2018 ACC Expert Consensus Decision Pathway on Novel Therapies for Cardiovascular Risk Reduction in Patients With Type 2 Diabetes and Atherosclerotic Cardiovascular Disease

Most morbidity and mortality in type 2 diabetes come from macrovascular events; hence, the cardiologists has a key role in optimizing these patients’ care.

The cardiologist is well-positioned to address three key areas in the management of patients with type 2 diabetes: screening for type 2 diabetes in their patients with or at high risk of cardiovascular disease, aggressively treating cardiovascular risk factors, and incorporating the data for newer antihyperglycemic agents into routine practice.

Patients and physicians can now choose from numerous medications that have important cardiovascular benefits, in addition to their effects on blood glucose.
Patients and providers can choose medications that have demonstrated benefits in reducing myocardial infarction, stroke, and cardiovascular death, rather than just reducing blood glucose.

Cardiologists have an opportunity to play an integral role in preventing and treating cardiovascular disease in patients with type 2 diabetes.
They should consider these new medications part of their armamentarium in reducing cardiovascular morbidity and mortality in patients with type 2 diabetes and established atherosclerotic cardiovascular disease ( ASCVD ).

Furthermore, these cardiovascular benefits are independent of their effects on glucose.

Sodium-glucose cotransporter 2 ( SGLT2 ) inhibitors have emerged as important new oral therapies for patients with type 2 diabetes.

Large randomized controlled clinical trials in patients with type 2 diabetes, most of whom had established atherosclerotic cardiovascular disease, have demonstrated that two drugs in this class, Empagliflozin and Canagliflozin, reduce major adverse cardiac events and heart failure hospitalization.
Empagliflozin also significantly reduces the risk of cardiovascular and all-cause mortality.

Similarly, glucagon-like peptide-1 receptor agonists ( GLP-1RAs ) have demonstrated benefits for cardiovascular risk in patients with type 2 diabetes.
Of the six Food and Drug Administration ( FDA )-approved GLP-1RAs, to date only Liraglutide has been definitively demonstrated to significantly reduce cardiovascular events.
Available data do suggest the potential for clinically relevant heterogeneity within the class.

In deciding between the two agents, patients at high risk for heart failure ( and with established heart failure ) may derive more benefit from an SGLT2 inhibitor with demonstrated cardiovascular benefit, whereas those with osteoporosis, prior amputations, severe peripheral artery disease, peripheral neuropathy, or active lower extremity soft tissue ulcers or infections may have a more favorable benefit / risk balance if initially treated with a GLP-1RA with demonstrated cardiovascular benefit.

Based on limited data, it appears reasonable to use both an SGLT2 inhibitor ( Empagliflozin preferred ) and a GLP-1RA with demonstrated cardiovascular benefit ( Liraglutide preferred ) concomitantly if clinically indicated, even though such combination therapy has not been studied for cardiovascular risk reduction. ( Xagena_2018 )

Source: American College of Cardiology ( ACC ), 2018