Note to myself: In addition to this post, please review:
- Link To And Excerpts From The Vidcast And Transcript To “ACC Pathway Empowers Cardiologists to Use Diabetes Drugs for Heart Disease” From Medscape. Posted on November 1, 2019 by Tom Wade MD
- Link To And Excerpts From The Article ACC Decision Pathway on CV Risk Reduction in T2D and ASCVD. Posted on November 2, 2019 by Tom Wade MD
- Link To “Video | ACC Decision Pathway on CV Risk Reduction in T2D and ASCVD: Key Points from the 2019 ACC Task Force on Expert on Expert Consensus Decision Pathways”. Posted on November 2, 2019 by Tom Wade MD
- Links To And Excerpts From “2018 ACC Expert Consensus Decision Pathway on Novel Therapies for Cardiovascular Risk Reduction in Patients With Type 2 Diabetes and Atherosclerotic Cardiovascular Disease”. Posted on November 2, 2019 by Tom Wade MD
Here is the link to and excerpts from the vidast and transcript of ACC Pathway Empowers Cardiologists to Use Diabetes Drugs for Heart Disease by Anne L. Peters, MD. July 24, 2019 from Medscape.
Here are excerpts from the above transcript:
Today I’m going to discuss the American College of Cardiology (ACC) Expert Consensus Decision Pathway[1] on novel therapies—the SGLT2 inhibitors and GLP-1 receptor agonists—for cardiovascular risk reduction in patients with type 2 diabetes and atherosclerotic cardiovascular disease.
Cardiologists are concerned because cardiovascular disease is the leading cause of death in patients with diabetes. Indeed, 65% of deaths in patients with diabetes are due to cardiovascular disease. They have higher risks for coronary heart disease, heart failure, and stroke.
Even though our diabetes drugs have not primarily been shown to reduce cardiovascular disease risk until recently, we have been able to show that lowering glucose levels reduces risk for microvascular complications such as nephropathy, neuropathy, and retinopathy.
We now have these tools [the SGLT2 inhibitors and GLP-1 receptor agonists] that can help reduce macrovascular events in our patients, which puts cardiologists in a good position to discuss using these agents for the treatment of patients with type 2 diabetes and established cardiovascular disease. Most patients with type 2 diabetes see a primary care doctor who can also have this discussion and start these agents.
I think cardiologists [and primary care physicians] need to discuss with their patients the utility and benefit of starting an SGLT2 inhibitor or a GLP-1 receptor agonist.
A Simple Pathway
The ACC consensus pathway is quite simple. It says that if a patient has type 2 diabetes and established clinical atherosclerotic cardiovascular disease, the cardiologist should address two things concurrently. One is “guideline-directed medical therapy”—essentially, all that we endocrinologists know to address at baseline: metformin, lifestyle changes, antiplatelet therapies, blood pressure lowering, and lipid lowering. Concurrently, one should consider adding an SGLT2 inhibitor or a GLP-1 receptor agonist with demonstrated cardiovascular outcomes benefit.
If a patient isn’t interested in adding one of these two classes of drugs to their treatment, then nothing further can or should be done, according to this guideline. [But revisit the topic later. The patient’s thoughts or circumstances may have changed.]
The CANVAS study with canagliflozin raised concerns about osteoporosis, prior amputations, severe peripheral artery disease, peripheral neuropathy, and soft tissue ulcers. For patients who have a risk for lower-extremity amputation, they suggest using a GLP-1 receptor agonist as initial treatment. In my opinion, though, we need to individualize this in terms of looking at our patients and at which agent seems best for each of them.
And they talk about heart failure as something that we all need to consider. Those of us who treat lots of patients with type 2 diabetes see lots of heart failure. And the authors suggest that if you look at all of the clinical trials we’ve done, most of them show that heart failure is a more common outcome than myocardial infarction, stroke, or death. We all know the importance of treating patients to reduce their risk for recurrent episodes of heart failure and hospitalization. I believe that SGLT2 inhibitors, and to some degree the GLP-1 receptor agonists, may be beneficial.
Finally, they discuss data from the heart failure outcomes trials showing that empagliflozin has a benefit—similar to all the other therapies we have—in reducing mortality in patients with heart failure.
Ongoing trials are using SGLT2 inhibitors in patients with heart failure who don’t necessarily have diabetes. There are two EMPEROR trials. The sample size in the EMPEROR-Preserved trial (which means preserved left ventricular [LV] function) is around 4000. In the reduced LV function trial, the sample size is 2800. The DAPA Heart Failure trial includes 4500 patients. That trial will likely be reported at the end of 2019, and the EMPEROR trials will probably be reported around the time of the 2020 American Diabetes Association meeting.
All of us—primary care providers, educators, pharmacists, cardiologists, and endocrinologists—need to talk about the use of these agents for glucose-lowering as well as improving cardiovascular outcomes in our patients with diabetes and preexisting cardiovascular disease. Thank you.
