A renowned specialist panel consisting of a cardiologist, ophthalmologist, neurologist and nephrologist discusses how to manage complications of diabetes - cardiology session.
Back to Symposium Page » okay. With that, I'm gonna turn to our next speaker. Dr Bruce Camera. He is a cardiologists. That's part of the script Mercy Group and has really a specialized expertise in ultrasound and in particular, handheld ultrasound. I have known Bruce for many, many years and have seen this evolve over the many years that he's been doing that this he is an international speaker and renowned for the research he's done in this area. He trains all the residents down their mercy, had how to use this. So, you know, just think about how this might be used in the future is part of routine medical care. And you know, that's what Bruce is trying thio take us into for the future. Andi. He's going to touch on a topic that maybe it's not a Z, clearly cardiology, but incredibly important in diabetes, Nash and early fatty infiltration of liver in other areas. And because of his expertise in this handheld ultrasound, he's seeing a lot more of this. So, Bruce, I'm gonna let you take it away. Thank you, Athena. It's so great to see you. Good afternoon, everybody. Because it's Friday the 13th. I am going thio have to switch here into this different mode. Onda. Hopefully that shows up. Are we good there, Athena? So thank you, Athena, for for having me. This is, um, my area, which is point of care ultrasound. And I thought I'd give a 15 minute blurb on how I use ah, point of care, ultrasound and diabetes or in pre diabetes. And probably more importantly, how I interpret the literature that's coming in in regards Thio, the diabetic advancements that we're seeing. So I have no complex to disclose. And let me just show you this when I show this this is Renee Lennox original stethoscope. When I show this to my kids, the first thing they ask is, um what end do you look through? And e say no, you don't look through this thing. You you put one end of your ear and the other end went against the patient's chest. And then they ask the second question Well, then why do you call it a stethoscope? Because you're not seeing anything. And that's absolutely correct. They should be renamed audio Stepha phones, and that includes what we use now. We used an audio stepha phone because we really didn't have a stethoscope, something we could see into the chest with until about 2007. These were pocket sized original devices that came out. There were about 8000 bucks low, pricey, and they had the cardiac frequency and hear the early models of them. But of course, you know, trust technology, and things will get cheaper there now under $2000 they're multi frequency. They hook up to your phone. Um, and very soon, uh, available now are ones that don't even have a wire they can project to. Any screen in the room wasn't that wonderful, even project to a screen outside of the room, believe it or not. And these will be chock full because they're hooked up to your phone. The chock full with so much AI that they'll make a lot of the diagnoses that I'm talking about in today's talk automatically. So this is just briefly that's that audio steps of phone. That's our stethoscope, and these are the new pocket sized ones that you could see. And as I said, hook up to your phone and now even, um, even wireless with AI on them. So I've spent a good portion of my career looking at, How would I taken ultrasonic stethoscope and actually put it on a patient's chest? And what would I look for now? Now that we're talking about, we're not listening to anything. What would I look for? And this is the clue exam we came up with, which looks at all evidence based targets, but in particular it was to be used in the office on an outpatient and be done within two minutes. And in that examination, within it are three spots that were particularly useful for patients with diabetes. And I want to go over those today. The three spots are looking at the left atrial size, looking at the carotid for minimal or trivial after Romans plaque and then looking at, um, the liver for fatty infiltration and these finding you cannot find with your audio stepha phone. You need your ultrasonic stethoscope. So the first target, just real brief ultrasound here is on the left is a normal left atrium. You can see the LV, the L A. In the aorta and what we're gonna do if you could see my little arrow here, is that the aorta diameter in this case is larger than the left. Mhm the left atrium. It's got a smaller diameter than the aorta that's normal. That's a normal left, a trail size. Well, when you're left, atrium gets bigger. Look on the right with left H enlargement. It's obvious that the left atrium is bigger than the aorta that's left a trail enlargement. So the sign that we're talking about is when the left atrium looks larger than the aorta. Very simple. It has about an 80 percent sensitivity specificity for left atrial enlargement. When you measure it by echo and, of course, by echo, we trace the the left atrium, and we calculate volumes based upon an assumption of a pro late ellipse shape. Um, and But even if you look just at the diameter in these 52,000 echo referrals from Spain, the larger the diameter, the mawr, your mortality is. So if a severely enlarged left atrium has a 40 60 55% um, 10 years survival. I'm sorry, 45% 10 year survival. So we actually look to say, how could could could you learn this? Couldn't resident learn how to do this? And the answer is Yes. After only one hour of training you guys, I bet you would easily begin to see how you can see this from across the room on the left atrium is larger than the aorta. You don't need a lot of of echocardiography training to recognize this, but we want to step further. We said, Well, does this sign actually matter? Let's not talk about diamonds. Let's just say does this sign actually matter? And we went to Kaiser and we proved that yes, it does. That left atrial enlargement sign on 62 year old outpatient, uh, patients referred for echo. Their mortality in five years was 23%. If they have the left atrium, Marchment signed versus 8% if they didn't. So this sign meant something. And when you plot it on the diameter of those Spanish referrals that study, it falls right along with mild to moderate left atrial enlargement. So let's start talking about diabetes does left actual volume index, which is the newer echo cartographic image. Uh, does it relate to, um, outcome? And the answer is yes. Just like the left atrial enlargement sign does, it relates to survival and cardiovascular outcomes but what's important about this slide? What I find important about the slide is when you look at this cohort of type two diabetes. 34% had mild or greater left atrial enlargement in this population study. If you take other population studies of these same aged individuals, let you'll find left atrial enlargement in 5%. So it's much more common if you have Type two diabetes. So why is it so mortal left? Atrial enlargement relates to a schema. Here's a Here's a left actual size and how it relates toe echocardiography relates to stress echo results, and you can see what whether you're echo your stress. Echo result is normal or abnormal, which is the dotted lines through the left atrial left atrium. Being dilated is prognostic. In addition, in a meta analysis of just echo studies Left Tho enlargement relates to stroke Andi. That's reasonable because of the effect of hypertension, um, and atrial fibrillation in those studies, and then finally left. Actual volume also predicts, instead of heart failure because it relates to BNP. Yeah, here's the rub. In diabetes, a fib is three times more common and has a higher risk for stroke if you have diabetes And, um, you know that by the chad score the chads vast score where diabetes is a risk factor for high risk for stroke. This very recent study came out and in a Danish registry showed I've I've over lied. I've put on top these him equality. Once he percentages in in, um on top of this graph and you could see as the risk of embolism or stroke occur that it relates to your hemoglobin a one c diabetic control Thea Other bad thing is that CHF is three more three times more common in diabetes as well. And here you can see both the prevalence and incidents in a Kaiser cohort of, um, chf. If, uh, if you have diabetes versus control and this is particularly important because now, as you just heard with the SG lt two inhibitor data, what drives a lot of the mortality or at least within the combined in points of mortality, is a very strong signal for hospitalized heart failure. So could it be that the people who are really benefiting from SG lt to inhibition are the people who are developing left atrial enlargement and that will be a very interesting question to answer. Um, as time as time goes on, let's go to Target number two. Now shifting to the Karate Kid, The carotid is, you know, the best predictor of diseases, the disease itself. If you can see the disease in the carotid bifurcation, which is a very prone bifurcation, then in a way, whatever your cholesterol is, it's too high for you because it's already gotten into your, uh, your arterial wall. So the carotid plaque is a good surrogate for a high risk patient with, um, Afro sclerotic disease. Can residents learn how to do this? Yes, they can. Just after one hour of instruction, they develop these sensitivities and specificities and accuracy. And that's only after one hour of looking at minimal disease disease you could not hear with the stethoscope. If you look at population studies like the Mesa trial, whether you have plaque or not really starts to separate, um, survival curves and incident cardiovascular disease curves. And if you use our threshold that we use 7.55 to 7.5% 10 year risk of death or CHD endpoints, you end up seeing that it separates between people who are black and you don't have black. And note that 42% of these patients who are 61 years old had created plaque. So why does this matter in the diabetic patient? Well, it turns out the prognosis is even worse, just like with a fib, just like with, um, chf if you have diabetes. Here is Avian Vienna's University of Vienna study um, that looked at patients with diabetes and without diabetes and stratified them to whether that they had plaque less than 50% or greater than 50%. And here you can clearly say that the worst group is the group that has diabetes and a credit plaque greater than 50%. And maybe that's the person that you get aggressive on. Maybe that's the person you get their l D l less than 50. Um, maybe that's the person you look for GOP one agonist therapy for because of such a high cardiovascular risk, maybe that's the person you start aspirin on. Alright, Now Target three is the is the most exciting when I think and it is fatty liver. Now, this is how we make fatty liver, uh, in a goose because a goose is a migratory bird and it needs to fly a long distance, and therefore it needs, ah, lot of calories. So we feed it grain and we get this liver that's fatty, that we call for Agra, right? We love that on, and it is a a twist in this country, a form of animal abuse. So, um, but But there are two organisms on here that have fatty liver. And of course, that's one we're concerned about his fatty liver, though. Unlike the goose, you have the first rule out the influence of alcohol. The liver normally contains less than 5% fat, and we're gonna call by ultrasound fatty liver when it gets the 30%. Although various gold standard studies, depending on your gold standard, vary the content between five and 30%. And finally Favre 50% fat. That's why it tastes okay. Just a quick review. It's the most common liver disease. One in three people have it in the United States. It has surpassed. Alcohol is the number one cause of cirrhosis associated with diabetes, obesity, metabolic syndrome, trackless rides happens when you're about 50 peaks at about 50 75% of the obese have nah fold, or now it's being called metabolically associated fatty liver disease or muffled. 40% of national patients are obese. Um, the 10 to 30% of of natural patients get Seattle hepatitis, which we call Nash, uh, in 10 years, and that can progress to cirrhosis and finally, cirrhosis to peddle cellular. See a three key is that serious liver disease occurs in 2 to 4 times higher if you have Type two diabetes. So these three targets left NATO enlargement, um, current disease and fatty liver disease, especially mortal in the diabetic patient. Here's the progression. They call this the to hit hypothesis. You store your fat in your liver, and then it becomes an oxidative stress. Stella cells become activated and you start to fight gross. So off 100 patients with type two diabetes 75 will get natural. 20 will get. Nash, too, will get cirrhosis and and point to will get past cellular. You are sort of the figures, and these are the tools you can use to detect these things. Uh, abdominal ultrasound lt being positive at the Nash stage and some fibrosis scoring or scanning within cirrhosis. So how do you know which of your three patients has the natural? Who has? Never. Then when should you screen them? Should you screen them when they're young, when their Children or as they get older and who has gnashed? Well, ultrasound has very high sensitivity and specificity and can be easily learned. But it's very subjective. As you can tell, this is what we're looking at, the brightness of the liver to the right. It does look like Pat A and the cortex of the kidney, which is dark when this is brighter than the kidney. In this case, there is fatty liver as your diagnosis. Everything. Here's a normal example where they are equally ECA genic. Like I said, this is a very easy visual diagnosis, which has some subjectivity. But the sensitivity specificity in this study was excellent, and these people learned in 20 minutes after looking at a prototype image, So what are we supposed to do? There are no guidelines on screening for this in in America. The A s L. D. Said there are no recommendations for screening, even in high risk groups like diabetes. European guidelines say yes. No, we want you to screen, want you to screen with LFTs and an ultrasound, especially in high risk patients. And in the UK guidelines, there is no recommendations for screening. So when you the literatures replete right now, but since there's no no formal recommendations for suggested recommendations, and here are two for examples. But when you look at these, for example, that keep in mind that they're trying to measure how maney inappropriate referrals goto hepatitis hepatology ists because we don't have that many hepatology around. So what are you supposed to do? Well, these, uh, these physicians these review papers looked at on Lee the high risk patients that is patients with Type two diabetes and who are over 50 years and to screen them with an L T. And an abdominal ultrasound. And once you get those back now, granted, your abdominal ultrasound could be at the bedside. Once you get those back, you calculate 1/5 4 score or uh, natural score, and you determine if they're at high risk for fibrosis. And if they are, you could either get what's called a fiber scan by yourself, or you could refer them to hip pathologists, and they can decide how to stratify them. The American Diabetes Association says it is time to include Nash and the management of patients with Type two diabetes in the same way you do retinopathy or no for apathy, and that they recommend that patients with Type two diabetes and elevated a lt or or fatty liver on the ultrasound should be evaluated for Seattle hepatitis or liver fibrosis. So finally, so what does this mean? What do these three targets that you can't hear but can see with an ultrasound stethoscope? How would they affect the next 100 patients that you see in your clinic? Well, you can make arguments now, based upon the literature that perhaps people left NATO enlargement. They might do better with an SG lt two inhibitor. And those patients with at the aroma might be better with the highest intensity treatment, even as primary prevention or dealing with the residual risk with EPA or GLP one agonists. And maybe within Apple, you spend more time focusing on weight loss even modest and exercise. Well, I because this is, ah, case, that's for me worth 1000 words, because this is a friend of mine who's who's in a choreographer. And I told him, Hey, you know what? We were looking at his liver. You have fatty liver. Would you mind being a volunteer to be a model? And that was in 2014. He had a risk H a risk of 17%. And he should have been on Lipitor 80. And I said you had the two most obscene words evidently in medicine, which is fatty and liver. And when I put them together, he didn't forget it. He said. You told me I had fatty liver. I want it changed my life. And how did it change his life? Well, first, let me give you his baseline. It was 58 weight, 1 60 trackless rights for 12. And he had snaffled. So he started to exercise 45 minutes a day. He started to juice use portion control. He lost a modest amount £10 and he said he slept better. But his risk felt the next year to 6.6. And so when I invited him back to be a model for our ultrasound conference, he didn't have natural anymore, but and so I couldn't use him. And this is what he's done as his age has gone up, his weight has gone down his triglycerides. If I have gone down and he no longer has evidence of snaffled on ultrasound, and last year he finished a triathlon, and he attributes all this for me, calling him ah, patient with fatty liver. And I do think if you show patients these results, you get much, much more bang for your buck. It's not just for you that your imaging, this patient, the images affect their behavior. So, in summary, number one left atrial enlargement 30% of time, crowded plaque, 50% of time and fatty liver 70% of time are very common things that you're going to see in your patient population. Importantly, healthcare providers can screen for these targets after only three hours of training, which is, you know, it could be done during this course, um, and get relatively modestly priced pocket sized ultrasound devices to do physical examination on the next 100 patients. And what would happen while patient compliance, risk stratification and cardiac care could potentially be improved by using point of care Ultrasound e want to thank you guys for your attention, and I'll hand it back to you. Athena. That was great. Bruce, thank you so much. Absolutely fascinating.