One of the most serious complications of diabetes is heart disease. Approximately 65 percent of diabetics will develop some form of cardiovascular disease during their lives, yet physicians are still struggling to determine the safest and most effective treatments for diabetics who have suffered heart attacks. After reviewing more than 8,000 cases from the Medicare database, Robert Wood Johnson Foundation (RWJF) Clinical Scholar 2009-2011 Kasia Lipska, M. D., discovered that older diabetics had higher levels of mortality after surviving a heart attack when they were discharged from the hospital without medications designed to manage their blood sugar.
“We conducted this research because we have lots of good diabetes studies, but we don’t know enough about translating that research into effective care,” said Lipska, an endocrinologist. “We are good at understanding the mechanism of diabetes and targeting it, but that does not always provide the best results in patients. An example would be the drug rosiglitazone (marketed as Avandia). It successfully lowers blood sugar, but with possibly severe side effects, such as an increased risk of heart attack. This shows that patients will not necessarily do better if you just focus on their blood sugar level,” she explained.
“For our study, we examined the effect of diabetes medication on the mortality of diabetic heart attack survivors,” Lipska said. Her work, “The Discontinuation of Anti-Hyperglycemic Therapy and Clinical Outcomes in Older Patients with Diabetes after Acute Myocardial Infarction,” was published in the March 2010 issue of Circulation: Cardiovascular Quality and Outcomes.
“We focused on diabetes patients who came into the hospital taking glucose-lowering medication, but were discharged, after heart attacks, with new treatment regimens. We found, for instance, that one in eight were discharged without a prescription for any diabetes medication at all. We could not determine if the patients did not want that level of care, if there were medical reasons for stopping the medications or if the physicians simply forgot to add the medications to the care regimen," Lipska said.
“In a separate study, conducted with my colleague, Kay Lovig, M. D., we reviewed the charts of a smaller sample of people with diabetes who had suffered heart attacks and found that nothing was said about why the medications were changed in 90 percent of the cases, even though many hospitals require medication reconciliation. Many patients may not know to ask: ‘Why aren’t my diabetes medications here?’” Lipska added, “For this reason, physicians must be more vigilant about giving careful discharge instructions.”
New Research on Better Treatments
“I’m now studying additional care issues for diabetics who have had heart attacks,” Lipska explains. “In 2011, in conjunction with the Mid-America Heart Institute, I hope to release the results of research on the impact of glucose variability on mortality while these patients are in the hospital.”
Lipska and her team decided to tackle the issue because current research offers conflicting advice about what levels of blood sugar best contribute to healing after a heart attack. “Some research shows that tight blood sugar control around the time of a heart attack may be harmful. Other studies show the opposite effect,” Lipska said. “We do know that if a person has a high average blood sugar after a heart attack that portends a worse outcome. Now, we want to see whether it matters how much the glucose levels rise and fall during a hospital stay.”
Changing the Way Doctors See Diabetes
Lipska credits her experiences as an RWJF Clinical Scholar with helping her to learn how to conduct better research and use her findings in ways that will genuinely help patients. “The support I’ve received as a scholar has been amazing. I’ve gotten great training and a perspective on how research can contribute to policy and improved care,” she said. “Being mentored by faculty and other scholars who think about issues in this way is extremely helpful.”
“I’m learning that it is important to question existing assumptions. For example: does lowering a risk factor for a disease necessarily lead to improved patient outcomes? In the case of diabetes, I would like to understand which methods of lowering blood sugar best improve the lives of patients,” Lipska said.
The Robert Wood Johnson Foundation Clinical Scholars program supports physicians through training, development and teaching research methods that may help them find solutions to many of the challenges physicians face when providing care. To learn more about the program, visit: http://rwjcsp.unc.edu/. To keep up with the latest projects conducted by RWJF scholars, fellows and alumni, as well as updates about their programs, visit Leaders Link.