Appropriateness of Starting an SGLT2 Inhibitor in a Patient with Prior CVD and a High Risk for Heart Failure
A 63-year-old Caucasian man presents to the outpatient cardiology clinic for a routine follow-up appointment. He has a history of hypertension, dyslipidemia and suffered a non ST segment myocardial infarction 2 years ago. The coronary angiogram at that time demonstrated diffuse coronary artery disease with an 80% stenosis of the proximal left circumflex artery identified as the culprit lesion. Primary percutaneous intervention was performed with placement of a drug eluting stent. Furthermore, non obstructive plaques (<40%) were visualized in the right coronary artery and left anterior descending coronary artery. Transthoracic echocardiography showed preserved left ventricular ejection fraction (57%) and the absence of significant valve disease. The patient reports no history of tobacco or illicit drug use, but drinks two glasses of beer on average each day. His family history is remarkable for type 2 diabetes and coronary artery disease in his father and elder brother. His current medications include aspirin, atorvastatin 80 mg OD, lisinopril 20 mg OD, metoprolol XL 50 mg OD and amlodipine.
The patient is single and works as a computer programmer. His lifestyle is sedentary. He admits not being engaged in any sports or physical activity during his leisure time and finds it difficult to adhere to a healthy diet. Upon evaluation in the clinic, he denies any complaints and the clinical examination is unremarkable. Blood pressure is 135/76 mmHg and heart rate 92 bpm. His length (181 cm) and weight (101.5 kg) yield a body mass index of 31 kg/m2. Laboratory results are notable for a glycated hemoglobin level of 8.1%, total and low density lipoprotein cholesterol of 163 mg/dL and 85 mg/dL, respectively, as well as a serum creatinine of 1.44 mg/dL corresponding to an estimated glomerular filtration rate (eGFR) of 51 mL/min/1.73m2 by the Chronic Kidney Disease Epidemiology Collaboration (CKD EPI) formula.
Because of the new diagnosis of type 2 diabetes, fasting glucose is assessed and found to be elevated at 278 mg/dL. The albumin to creatinine ratio is 276 mg/g on a spot urinary sample. Eye examination shows early non proliferative diabetic retinopathy. The patient is very concerned about the diagnosis of type 2 diabetes as his father needed chronic ambulatory hemodialysis for end stage kidney disease when he was about the same age, which is a frightening prospect for the patient.
You discuss treatment options with the patient and propose to start metformin in addition to making healthy lifestyle recommendations. The patient is however reluctant to take metformin, as this medication made his brother feel sick all the time. He asks whether metformin gives him the best chance to prevent end stage kidney disease and recurrence of his heart problems.
When considering to start treatment with a sodium-glucose transporter 2 (SGLT2) inhibitor in this patient, which of the following statements is FALSE and should not be part of your evaluation?