Diabetes – discipline and vigilance

By Dr. Muhammad Hafizullah

First question a cardiologist asks about a patient presenting with a heart disease is, "Are you diabetic?" Affirmative or negative reply determines the course of treatment. For same extent of illness, the plan may be very different for diabetic and non-diabetic patients.

Angioplasty may be preferred treatment for a non-diabetic where as bypass surgery may be chosen for a diabetic patient. Diabetic patients have been proven to do better with bypass surgery as compared to angioplasty. Even while performing angioplasty the choice of drug eluting stent versus bare metal stent is determined by diabetic status. Diabetic patients have better outlook with drug eluting stent with lower restenosis rates. Of course the choice of treatment translates into higher costs for treatment of diabetics.

My cardiologist informed me, "Not only that more diabetics sustain heart attacks they have more problems during a heart attack! Complications of heart attack as recurrent chest pain and heart failure are far more commonly encountered in diabetics versus non-diabetics. Death rate is higher in diabetics in the hospital stay and after discharge. Requirements for angiography and intervention like angioplasty and bypass surgery are higher in diabetics during the hospital stay after a heart attack."

I had always thought that bypass surgery is like a panacea for most cardiac ailments. Even here diabetics, I learnt, do not do very well.

More diabetics end up under the knife of the surgeon requiring bypass surgery as compared to non-diabetics. During the course of bypass surgery diabetics have more problems because usually vessels that require bypass are smaller in calibre and disease is more diffuse.

Grafts-conduits used for bypassing blockages implanted by surgeons cannot function very well if the disease is diffuse as blockages may develop in distal segments obstructing smooth flow of blood. Pumping of heart may be weaker in diabetic hearts hence causing problems during and after surgery, especially while patients are being removed from bypass machine. The stay in intensive care is more prolonged as diabetics encounter more problems such as infections. Healing of wounds of chest and legs is rather compromised and wound-related problems are more frequent. Average hospital stay is longer for diabetics after surgery.

Heart problems seem to follow diabetics like a shadow. Recurrence of heart problems like angina, unstable angina and heart attack is far more common in diabetics after a cardiac event like a heart attack, angioplasty or bypass surgery. For secondary prevention of subsequent events better and aggressive planning is required.

This entails more rigorous efforts to bring the levels of sugar, cholesterol and blood pressure lower by exercising more rigorously, following dietary restrictions more religiously and employing more drugs and higher dosages

A lot of research has been conducted in the field of diabetes and heart diseases. Based on extensive studies, recently, diabetes has been declared as equivalent to having had coronary heart disease or a heart attack by cardiology groups and diabetic associations. This necessitates more aggressive approach for diabetics to prevent heart diseases and strokes. Associated risk factors, which may not be very vital in non-diabetics, become more important in the setting of diabetes. More enthusiastic approach is required in treating the risk factors.

After all those details, my question to my cardiologist was, "Is it the end of world for diabetics or is there a way forward?" The scenario painted above, though realistic, has 'doom and gloom' written all over. The smile on his face ignited some candles of hope. "Of course these are the hard realities based on statistics but again there are many examples that had diabetes for decades and they lived a full life and enjoyed every moment of it. There are athletes, cricket and tennis players who have competed and won at highest levels in spite of diabetes. There are many statesmen, scientists, doctors, engineers, entrepreneurs and bureaucrats who are diabetics and lead a complete life. There are innumerable artists who in spite of their busy schedules and demanding hours have been able to keep diabetes under control and still enjoy all the bounties of life."

Diabetes is following a relentless course and its onslaught has to be checked. The treatment of all the different presentations of Coronary artery disease like angina, acute coronary syndrome, heart attack, heart failure and sudden death is very expensive and needs huge resources. Even the affluent western societies have failed to ensure free treatment for all the cardiac disorders. Our salvage lies in the prevention of disease. We need to identify the risk factors and devise a strategy for primordial and primary prevention. Non-modifiable risk factors like age, sex and family history determine the risk profile of a person and set the threshold for treatment. Diabetes can be prevented by watching diet, keeping weight in normal limits and most importantly exercising regularly.

The correct approach for the diabetics to adopt is to exercise more caution. Diabetes has to be regulated meticulously and aggressively. Diabetes enhances the risk profile and all the risk factors have to be taken seriously. One has to look for all the risk factors and treat them aggressively. Threshold for treatment of added risk factors should be lower and the treatment goals have to be lower than non-diabetics. Consequently more vigilance is required in diet and higher doses are needed to control the associated risk factors.  Smoking has to be discouraged and every effort has to be made to stop it. Obesity has to be controlled and exercise has to be encouraged.

The bottom line in the management of diabetes is "discipline and vigilance". Diabetes has to be tackled as an 'account' - a very precious and rewarding account, which requires very close vigilant monitoring on minute to minute basis. In diabetes, the effects of 'offenders' - dietary, exercise or reduction in drug have to be considered and risks have to be stratified. One has to be ready for the consequences for little indiscretions in diet, exercise and drugs.

Diabetes has to be considered like an enemy which is most unforgiving, though the effect may not be apparent there and then, but the price has to be paid back with interest in the due course of time.