During a Current Issues debate at the Scientific Sessions, four experts examined whether distinguishing between primary and secondary prevention strategies can improve cardiovascular disease outcomes for diabetes patients. The virtual presentation featured separate debates about atherothrombotic complications and heart failure complications.
Drawing the Line between Primary and Secondary Prevention—Necessary or Too Simplistic? can be viewed by registered meeting attendees at ADA2020.org through September 10, 2020. If you haven’t registered for the Virtual 80th Scientific Sessions, register today to access all of the valuable meeting content.
Christie M. Ballantyne, MD, and Roger S. Blumenthal, MD, debated the need to distinguish between primary and secondary prevention strategies for atherothrombotic complications.
Dr. Ballantyne said the simplest approach would have all diabetes patients at high risk for atherothrombotic complications undergo corresponding aggressive treatment. But this one-size-fits-all approach involves expensive add-on therapies such as PSK9 (proprotein convertase subtilisin/kexin type 9) inhibitors, GLP-1 (glucagon-like peptide-1) receptor agonists, and SGLT2 (sodium-glucose cotransporter 2) inhibitors.
The intensity of lipid-lowering therapy depends on the absolute risk of coronary heart disease, with an emphasis on individually tailored treatments, Dr. Ballantyne said. The greater the risk, the greater the benefit from more aggressive interventions, he added, noting that guidelines published by the American Heart Association/American College of Cardiology and the ADA distinguish between primary and secondary prevention in their treatment algorithms.
“It’s important that we look at both primary and secondary prevention as a starting point in terms of how we’re going to differentiate therapies,” said Dr. Ballantyne, Professor of Medicine and Director of the Maria and Alando J. Ballantyne, M.D. Atherosclerosis Clinical Research Laboratory at Baylor College of Medicine. “Clearly, people in secondary prevention are at greater risk and need more intensive therapies.”
Roger S. Blumenthal, MD, Professor of Medicine at Director of the Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, supported aggressive treatment starting earlier for patients with diabetes, especially if a high-intensity statin and generic ezetimibe can be used.
While noting that clinicians worry about different recommendations from various guildelines, Dr. Blumenthal said he likes the concept of the 2019 European Society of Cardiology/European Atherosclerosis Society guidelines for the management of dyslipidemia. Those revised guidelines for secondary prevention recommend an LCL-C level of <55 mg/dL for patients with atherosclerotic cardiovascular disease (ASCVD) and other high-risk conditions.
The correct paradigm, Dr. Blumenthal said, is to focus on preventing atherosclerosis rather than ASCVD events alone. He advises diabetes patients that LCL-C <55 mg/dL is optimal.
“If I can get those numbers down early on with lipid-lowering therapy, preferably with a high-dose statin, then I have more time in my visit to spend on the more difficult things like fine-tuning diet and exercise,” Dr. Blumenthal said.
The second half of the session focused on heart failure complications.
Milton Packer, MD, Distinguished Scholar in Cardiovascular Science at Baylor University Medical Center, noted that the debate title didn’t properly frame the question. Once a patient has heart failure, it’s no longer possible to prevent heart failure, he said, so there’s no such thing as secondary prevention of heart failure.
Interventions used to prevent heart failure by addressing risk factors generally are not effective for patients with established heart failure, Dr. Packer continued. Conversely, interventions used to treat heart failure don’t have proven preventative effects to address early risk factors.
The correct question to ask is whether it’s necessary to draw a line between prevention of heart failure in a patient with no prior heart failure and treatment of heart failure in a patient who has heart failure. In response to that question, Dr. Packer answered yes.
“If we do not, we will be treating many people with the wrong drugs at the wrong time for the wrong type of heart failure,” he said.
Javed Butler, MD, MPH, MBA, Professor of Physiology and Chairman for the Department of Medicine at the University of Mississippi, said that prevention strategies have traditionally been divided into three categories: primary, secondary, and tertiary.
“These categorical bins in which we put these diseases may be OK conceptually. But as we understand the disease processes more and the science progresses, I think that this may serve—from a public health perspective, from a disease perspective—to be inaccurate,” Dr. Butler said.
It’s often easy to divide treatments for diseases into these prevention categories, but not syndromes like heart disease because of the near impossibility of determining the onset of heart failure. That inability makes focusing on the difference between primary and secondary prevention too simplistic, Dr. Butler said. Instead, focus on event prevention. Whether it’s preventing the first or recurrent hospitalization from heart failure, the prognosis remains the same, he said.