AHA Scientific Statement on Management of Stable CAD in T2DM
- Authors:
- Arnold SV, Bhatt DL, Barsness GW, et al.
- Citation:
- Clinical Management of Stable Coronary Artery Disease in Patients With Type 2 Diabetes Mellitus: A Scientific Statement From the American Heart Association. Circulation 2020;Apr 13:[Epub ahead of print].
The following are key points to remember from this American Heart Association (AHA) Scientific Statement on clinical management of stable coronary artery disease (CAD) in patients with type 2 diabetes mellitus (T2DM):
- T2DM is associated with a prothrombotic state due to altered platelet activation, adhesion, and aggregation, as well as increased platelet turnover, which may impair responsiveness to aspirin and clopidogrel.
- In the THEMIS trial, patients with T2DM and CAD but no history of myocardial infarction (MI) or stroke were randomized to ticagrelor + aspirin or aspirin alone. In the ticagrelor + aspirin arm, significant reduction in major adverse cardiovascular events (MACE) was seen only among patients with prior percutaneous coronary intervention (PCI), at the expense of increased bleeding risk.
- The optimal blood pressure target in T2DM has long been a subject of controversy. The 2017 hypertension guidelines recommend a target of <130/80 mm Hg. Lower blood pressure targets may reduce stroke risk, but in the presence of CAD, excessive blood pressure lowering can increase MI risk due to reduced coronary perfusion pressure. Individualization of blood pressure goals based on patient risk factors is suggested.
- Beta-blockers with vasodilatory effects (carvedilol, labetalol, nebivolol) have neutral or beneficial effects on glycemic control, while metoprolol and atenolol have adverse metabolic effects.
- Ranolazine has beneficial effects on glycemic control (hemoglobin A1c reduction approximately 0.5-0.7%) attributable to a reduction in glucagon secretion. The antianginal and glucose-lowering effects of ranolazine appear to be greater in patients with poorly controlled T2DM.
- In the IMPROVE-IT trial, the addition of ezetimibe to simvastatin resulted in a larger reduction in MACE among patients with DM than in those without (absolute risk reduction 5.5% vs. 2.0%).
- Among patients with T2DM, cardiac rehabilitation results in improvement in exercise capacity and reduction in hospitalizations and mortality similar to those in patients without T2DM. Individualized T2DM assessment and management should be included in cardiac rehabilitation programs.
- The impact of intensive glycemic control on macrovascular events has varied in major trials. As different classes of T2DM drugs have been associated with differential effects on cardiovascular outcomes, the glucocentric view of T2DM care is being replaced by a focus on specific methods of glycemic management.
- Insulin and sulfonylureas seem to be neutral in terms of CAD risk, but important adverse effects include weight gain and hypoglycemia.
- Sodium glucose cotransporter-2 (SGLT-2) inhibitors, including empagliflozin, canagliflozin, and dapagliflozin, are the first drugs for which clear cardiovascular benefits have been demonstrated. Of the glucagon-like peptide-1 receptor agonists (GLP1-RAs), liraglutide and semaglutide have been shown to reduce MACE. The American Diabetes Association and European Association for the Study of Diabetes now recommend SGLT-2 inhibitors and GLP1-RAs in patients with T2DM and high cardiovascular risk, favoring SGLT-2 inhibitors if heart failure or chronic kidney disease is present.
- Optimal medical therapy remains the mainstay of CAD care in T2DM patients, whether for primary or secondary prevention. Surgical and percutaneous revascularization outcomes are less favorable in patients with T2DM as compared to patients without T2DM. In multiple trials, coronary artery bypass grafting has been found superior to PCI with respect to MACE and need for subsequent revascularization.
Clinical Topics: Cardiac Surgery, Cardiovascular Care Team, Diabetes and Cardiometabolic Disease, Dyslipidemia, Invasive Cardiovascular Angiography and Intervention, Prevention, Atherosclerotic Disease (CAD/PAD), Aortic Surgery, Cardiac Surgery and Arrhythmias, Cardiac Surgery and SIHD, Lipid Metabolism, Interventions and Coronary Artery Disease, Exercise, Hypertension
Keywords: Adrenergic beta-Antagonists, Angina Pectoris, Blood Pressure, Cardiac Rehabilitation, Coronary Artery Bypass, Coronary Artery Disease, Diabetes Mellitus, Type 2, Dyslipidemias, Exercise, Glucose, Hypertension, Hypoglycemia, Insulin, Labetalol, Metabolic Syndrome, Metoprolol, Myocardial Infarction, Myocardial Revascularization, Percutaneous Coronary Intervention, Primary Prevention, Risk Factors, Secondary Prevention, Sodium-Glucose Transporter 2, Stroke, Thrombosis
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