Type-2 Diabetes Requires Comprehensive Cardiovascular Risk Reduction

Cardiovascular risk reduction in patients with type-2 diabetes should include the use of SGLT2 inhibitors and/or GLP-1 receptor agonists (GLP-1RAs), according to a new report from the American College of Cardiology (ACC).

"We believe the most important recommendation is that cardiologists consider these medications as important tools to improve the outcome of their patients with cardiovascular (CV) disease and type-2 diabetes (T2D)," said Co-Chair of the writing committee Dr. Brendan M. Everett of Brigham and Women's Hospital, Harvard Medical School, in Boston.

"Specifically, the medications in these two classes that have shown benefit on cardiovascular outcomes should be considered as medicines offering cardiovascular benefit, and therefore another therapeutic option for cardiologists caring for these high-risk patients," he told Reuters Health by email.

Intensive glucose control has been shown to improve microvascular outcomes in patients with T2D, but clinically important improvements in hemoglobin A1c have not been associated with improved cardiovascular outcomes in patients with T2D and cardiovascular disease.

Many SGLT2 inhibitors and GLP-1RAs have been shown to significantly reduce the risk of major adverse cardiovascular events in patients with T2D and CV disease beyond their direct glucose-lowering effects.

Dr. Everett and colleagues provide practical guidance on the use of specific agents for reducing CV risk in patients with T2D in their expert consensus decision pathway. They suggest that cardiovascular specialists should play a key role in screening for T2D in their patients with or at high risk of CV disease; that CV risk factors should be treated aggressively; and that newer glucose-lowering agents with evidence for improving CV outcomes should be incorporated into routine practice.

They recommend that cardiologists concurrently optimize guideline-directed medical therapy for prevention (including lifestyle, blood pressure, lipids, glucose and antiplatelet agents) and recommend starting SGLT2 inhibitors or GLP-1RAs with proven cardiovascular benefit depending on patient-specific factors and comorbidities.

Based on the available evidence, an SGLT2 inhibitor with demonstrated cardiovascular benefit is recommended for patients with T2D and heart failure or who are at high risk of developing heart failure, diabetic kidney disease, clinically evident atherosclerotic cardiovascular disease (ASCVD), or any combination of these conditions.

A GLP-1RA with demonstrated cardiovascular benefit is recommended for patients with established or at very high risk for ASCVD.

A new diagnosis of T2D in patients like these should prompt a patient-clinician discussion about starting one of these classes of medication to improve cardiovascular outcomes.

There may be specific situations in which combination therapy with SGLT2 inhibitors and GLP-1RAs is appropriate, but the strategy has not been studied for cardiovascular risk reduction and out-of-pocket costs of using both classes of drugs may be very high for some patients, the authors write.

Co-Chair Dr. Sandeep R. Das of UT Southwestern Medical Center, in Dallas, told Reuters Health by email, "There is now absolutely compelling data for the medications discussed here to improve 'hard' cardiovascular and renal outcomes (such as heart attack, heart failure hospitalization, progression to end stage renal disease) in patients with diabetes. Their effects on blood glucose are, frankly, less important than their CV and renal benefits. Cardiologists need to get comfortable with prescribing these drugs themselves rather than deferring to the patients' diabetes-care providers to do that."

"It is really exciting to have these new tools in our kit to help improve outcomes in our patients and to be able to improve their cardiac and renal outcomes," he said.

Dr. Everett added, "We hope that physicians will be able to understand the benefits and risks of each of these medications, and that they will be able to use that understanding to work together with their patients and their patients' other providers to identify the best agent with CV benefit. We hope the document provides them with enough information to help their patients make an informed decision, and then to feel comfortable prescribing one of the medications and monitoring their patients for any potential adverse effects."

The complete report, including detailed evidence supporting the recommendations, appears in the Journal of the American College of Cardiology and is endorsed by the American Diabetes Association.

"We anticipate that the algorithms proposed here will change as new evidence emerges but that the overarching goal of improving CV outcomes in patients with T2D and clinical ASCVD will remain consistent," the authors note.

—Will Boggs MD

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