Reducing Cardiovascular Risk Following Stroke
A 71-year-old woman attends your outpatient clinic after a recent admission for a stroke.
Background history includes the following:
- Type 2 diabetes mellitus
- Hypertension
- Coronary artery disease: CT coronary angiogram – 20-30% (mild) diffuse disease in left anterior descending artery.
Current medications are:
- Metformin 1g twice daily
- Perindopril 5mg once daily
- Atorvastatin 40mg once daily
- Aspirin 100mg once daily
- Clopidogrel 75mg once daily (three-month course per neurologist)
Labs performed prior to her visit today reveal the following:
- HbA1c 7.6%
- eGFR 75mL/min/m2
- LDL-C 61mg/dL; TG 115mg/dL
Approximately two months ago the patient was admitted to the local hospital with speech difficulties and weakness of her right upper and lower limb. CT imaging showed a small ischemic stroke with diffuse intracranial atherosclerotic disease. CT imaging of her neck vessels revealed 20-30% disease in her extracranial vessels. A 24-hour Holter monitoring showed no evidence of atrial fibrillation. She was discharged on a three-month course of dual antiplatelet therapy with plans for aspirin monotherapy thereafter.
On review today almost all of her deficits have improved with only very mild residual dysarthria. Blood pressure is 128/70 mm Hg seated, heart rate is 72 beats per minute and regular. Her body mass index (BMI) is 32kg/m2.
Which of the following changes would be your first priority in reducing this patient's cardiovascular risk?
Show Answer
The correct answer is: D. Add liraglutide 0.6mg once daily.
Given her CTA findings, the provisional cause of her stroke is likely to have been intracranial atherosclerotic in nature. Such a process is believed to be the underlying cause of ~10% of ischemic strokes.1 However, undetected atrial fibrillation remains a potential etiology as there are a number of shared risk factors; further investigation with extended monitoring may need to be considered.
With regards to her cardiovascular risk, answers C and D are the top priority. The American Diabetes Association (ADA) guidelines and the ACC consensus statement2 recommend the inclusion of a glucose-lowering drug with proven cardiovascular benefit in a patient with established cardiovascular disease. In this context either a sodium glucose co-transporter 2 inhibitor (SGLT-2i) (C) or a glucagon-like peptide-1 receptor agonist (GLP-1RA) (D) would be a reasonable next step. The current data suggest GLP-1RA cardiovascular benefits may be mediated through anti-atherosclerotic pathways whereas SGLT-2i may be predominantly through the prevention of heart failure development and/or progression. Thus, if needing to choose a 'preferred' option between these two classes for this patient, a GLP-1RA may be the best option for two reasons – not only is she likely to derive the full benefit from her predominant atherosclerotic CVD phenotype (two vascular bed atherosclerosis) but also may experience favorable weight loss (~3-5%) in the setting of her elevated BMI.3 Further, the addition of either agent is likely to help her achieve an HbA1c goal of <7%.
The patient is on a high-intensity statin already and has achieved an LDL-C <70mg/dL. Hypertension is an important modifiable risk factor for patients who have had a prior stroke; however, her blood pressure is reasonable at present and may not require additional perindopril at this time (B). Icosapent ethyl has proven benefit in patients with elevated trigylcerides (>135mg/dL,)4; however, whether this benefit applies to patients with more modest elevations in triglycerides such as this patinet remains unknown.
Educational grant support provided by: Boehringer Ingelheim Lilly.
To visit the hub for the CV Risk in Diabetes: Emerging Science Grant, click here!
References
- Sacco RL, Kargman DE, Gu Q, Zamanillo MC. Race-ethnicity and determinants of intracranial atherosclerotic cerebral infarction. The Northern Manhattan Stroke Study. Stroke 1995;26:14.
- Das SR, Everett BM, Birtcher KK, et al. 2018 ACC Expert Consensus Decision Pathway on Novel Therapies for Cardiovascular Risk Reduction in Patients With Type 2 Diabetes and Atherosclerotic Cardiovascular Disease. J Am Coll Cardiol 2018;72:3200-23.
- Del Olmo-Garcia MI, Merino-Torres JF. GLP-1 Receptor Agonists and Cardiovascular Disease in Patients with Type 2 Diabetes. J Diabetes Res 2018;2018:4020492.
- Bhatt DL, Steg PG, Miller M, et al. Cardiovascular Risk Reduction with Icosapent Ethyl for Hypertriglyceridemia. N Engl J Med 2019;380:11-22.
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