NEWS RELEASE --------------------------------------------------------------------- --- HIDDEN HEART HAZARDS IN PEOPLE WITH DIABETES REPORTED Risks Beyond Glucose Control Identified; Aggressive Testing and Treatment Advised June 9, 1996 (SAN FRANCISCO, CA) -- People with diabetes may develop severe heart disease over many years without any symptoms, such as chest pain, and merit special testing and treatment to help preserve heart function, according to reports presented here today at a symposium on Diabetes and Heart Disease at the American Diabetes Association's 56th Annual Scientific Sessions. "Diabetes is the third leading cause of heart disease among Americans, and heart disease is the leading cause of death among people who have diabetes, making this an extremely important area of study," reported George L. Kin, MD, who chaired the symposium, in a recent interview. He is a senior investigator at the Joslin Diabetes Center in Boston and an associate professor at Harvard Medical School. Symposium participants described the special heart disease hazards that may face people with diabetes, how they should be evaluated and treated with an emphasis on preserving function of the left ventricle -- the key pumping chamber of the heart -- to help decrease their greater risk of sudden death, and cutting edge research underway to develop new therapies. Approximately 16 million Americans have diabetes, a serious disease that affects the body's ability to produce or properly respond to insulin, a hormone that allows blood sugar to enter the cells of the body and be used for energy. In addition to heart disease, diabetes also can lead to other severely debilitating or fatal complications, such as blindness, kidney disease, stroke, and amputations. It is the fourth-leading cause of death by disease in the U.S. Hidden Heart Hazards "Even though coronary artery disease is more prevalent among those with diabetes compared to the rest of the population, the majority of diabetes patients do not have an adequate warning system to tell them that they have heart problems," reported Richard W. Nesto, MD, co-direcor of the Institute for Prevention of Cardiovascular Disease, Deaconess Hospital, at Harvard Medical School. "In particular, those with neuropathy -- damage to nerve fibers commonly seen in diabetes -- do not have angina or chest pain, although they may have such supposedly atypical symptoms as sweating, nausea, vomiting, shortness of breath, fatigue, and disorders of glucose regulation." People who have such symptoms should report them to their physicians promptly and discuss having a comprehensive cardiac evaluation. "Too many patients with diabetes are diagnosed with coronary artery disease when it is far advanced and can no longer be treated aggressively because of years of silent heart damage," he amphasized. He hopes that greater awareness of their defetive chest pain warning system and more rigorous evaluation will get more patients into treatment sooner -- before a heart attack occurs. Focus on Left Ventricular Function Although it is commonly believed that coronary artery plaques (atherosclerosis) are the main heart problem in people with diabetes, recent studies indicate that the most important determinant of survival in diabetes following a heart attack is the status of the heart's main pumping chamber. Disorders that cause heart disease fatalities -- including sudden death, congestive heart failure and cardiogenic shock -- are usually related to the inability of the heart to pump correctly. "Diabetes entails a wide variety of conditions that impair the ability of the left ventricle to heal after an acute myocardial infarction, leading to an exaggerated decline in its function beyond that predicted by the extent of the coronary artery disease alone," said Dr. Nesto. "Therefore, strategies to protect left ventricular function are paramount for people with diabetes." Recent clinical trials have shown that the response of diabetes patients to such traditional heart drugs as aspirin, beta blockers, lipid-lowering agents, and ACE inhibitors help to increase their survival after a heart attack, in some cases to a greater degree than in patients without diabetes. Caution on Testing While Dr. Nesto urged that people who have had diabetes for more than ten years, especially those with other heart disease risk factors -- such as hypertension, overweight, smoking, and family history of heart disease -- should be considered for coronary disease screening such as by exercise stress testing, he cautioned about potentially problematic results. "Care must be taken in screening asymptomatic individuals due to the false positive rate, which can lead to unneccessary, expensive and high risk procedures," he warned. "Nonetheless, people with diabetes have such a high prevalence of coronary disease and such a high mortality that screening may be warranted even in the absenc of symptoms." Special Risk Factors While the risk factors for heart disease are similar in those with and without diabetes, Steven M. Haffner, MD, professor of medicine at the University of Texas Health Science Center at San Antonio reported that people with diabetes seem to have some extra problems, such as smaller and more dense LDL -- the so-called "bad" cholesterol. Further, while good blood glucose control is helpful in preventing heart disease, his studies who its effect to be relatively modest. "Recent data suggests that even before clinical diabetes is diagnosed, these people are at increased risk for cardiovascular disease due to greater problems with blood pressure and lipid abnormalities," he explained. "So a strategy to fully prevent the excess risk of cardiovascular disease would depend not only on glycemic control but also on aggressive treatment of all heart disease risk factors among those with diabetes as well as those at high risk of diabetes."l Insights for Tomorrow Willa A. Hseuh, MD, professor of medicine and chief of the division of endocrinology, diabetes and hypertension at the University of Southern California, discussed mechanisms of cardiac remodeling -- a damaging process in which heart muscle cells enlarge and other cells increase production of proteins that hold the heart together -- leading to heart failure. Animal studies suggest that the high blood glucose levels seen in diabetes may accelerate some of these mechanisms. Victor Dzau, MD, chairman of the department of internal medicine at Stanford University School of Medicine, discussed new molecular approaches now being explored for the treatment of heart disease. Instead of using drugs to normalize heart function, he and his colleagues are pioneering the introduction of new genes into the heart or coronary arteries to reverse heart failure or atherosclerosis. Promising animal studies might offer hope to those with diabetes and atherosclerosis, because both have similar clinical consequences. ---------------------------------------------------------------------