Kansas City, MO–Type 2 diabetes patients who have coronary artery disease (CAD) might require more aggressive treatment than other patients with heart issues, according to a new scientific statement advising how to do that.

A new American Heart Association Scientific Statement, published in Circulation, offers an overview of the most current advances for treating patients who have concurrent CAD and T2D.

“Recent scientific studies have shown that people with T2D may need more aggressive or different medical and surgical treatments compared to people with CAD who do not have T2D,” said writing group chair Suzanne V. Arnold, MD, MHA, associate professor of medicine at the University of Missouri Kansas City, and a cardiologist at Saint Luke’s Mid America Heart Institute, also in Kansas City.

The goal in the past was to reduce glucose to healthy levels, but that might not be enough to lower cardiac risk, according to the document.

“What we’ve learned in the past decade is how you control glucose levels has a huge influence on cardiovascular risk. Lowering blood sugars to a certain level is not sufficient,” Dr. Arnold explained. “There are now more options for controlling glucose in people with T2D, and each patient should be evaluated for their personal risk of cardiovascular disease, stroke and kidney disease. This combined health information as well as the patient’s age should be used to determine the appropriate therapies to lower glucose.”

The guidance emphasizes that T2D is more than just a comorbidity that affected the development and progression of coronary artery disease.

Among the factors forcing clinicians to reconsider the role of T2D in CAD are that, in addition to being associated with increased cardiovascular risk, T2D has the potential to affect a number of treatment choices for CAD and, although glycemic control has been recommended as a part of comprehensive risk-factor management in patients with CAD, evidence is increasing that the mechanism by which glucose is managed can have a substantial impact on cardiovascular outcomes.

“In this document, we discuss the role of glycemic management (both in intensity of control and choice of medications) in cardiovascular outcomes,” the authors write. “It is becoming clear that the cardiologist needs both to consider T2DM in cardiovascular treatment decisions and potentially to help guide the selection of glucose-lowering medications.”

Metformin is the most frequently recommended medication for initial treatment to lower glucose in people diagnosed with T2D and has some clear advantages: It often leads to mild weight loss, is at least neutral in terms of cardiovascular effects, is inexpensive and has a long use and safety history.

The AHA statement suggests, however, that the latest research indicates several newer classes of medications may both lower glucose and reduce the risk of cardiovascular diseases.

It points to sodium-glucose cotransporter inhibitors (SGLT2 inhibitors), oral medications which were the first class to show clear benefits on cardiovascular outcomes. A recent study suggested that patients taking SGLT2 inhibitors were significantly less likely to die of cardiovascular disease.

The statement also discusses glucagon-like peptide-1 receptor agonists (GLP-1 receptor agonists), a class of injectable medications that lower blood glucose and can also cause a reduction in weight. While recent study results about their efficacy in reducing cardiovascular diseases have been mixed, a few GLP-1 receptor agonists have been shown to reduce the risk of major cardiovascular events caused by cholesterol build-up in the arteries, such as heart attacks and strokes, the authors note.

The AHA statement also advises that, for older adults, some flexibility on glycemic control levels could be beneficial by reducing the risk of hypoglycemia. “Hypoglycemia is incredibly hard on the heart and should be avoided particularly in older patients;” Dr. Arnold explains. “We must ensure that we are weighing all of the options in consideration of the whole patient, keeping in mind that what may be appropriate for a 60-70 year old patient is likely not the same as for an 85-year old.” Metformin, SGLT2 inhibitors and GLP-1 receptor agonists all have lower risks of hypoglycemia than some T2D agents.

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