 diabetes and cardiovascular disease with a holistic, cardiometabolic lens is a step in the right direction, there is more work to be done. Cardiovascular disease is the leading cause of death and a major cause of heart attacks, strokes, and heart failure for people living with type 2 diabetes – yet in a recent survey of people age 45 and older with type 2 diabetes conducted online by The Harris Poll, only half recognize their risk or have discussed their risk for heart attacks or strokes with their health care providers. It is vital that the conversation regarding the link between type 2 diabetes and cardiovascular disease occurs early and often with every patient living with type 2 diabetes and that decisions in treatment are made taking this new focus to the heart of the matter – improving the lives of those living with cardiometabolic disease.
Please visit Know Diabetes by Heart for additional information and tools to support your practice.