A diabetic patient asked me the other day about an article he had read, warning that diabetes by itself puts one at the same risk as someone who has had a previous heart attack.

Although compilation (meta-analysis) of observational data suggests that diabetes may be a coronary heart disease (CHD) equivalent, I think this is a bit exaggerated, causing undue anxiety for many diabetic patients.

If one’s diabetes is diagnosed early and treated adequately, the risk is not that significant and almost equal to that of a nondiabetic. However, if one’s diabetes has been long-standing, say, more than 10 years, with erratically controlled blood sugar levels due to an unhealthy lifestyle and poor compliance in taking one’s anti-diabetic medicines, then the risk of developing a heart attack may be equal to, if not higher than, that of a nondiabetic heart attack survivor.

Monitoring does not necessarily require pricking oneself daily to check blood sugar levels, although this may be ideal in patients on insulin. The physician may just request a certain blood test called glycosylated hemoglobin (HbA1c) every three to six months. The HbA1c level is a reflection of average blood sugar levels over the last three to four months. The goal is to keep it less than 7 percent.

We don’t want it too low, because of the risk of hypoglycemia or low blood sugar levels. This may carry more risks than someone with slightly elevated blood sugar levels. In fact, some diabetics may also get heart attacks with very low blood sugar levels.

Elderly patients

So, in elderly patients, doctors prefer a higher HbA1c level of around 7.5 percent. In frail elderly, especially those who cannot communicate anymore if they’re not feeling well, a higher level of 8 percent up to 8.5 percent may be preferred. This emphasizes that hypoglycemia may be riskier in this age group than a modestly elevated blood sugar level.

In the elderly, it’s best to follow the “principle of least intervention” because sometimes, they develop more complications with more aggressive treatment. I don’t even prescribe any diet on my patients 80 years old or older. I allow them to eat anything they want, but of course, in moderation.

Some also get depressed and lose their zest for life. I have been frequently criticized for my liberal attitude in elderly patients, and so, when the newer diabetes guidelines got published, recommending higher blood sugar levels for this age group, I sort of felt vindicated.

Diabetes is just one of the risk factors for heart attacks and cardiovascular disease (CVD) in general. Preventing a heart attack, especially a repeat heart attack, is of utmost importance. Two years ago, top cardiovascular experts in Europe gathered and came out with recommendations on how to prevent a repeat heart attack.

The biggest consequence of CVD is myocardial infarction (heart attack), according to professor Massimo F. Piepoli, the lead author of the consensus paper published in the European Journal of Preventive Cardiology. Someone who has had a heart attack, particularly a diabetic, has a 20-percent risk of having another serious “cardiovascular event in the first year.”

A “cardiovascular event” is a general term for complications including a heart attack, stroke, and death from a cardiovascular cause. This level of risk remains even if one is receiving optimal treatment and care. For those who are not optimally treated, or are not compliant with treatment, the risk is even higher.

If a heart patient thinks that taking a palmful of medicines or having a stent inserted in his arteries are assurances against a second heart attack, he or she is in for a disappointment. A heart-healthy lifestyle is still the most effective way to avoid another heart attack, according to ESC prevention spokesperson professor Joep Perk. This, supported with good medical treatment and regular follow-up, markedly reduces the risk.
Stop smoking totally

According to the paper, to prevent a repeat heart attack, one should stop smoking (totally!), engage in regular physical activity, eat a heart-healthy diet (high fiber, low animal fats), and take prescribed medications to protect heart arteries, prevent atherosclerosis (slow gradual blockage of the arteries), and control risk factors such as high blood pressure and high bad cholesterol (low density lipoprotein type of cholesterol).

A usual drug regimen for heart attack victims would consist of blood thinners like aspirin, statins—drugs for cholesterol taken even if cholesterol levels are normal, due to their other effects—heart-protective drugs like an angiotensin converting enzyme (ACE) inhibitor, and a beta-blocker.

These used to be expensive drugs, but with a lot of generic brands in the market, they are now well within the reach of the ordinary patient. Hopefully, our local drug manufacturers can duplicate what India has done by manufacturing a “polypill,” a single capsule or tablet containing all these essential drugs. The polypill is usually cheaper than the total cost of the individual components, and patient compliance is also enhanced since they only have to take one pill.

Of course, the effectiveness of these heart pills may be nullified if one continues to smoke. “Stopping smoking beats everything for preventing heart attacks,” Professor Perk explained. “Combine that with exercise and a healthy diet and we could avoid 80 percent of all myocardial infarctions.”

According to a previous survey done in Europe, despite all counseling after a heart attack, 16 percent of patients still smoke, 38 percent remain obese and 60 percent are sedentary with little or no physical activity.

I’m not aware of any similar survey among Filipinos but I suspect it’s worse here. The attending physicians must make more intensive and consistent efforts to motivate their patients to minimize their risk for another heart attack.

“Having a heart attack is an upsetting experience but it does not seem to motivate patients to adopt a healthy lifestyle to avoid having another one,” professor Piepoli lamented. “We also know that more than half of heart attack patients stop taking their preventive medications.”

Professor Piepoli summed it up well: “We have scientifically proven ways to prevent second heart attacks. But we need to empower patients to better understand their risk factors after myocardial infarction and take a central role in their recovery.”

In a way, preventing a repeat heart attack is a personal commitment. The doctor can only prescribe, educate, support and motivate, but making that life-changing decision rests on the patient.