Study: People With Type 2 Diabetes, Heart Disease May Benefit From New Therapies

Individuals with type 2 diabetes (T2D) who also experience coronary artery disease (CAD) may need to be treated more aggressively than those with coronary artery disease who do not have diabetes, according to a American Heart Association (AHA) scientific statement published in the journal Circulation.

A person with T2D cannot efficiently use the insulin that their body makes to keep their glucose at a healthy level, which leads to these individuals being overweight or having high blood pressure or high cholesterol. Reducing glucose to healthy levels was considered the most important goal of therapy for T2D for many years, according to the AHA statement.

“What we’ve learned in the past decade is how you control glucose levels has a huge influence on cardiovascular risk,” said Suzanne V. Arnold, MD, MHA, chair of the writing group for the scientific statement, in a press release. “Lowering blood sugars to a certain level is not sufficient. 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.”

For those diagnosed with T2D, metformin is the most frequently recommended medication for initial treatment to lower glucose. This medication can lead to mild weight loss, is a neutral treatment option in terms of cardiovascular effects, and has a long history of use and safety, according to the statement.

With this, the new statement mentions that the latest research indicates several newer classes of medications may both lower glucose and reduce the risk of cardiovascular diseases.

The first class of medications to show clear benefits on cardiovascular outcomes was the sodium-glucose co-transporter (SGLT2) inhibitors, with a new study finding that patients taking SGLT2 inhibitors were significantly less likely to die of cardiovascular disease. These patients had a reduced risk of heart failure, less progression of chronic kidney disease, and they lost weight, according to the researchers.

In addition, recent studies have tested glucagon-like peptide-1 (GLP-1) receptor agonists on patients with T2D. GLP-1 receptor agonists are a class of injectable medications that lower blood glucose and can also cause a reduction in weight. Results from clinical studies have been mixed regarding their efficacy in reducing cardiovascular diseases; however, 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, according to the researchers.

Relaxing glycemic control slightly might be beneficial for older adults due to its ability to reduce the risk of hypoglycemia. Further, preventing blood from forming clots is an important goal of CAD treatment.

“Aspirin, which is a blood thinner, may be appropriate for many people with CAD, but may not work as effectively in people with T2D and CAD,” Arnold said in a press release. “Therefore, newer, stronger antiplatelet medications (a form of blood thinner) should be considered. Since all antiplatelet medications increase the risk of bleeding, it is important to balance the risk for each patient of increased bleeding versus the benefit of reducing the tendency of the blood to clot.”

The decision on which type of interventional procedure is best to use to re-open an artery to increase blood flow in indicated patients may be influenced by T2D, according to the researchers. Certain studies have found a greater reduction in the 5-year risk of death, heart attack, or recurrent angina or chest pain when patients with T2D and CAD undergo coronary artery bypass graft surgery to widen a narrowed blood vessel instead of treating the narrowing with angioplasty and stenting, according to the press release.

Unhealthy cholesterol levels, such as high low-density lipoproteins (LDL), low high-density lipoproteins, and high triglycerides, which are major risk factors for CAD, are common among people with T2D. In many patients, even if LDL levels are not significantly high, people with T2D often have a type of LDL particle that is more likely to increase the risk of atherosclerosis.

Since the majority of patients with T2D have hypertension, blood pressure control is the priority in managing CAD in patients with T2D, according to the researchers.

“More aggressive steps may be needed to improve the cholesterol levels in people with T2D,” Arnold said in a press release. “Statins, the cornerstone of cholesterol-lowering therapy, may slightly increase blood sugar levels, however, the overall cardiovascular risk reduction they provide is far more beneficial. Blood sugar changes are not a reason to avoid prescribing statins for people with type 2 diabetes.”

Additionally, some patients with CAD and T2D may also benefit from lowering cholesterol with additional classes of medications, such as oral cholesterol absorption inhibitors or newer injectable medications, which have been shown to be beneficial in people with diabetes, according to the researchers.

“While treatment with medication is very important in the treatment of people who have both T2D and CAD, no pill is a substitute for a healthy lifestyle,” Arnold said in a press release. “No matter what new medicines there are, a heart-healthy diet, achieving and maintaining a healthy weight, regular physical activity and treating sleep disorders remain the major cornerstones of treatment for T2D and cardiovascular disease.”

REFERENCE

People with type 2 diabetes and heart disease may benefit from newer therapies [news release]. Dallas, TX; American Heart Disease: April 13, 2020. https://newsroom.heart.org/news/people-with-type-2-diabetes-and-heart-disease-may-benefit-from-newer-therapies. Accessed April 16, 2020.