ACC Decision Pathway on CV Risk Reduction in T2D and ASCVD

Authors:
Das SR, Everett BM, Birtcher KK, et al.
Citation:
2018 ACC Expert Consensus Decision Pathway on Novel Therapies for Cardiovascular Risk Reduction in Patients With Type 2 Diabetes and Atherosclerotic Cardiovascular Disease: A Report of the American College of Cardiology Task Force on Expert Consensus Decision Pathways. J Am Coll Cardiol 2018;Nov 26:[Epub ahead of print].

The following are key points to remember from the 2018 ACC Expert Consensus Decision Pathway on Novel Therapies for Cardiovascular (CV) Risk Reduction in Patients With Type 2 Diabetes (T2D) and Atherosclerotic Cardiovascular Disease (ASCVD):

  1. Most morbidity and mortality in T2D come from macrovascular events; hence, the CV specialist has a key role in optimizing these patients’ care.
  2. The CV specialist is well-positioned to address three key areas in the management of patients with T2D: screening for T2D in their patients with or at high risk of CVD, aggressively treating CV risk factors, and incorporating the data for newer antihyperglycemic agents into routine practice.
  3. Patients and physicians can now choose from numerous medications that have important CV benefits, in addition to their effects on blood glucose. Patients and providers can choose medications that have demonstrated benefits in reducing heart attack, stroke, and CV death, rather than just reducing blood glucose.
  4. Cardiologists have an opportunity to play an integral role in preventing and treating CVD in patients with T2D. They should consider these new medications part of their armamentarium in reducing CV morbidity and mortality in patients with T2D and established ASCVD. Furthermore, these CV benefits are independent of their effects on glucose.
  5. Sodium-glucose cotransporter 2 (SGLT2) inhibitors have emerged as important new oral therapies for patients with T2D. Large randomized controlled clinical trials in patients with T2D, most of whom had established ASCVD, have demonstrated that two drugs in this class, empagliflozin and canagliflozin, reduce major adverse cardiac events and heart failure (HF) hospitalization. Empagliflozin also significantly reduced the risk of CV and all-cause mortality.
  6. Similarly, glucagon-like peptide-1 receptor agonists (GLP-1RAs) have demonstrated benefits for CV risk in patients with T2D. Of the six Food and Drug Administration (FDA)-approved GLP-1RAs, to date only liraglutide has been definitively demonstrated to significantly reduce CV events. Available data do suggest the potential for clinically relevant heterogeneity within the class.
  7. In deciding between the two agents, patients at high risk for HF (and with established HF) may derive more benefit from an SGLT2 inhibitor with demonstrated CV 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 CV benefit.
  8. Based on limited data, it appears reasonable to use both an SGLT2 inhibitor (empagliflozin preferred) and a GLP-1RA with demonstrated CV benefit (liraglutide preferred) concomitantly if clinically indicated, even though such combination therapy has not been studied for CVD risk reduction.
  9. Cardiologists should work together with the patient, and the other members of his/her care team, to determine whether he/she would benefit from these therapies, and to initiate therapy if appropriate.

Clinical Topics: Diabetes and Cardiometabolic Disease, Dyslipidemia, Heart Failure and Cardiomyopathies, Prevention, Vascular Medicine, Atherosclerotic Disease (CAD/PAD), Lipid Metabolism, Acute Heart Failure

Keywords: Amputation, Blood Glucose, Diabetes Mellitus, Type 2, Glucose, Glucosides, Heart Failure, Hypoglycemic Agents, Metabolic Syndrome X, Myocardial Infarction, Myocardial Ischemia, Osteoporosis, Peripheral Arterial Disease, Primary Prevention, Risk Factors, Sodium-Glucose Transporter 2, Stroke, Ulcer, Vascular Diseases


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