While the general public probably has become increasingly aware of the key roles played by high blood pressure, high cholesterol, smoking and obesity in cardiovascular disease, they are less likely to understand the role of diabetes as a forerunner to a severe cardiovascular event. That is one conclusion to be drawn from a survey of about 900 physicians compiled last month at the 62nd annual scientific sessions of the American Diabetes Association (ADA; Alexandria, Virginia) in San Francisco, California.

Though the physicians surveyed said that they typically discuss reducing risks for cardiovascular disease (CVD) with nearly all of their diabetes patients, they also report that their patients with diabetes are only moderately knowledgeable about their increased risks for cardiovascular disease. In fact, primary care physicians and endocrinologists said they believe their patients perceive amputation and blindness as the greatest risks of diabetes.

The survey was commissioned by the ADA and the American College of Cardiology (ACC; Bethesda,Maryland), and the results support previous research by the groups indicating that more than two-thirds of those suffering from diabetes (68%) are unaware of their increased risk for heart disease and stroke. By contrast, the responding physicians ranked diabetes atop the list of risk factors for CVD, with 90% saying that people with diabetes are "very" or "extremely" likely to suffer a cardiovascular event.

John Buse, MD, chairman of the ADA's cardiovascular initiative, "Make the Link! Diabetes, Heart Disease and Stroke," said the survey underlines the awareness by healthcare professionals concerning the link between diabetes and heart disease, "but it also confirms our concerns that patients with diabetes are not making this link and, as a result, are not taking steps to reduce their risks." He added that physicians "need to be much more aggressive in their approach to treating patients with diabetes." He said that diabetes is more than just managing blood glucose. "It's also about managing blood pressure and cholesterol."

Those in the survey also reported "poor compliance" with lifestyle modifications and challenges with multiple drug regimens as a barrier for treating CVD risk factors in patients with diabetes. Robert Frye, MD, Rose and Maurice Eisenberg professor of medicine at the Mayo Clinic (Rochester, Minnesota), and a member of the ADA's advisory group to Make the Link!, said that physicians need to work harder at increasing patient awareness concerning the diabetes/heart disease connection.

This connection also was highlighted in a recent issue of The Lancet indicating that heart disease increases the chances for diabetes. Researchers in Sweden studied heart attack patients admitted to two coronary care units in that country and measured the glucose tolerance of those without diabetes while in the hospital, at discharge and three months later. Besides finding fairly high rates of undiagnosed diabetes, the researchers found that in the two groups, 35% and 40% of them had impaired glucose tolerance when they left the hospital. This didn't change after three months.

Underscoring the stealth of atherosclerosis

The death last month of St. Louis Cardinals pitcher Darryl Kile, 33, probably highlighted for the general public the often silent character of cardiovascular disease: that a significant number of people with atherosclerosis can die with few symptoms or none at all. While final autopsy results will not be available until later this month, preliminary evidence indicated that Kile's death was the result of extreme blockage of his coronary arteries, a problem that often goes undetected because of its stealth-like symptoms. Additionally, early reports indicated that his heart was enlarged about 20% beyond normal.

News stories said he had complained of pain in his arm and shoulder shortly before he died. But an earlier clearer warning that he might have needed aggressive diagnosis and therapy was the death of his father by heart attack in his 40s. Early on, team officials said that a preseason physical exam, including an electrocardiogram, had revealed no problems, but the overall thoroughness of the exam was not described.

The death will probably heighten awareness of the need for more thorough assessment of cardiac risk for everyone, even those apparently in very good shape since even someone of the pitcher's age and athletic background is never completely immune, according to the American Heart Association (AHA; Dallas, Texas). It estimates 15,000 Americans die each year as a result of atherosclerosis, with the large majority 65 or older. But of the younger people who die of the disease, 80% of these deaths occur with the first attack, according to the AHA, and 50% of those who die suddenly have had no previous warning symptoms.

AAOCA more detectable in children

New research pointing the way to detecting a cardiovascular defect in children was unveiled last month at the 13th annual scientific sessions of the American Society of Echocardiography (ASE; Raleigh, North Carolina) in Orlando, Florida. The defect, called anomalous aortic origin of a coronary artery (AAOCA), is considered the second-leading cause of sudden cardiac death in children. Normally only seen as the result of an autopsy, AAOCA may be detected through echocardiography, according to researcher Robb Romp, MD, of the Duke Pediatric Cardiovascular Program (Durham, North Carolina). Using transthoracic echocardiography, the researchers viewed the hearts of children and identified those most at risk for sudden death. They were able to diagnose nine patients who would have otherwise not been detected and were therefore at risk. Once detected, the defect can be corrected by open-heart surgery.