The Changing Role of Preventive Cardiology in Managing Patients with Diabetes

The continued increase in diabetes prevalence remains a major cause of morbidity and mortality throughout the world. The associated microvascular and macrovascular complications of Type 2 diabetes are well documented.1 Tighter management of blood glucose levels have been shown to reduce microvascular complications such as retinopathy, neuropathy, and nephropathy, but the same cannot be said for macrovascular complications which include stroke, MI, and CV deaths. Two prominent trials, Action in Diabetes and Vascular Disease (ADVANCE) and Action to Control Cardiovascular Risk in Diabetes (ACCORD) failed to prove macrovascular benefit from intensive glycemic control. In fact, the ACCORD study demonstrated harm.2 Based on these results, the FDA in 2008 required all new diabetes medications to demonstrate cardiovascular safety as a condition for approval.

In 2015, the Empagliflozin Cardiovascular Outcome Event Trial in Type 2 Diabetes Mellitus Patients (EMPA-REG OUTCOME) showed, for the first time, a diabetes medication that significantly reduced death rates in patients who also had cardiovascular disease.Empagliflozin, a sodium glucose cotransporter 2 (SGLT2) inhibitor, was approved by the FDA in 2016 with an indication to reduce cardiovascular death in this group of patients.The results revealed a 14% relative risk reduction in death from cardiovascular disease, non-fatal MI, and non-fatal stroke. Over 3 years there was a relative risk reduction of 38% in cardiovascular causes of death. Additionally, data revealed a 35% reduction in hospitalization related to heart failure, a 38% risk reduction in macroalbuminuria, and a 32% decrease in death from any cause.5

Similar progress was made with the Liraglutide Effect and Action in Diabetes: Evaluation of Cardiovascular Outcome Results (LEADER) trial, which also showed a statistically significant decrease in cardiovascular death.6 Liraglutide, a glucagon-like peptide-1 (GLP-1) receptor agonists, became the second diabetes medication to receive FDA approval for breaking the barrier of cardiovascular death reductions.

In an expert analysis published by the American College of Cardiology, Dr. Rupesh Manam and Dr. Seth Baum describe the approval of these medications as a paradigm shift in the management of patients with diabetes. They contend that health care providers involved in preventive cardiology must now actively engage in utilizing these medications. Their recommendation is that, when not contraindicated, every diabetic patient with established cardiovascular disease should be considered for either empagliflozin or liraglutide therapy. Preventive cardiology providers should either initiate the drug or consult with endocrinology, nephrology or primary care providers to determine why these patients should not be taking these medications. They state in the article that lowering the risk of cardiovascular death cannot be ignored, and it is time for preventive cardiology practitioners to become more proactive in the management of patients with diabetes. Managing diabetes should be as important as managing other cardiovascular risks such as lipids, blood pressure, obesity, and tobacco abuse. They conclude that since the role of the preventive cardiology provider is to reduce cardiovascular death, the diabetic patient is now in their realm of care. 7

References:

  1. Wong, ND. In Focus: Cardiodiabetology: Endocrinologists and Cardiologists Working Together to Improve Clinical Outcomes. CardioSource WorldNews. Dec 1 2018. Accessed Nov 15 2018.
  2. Dluhy RG, McMahon GT. Intensive glycemic control in the ACCORD and ADVANCE trials. N Engl J Med 2008;358:2630-3.
  3. Hayward RA, Reaven PD, Wiitala WL, et al. Follow-up of glycemic control and cardiovascular outcomes in type 2 diabetes. N Engl J Med 2015;372:2197-206.
  4. Smith RJ, Goldfine AB, Hiatt WR. Evaluating the cardiovascular safety of new medications for type 2 diabetes: time to reassess? Diabetes Care 2016;39:738-42.
  5. Zinman B, Wanner C, Lachin JM, et al. Empagliflozin, cardiovascular outcomes, and mortality in type 2 diabetes. N Engl J Med 2015;373:2117-28.
  6. Marso SP, Daniels GH, Brown-Frandsen K, et al. Liraglutide and cardiovascular outcomes in type 2 diabetes. N Engl J Med 2016;375:311-22.
  7. http://www.acc.org/latest-in-cardiology/articles/2018/03/15/11/00/the-role-of-a-preventive-cardiologist-in-managing-the-diabetic-patient

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