1. & Laurence S. Sperling, M.D., FACC
Diabetes & CV Care Roundtable Session 3: Harmonizing Care Adapting the “Heart Team” Approach
June 20, 2017
Robert H. Eckel, M.D., FAHA
& Laurence S. Sperling, M.D., FACC

2. About the Presenters DISCLOSURES
Laurence S. Sperling, MD, FACC
Professor of Medicine
Director of The Center for Heart Disease Prevention
Emory University School of Medicine
Atlanta, GA
DISCLOSURES
No potential conflicts related to this presentation

3. About the Presenters DISCLOSURES
Robert H. Eckel, M.D.
Professor of Medicine
Division of Endocrinology, Metabolism and Diabetes
Division of Cardiology
Professor of Physiology and Biophysics
Charles A. Boettcher II Chair in Atherosclerosis
University of Colorado Denver Anschutz Medical Campus
Director Lipid Clinic, University of Colorado Hospital
DISCLOSURES
No conflicts related to this presentation

4. Partnership / Coordinated Care Critical
Chronic disease states
Recognition of negative consequences of fragmented care
Examples
HIV
Breast Cancer
Solid Organ & Bone Marrow transplantation
Endocrine Surgery

5. “Heart Team” Concept Adapt to a comprehensive diabetes care team
Central to TAVR , Multiple vessel CAD
(Class 1 Rec both European & ACC / AHA GLs)
Advanced heart failure , Adult congenital
Adapt to a comprehensive diabetes care team

6. Vital Importance of Involvement by an Informed Patient
Choices regarding diagnostic and therapeutic options should be made through a process of shared decision-making involving the patient and provider, explaining information about risks, benefits, and costs to the patient. I
IIa
IIb
III

7. The Heart Valve Team and Heart Valve Centers of Excellence
Recommendations
COR
LOE
Patients with severe VHD should be evaluated by a multidisciplinary Heart Valve Team when intervention is considered I C
Consultation with or referral to a Heart Valve Center of Excellence is reasonable when discussing treatment options for 1) asymptomatic patients with severe VHD, 2) patients who may benefit from valve repair versus valve replacement, or 3) patients with multiple comorbidities for whom valve intervention is considered
IIa

8. Heart Team Approaches to Revascularization Decisions
A Heart Team approach to revascularization is recommended in patients with unprotected left main or complex CAD.
Calculation of the STS and SYNTAX scores is reasonable in patients with unprotected left main and complex CAD. I
IIa
IIb
III I
IIa
IIb
III B

9. BARI 2D Trial: Primary Endpoint
5-year death rate
difference did not reach statistical significance.
Death (%)
n =155
n =161
BARI 2D Study Group, NEJM 2009

10. Risk Factor Goals Smoking Status: No smoking* LDL-C: <100 mg/dL*
Non-HDL-C: <130 mg/dL*
TG: <150 mg/dL**
SBP: <130 mmHg*
DBP: <80 mmHg*
Hemoglobin A1C: <7%*
*Goals based on Smith S et al. AHA/ACC Secondary Prevention Guidelines 2006 Update. JACC 2006;47:2130-9

11. Additional studies are needed to define optimal target levels for systolic BP and A1C for patients with T2DM.

12. Treating the ABCs Reduces Diabetic Complications
Strategy
Complication
Reduction of Complication
Blood glucose control
Heart attack
CVD
37%1
10%2
Blood pressure control
Cardiovascular disease
Heart failure
Stroke
Diabetes-related deaths
51%3
56% 4
44% 4
32% 4
Lipid control
Coronary heart disease mortality
Major coronary heart disease event
Any atherosclerotic event
Cerebrovascular disease event
35% 5
55%6
37%6
53%5
1 UKPDS Study Group (UKPDS 33). Lancet. 1998;352:
2 Kelly TN et al, Ann Int Med 2009:
3 Hansson L, et al. Lancet. 1998;351:
4 UKPDS Study Group (UKPDS 38). BMJ. 1998;317:
5 Grover SA, et al. Circulation. 2000;102:
6 Pyŏrälä K, et al. Diabetes Care. 1997;20:

13. Suboptimal CVD Risk Factor Control in T2DM
2018 adults, years old without CVD, 43% male, 55% African Americans - MESA, ARIC, Jackson Heart Study
42% HbA1c <7%
41% BP <130/80 mmHg
27% LDL-C <100 mg/dl
7.2% at goal for HbA1c, BP, and LDL-C
 risk of CVD with # of risk factors controlled
1 – 36%
2 – 52%
3 – 62%
Wong ND et al. Diabetes Care, 39: , 2016

14. “Heart Team”- Key Elements
Patient is center of the heart team
Shared decision making
Core is multidisciplinary coordinated care
Focus on:
Integrated practice unit
Improved quality/ outcomes
Systems approaches
Holmes D, et al Eur Heart J 2014;35(2):66-68
Head SJ, et al Eur Heart J 2013;

15. Diabetes Comprehensive Care Team (DCCT)
Minimal “Start team?
Optimal care team?
Infrastructure
Alignment of incentives/goals
Need to change reimbursement model and what is “valued”

16. The Minimal “Heart Team”
Preventive cardiologist
Diabetologist
Certified Diabetes Educator
Nurse Practitioner, RN and/or RD

17. The Optimal “Heart Team”
Preventive cardiologist(s)
Diabetologist(s)
Certified Diabetes Educator
Nurse Practitioner, RN and/or RD
Pharm D
Ready access to consultants
Nephrology
Retinology
Podiatry
Vascular medicine
Non-Invasive Imaging
Cardiology and/or radiology

18. Cardiometabolic Health Alliance / Diabetes Collaborative Registry
American College of Cardiology
American Association of Clinical Endocrinology
National Minority Quality Forum
Association of Black Cardiologists