Diabetes and Heart Health with Ryan Garbalosa, DO, FACC

In this episode we talk with Ryan Garbalosa, DO, FACC, a cardiologist practicing in the Carolina East Health System in New Bern, North Carolina.

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Interview transcript below:

Steve Legault: Hello and welcome to the ACOFP.DO FM Clinical Podcast. I'm, Steve Legault, the Director of Knowledge, Learning and Assessment and host for this episode. Today, we're going to be talking about cardiovascular disease and type 2 diabetes. We're welcoming Ryan Garbalosa, DO, FACC to the podcast. He practices as a cardiologist in the Carolina East Health System in New Bern, North Carolina. He's an alum of Nova Southeastern University College of Osteopathic Medicine, completed his residency at Palmetto General Hospital, followed by a Fellowship at the Deborah Heart and Lung Center in New Jersey. Welcome to the Podcast Dr. Garbalosa.

Ryan Garbalosa: Thank you for having me.

Steve Legault: Excellent, well for today's conversation. I thought it would be great to discuss type 2 diabetes and cardiovascular disease in a few different sections, beginning with risk and prevention. So what are the most important cardiovascular risk factors to monitor in patients with diabetes.

Ryan Garbalosa: A large portion of our knowledge of cardiovascular risk comes from the Framingham Heart Study something that's been going on for 70 years, and the risk factors for diabetics are just about the same as the risk factors for all the rest of us things like smoking, high blood pressure, high cholesterol, you know, our old favorites things that we're all familiar with.

Steve Legault: How aggressively should blood pressure be managed in patients with diabetes to reduce cardiovascular events.

Ryan Garbalosa: Blood pressure is pretty important, and it's a modifiable risk factor. The most recent Acc Aha guidelines came out in about 2017. They changed the definition of blood pressure as well as stage one hypertension to anything over 130 over 80. It's a class, one recommendation to start pharmacologic therapy, and any diabetic with stage one hypertension. In addition to your usual lifestyle modifications, diet exercise, particularly the dash diet. Our goal is to keep blood pressures under 130 over 80, which will in turn reduce their cardiovascular risk, reduce, stroke, reduce heart attack, and that's kind of based off what we saw in the Sprint Trial. Blood pressure is pretty important. They recently changed the guidelines. In 2017 we had an Acc. Aha update to hypertension, and they changed the definition of stage one hypertension to anything that was over 130 over 80, and this made a lot more people hypertensive, including diabetics and diabetics being that they are a. They have a specific, they have a risk factor themselves for being diabetic, for hypertension. They recommend that you aggressively treat their blood pressure with a goal of less than 130 over 80. It's a class, one recommendation, in addition to lifestyle, modification, like the dash, diet and exercise, and the more aggressive you are with treating their blood pressure, the more heart attacks and strokes you prevent, and that comes from data from the sprint trial.

Steve Legault: Excellent. Well, thank you, and kind of getting into medication management for this. How do the newer diabetes, medications, the SGLT2 inhibitors and GLP-1 receptor agonists. How do they impact cardiovascular risk?

Ryan Garbalosa: They're all pretty favorable. Ever since the black box labeling of TZD medications for heart failure several years back there's been a lot of scrutiny over the development of new diabetic medications, and even though GLP-1s were around at that time with exenatide, which is no longer produced, the newer ones, like Semaglutide and Tirzepatide. They're like all over the news. You got patients asking for them, and they've been shown to be beneficial. They have a decrease in morbidity, mortality in certain patients and the new SGLT2 inhibitors as well, have been making waves in the community, especially in the cardiovascular community, with their benefit in heart failure, both heart failure with reduced ejection, fraction, and heart failure with preserved ejection, fraction.

Steve Legault: Excellent. Are there any specific antihypertensive or lipid lowering agents that provide the best cardiovascular protection for patients with diabetes.

Ryan Garbalosa: As far as lipid lowering agents, the 2018 ACC Guidelines and a 2022 consensus statement said that all diabetics should be taking a statin. The evidence is a little hazy for patients who are younger than 40 or over 75, so you'll have to have a little more discussion with those groups of patients the research kind of trends towards using the medication, especially in the older patients. You definitely shouldn't be stopping statins in patients over 75. If they're already on it, it's shown to be harmful. But if you have a patient who's 78, 79, starting a statin might not have a huge benefit for them, and it's kind of outside of the research and guidelines. So you can again discuss with the patient the guidelines recommend a moderate intensity statin, and that encompasses most statins. But there's no real reason not to use the high potency statins Atorvastatin and Rosuvastatin. They're the ones that are recommended for anyone with cardiovascular disease. They're all readily available. They're all generic. They're cheap. And the only reason I don't use them is if there's any kind of tolerability issue. Then I'll start looking at other medications to use as far as blood pressure medications go. Like we all know most you should be starting these patients on things like ARBs. There is a class 2 B indication for all diabetic patients that have albuminuria because of adrenal protective effects. And honestly, even if they don't have albuminuria. ARBs are still a class one medication. They're basically all generic. They're readily available. They're very well tolerated. So that's another very important medication to be using in diabetics. Now, you notice I didn't say ACE inhibitors, and I want to say this with the caveat that the ACC and AHA Guidelines do not make this distinction. This is from my own practice, my own experience, and my own interpretation of the data that's available. ACE inhibitors to me are kind of an antiquated medication. ARBs, ow they're generic, they're well tolerated, they do not have the side effect of cough. They have a much lower incidence of Angioedema. There's some research data trial 2019 in the British Medical Journal, showing that long-term ACE inhibitor use might actually have an increased risk of things like lung cancer. Even in my practice, treating heart failure. The number one class one recommended treatment for heart failure. ARB-wise is sacubitril valsartan, you know, an ARB combination. So in my practice, ACE inhibitors are kind of phased out, and I stick with ARBs.

Steve Legault: That's great insight, thank you for that. When should switching a patient from Metformin to medication with proven cardiovascular benefits, be considered.

Ryan Garbalosa: Whenever they can afford it. And all joking aside, I'll admit I'm not completely up to date on the family practice side of diabetics without heart disease, and how to start and initiate medications. But I do know that when they come to see me there's some heart things that we need to take care of, and all heart failure patients with both reduced and preserved ejection fraction should be on SGLT2 inhibitors like Mpagliflozin or Dapagliflozin. In addition to this. There's more data emerging with the GLP-1 inhibitors like Semaglutide. There's some research like the select trial that's giving them the patients with cardiovascular disease, even if they don't have diabetes, and it's showing some morbidity, mortality benefits. Data is still emerging with the GLP1s. But you know, from what we have, if you can get on these medications, it's probably a good idea to be on them. They're backed by some good data.

Steve Legault: Awesome. Thank you. All right. So, jumping into complications and co-morbidities, how should family physicians approach the prevention and early detection of heart failure in patients with diabetes.

Ryan Garbalosa: Prevention is as simple as risk factor modification. Make sure the blood pressure. Cholesterol is treated, avoid smoking, encourage diet, and exercise. If the patient's overweight, encourage weight loss. As far as early detection, you want to pay very close attention to the symptoms that the patient is having. There are no screening recommendations for cardiovascular disease, with diabetics for asymptomatic, diabetic patients. But the symptoms might be pretty insidious. You want to make sure that they're not having any. You know strange symptoms or not, outside of the typical symptoms of chest pain, and shortness of breath. They may be just feeling tired. They might have reduced exercise tolerance. You just want to keep a high index of suspicion for those things.

Steve Legault: Thanks. And you just mentioned some different lifestyle kind of choices that can be made. Are there any modifications that have the strongest evidence for reducing cardiovascular risk and diabetes.

Ryan Garbalosa: I don't think there's any trials comparing the effectiveness of each modification head-to-head, but we can look to data showing that tobacco is the number one cause of preventable death, preventable death for everyone, diabetics, non-diabetics alike. I doubt there's anything we can do better than just not smoking. There's robust data, also showing the benefits of the DASH diet which was developed for hypertension, but it's just an all around good diet. The Acc has a recommendation that you should do 30 min of exercise 5 days a week, and you can kind of play with that on your own. They give you some leeway. If you want to bunch it up, let's say 3 days do 1 hour of exercise. Let's say you're a weekend warrior, you want to do Friday, Saturday, Sunday, that's okay, too, and the moderate activity they define as just anything that gets you breathing harder than normal. You can be lifting weights. You can be running, jogging. Anything is fine.

Steve Legault: Excellent. Thank you. And so, for the final portion of the conversation, I'd like to talk about interdisciplinary care. So when should a family physician refer a patient with diabetes to a cardiologist.

Ryan Garbalosa: This varies dramatically based on where you practice and the availability of both your primary care, docs and cardiology. Anytime a diabetic patient has heart failure, any atherosclerotic cardiovascular disease, or any kind of concerning symptoms, a lot of chest pain, a lot of shortness of breath with activities, they probably should be seeing cardiology. Sometimes the things like difficult to control, hypertension and hyperlipidemia might take over treatment on those patients. Some insurance companies will require them to be seeing a specialist or a cardiologist if they want a newer fancy medication like a PCSK9  inhibitor. But I understand there's a lot of specialist shortages in a lot of areas and your threshold for referring someone is going to vary based on how soon you can actually get someone in.

Steve Legault: Yeah, you touched on something important there. So my next question was going to be around what are the best ways to coordinate that care between primary care and cardiology for those patients.

Ryan Garbalosa: It can be either really easy or really hard, depending on the EMR system you use. Unfortunately, you know, if you're all in the same EMR, you have something like epic or something, you can communicate with each other, send people messages, you get your notes right away, your lab tests right away. It's very difficult if everyone's on a different electronic medical record system, you just have to make sure that you get your notes, your information to your refer your specialist and to the referring physician, either by some kind of electronic fax, or even sometimes patients, come in with a packet of notes from their from their doctor, so they make sure I can see it. So, whatever you can do. But it is important to have that communication back and forth.

Steve Legault: Excellent. Well, just want to thank you for being on the podcast today and sharing some of this insight with us in our audience.

Ryan Garbalosa: Thank you. Thank you for having me pleasure to be here.

Steve Legault: And thank you for listening to the ACOFP DO.FM Clinical, podcast a production of the American College of Osteopathic Family Physicians.