AHA: Aggressive treatment may benefit patients with diabetes, CAD
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The treatment of CAD in patients with type 2 diabetes may need to be more aggressive compared with those without diabetes to reduce the risk for MI and other complications, according to an American Heart Association scientific statement published in Circulation.
“What we’ve learned in the past decade is how you control glucose levels has a huge influence on cardiovascular risk,” Suzanne V. Arnold, MD, MHA, cardiologist at Saint Luke’s Mid America Heart Institute in Kansas City, Missouri, associate professor of medicine at University of Missouri-Kansas City, chair of the writing group for the scientific statement and a Cardiology Today Next Gen Innovator, said 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 type 2 diabetes, 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.”
Antiplatelet therapy
Antiplatelet therapy is important for this patient population as type 2 diabetes is a prothrombotic state, resulting in altered platelet function and coagulation, according to the statement. Although responsiveness to aspirin and clopidogrel-based therapy is impaired in these patients, clopidogrel alone may be a preferred option vs. aspirin for stable patients with type 2 diabetes and CAD, such as those without ACS or stent in the prior year.
“Given the availability of many effective tools and the emerging focus on value-based care and population risk management, the time has never been more optimal for this paradigm to be successfully implemented,” Arnold and colleagues wrote.
Several trials have shown that drugs like ticagrelor (Brilinta, AstraZeneca) and rivaroxaban (Xarelto, Bayer/Janssen) lowered the risk for MI, stroke, CV death and other major adverse CV events in patients with type 2 diabetes and CAD.
“The continued evolution of more potent antiplatelet agents and therapeutic regimens have demonstrated promise in reducing risk and preserving safety in a much broader population of patients with type 2 diabetes,” Arnold and colleagues wrote.
BP control is another important factor in the treatment of patients with diabetes and CAD, especially since there have been observations regarding the increased risk for microvascular and macrovascular events with a systolic BP of 115 mm Hg or higher. Despite this, the optimal BP target for this patient population continues to be debated. This becomes more difficult, especially because there are potential risks related to intensive BP reduction including MI.
Selecting antihypertensive agents for patients with type 2 diabetes should be based on adverse effect profile, efficacy in BP reduction, off-target effects, cost and convenience. First-line treatment for hypertension in these patients should be ACE inhibitors/angiotensin II receptor antagonists in the absence of other considerations, according to the statement.
Most patients with hypertension and type 2 diabetes will require more than one antihypertensive medication for BP control. Guidelines from the American Diabetes Association recommend dihydropyridine calcium channel blockers or thiazide-like diuretics.
Lipid management also plays a role in the treatment of patients with type 2 diabetes.
“LDL cholesterol levels in individuals with type 2 diabetes are often similar to those in individuals without type 2 diabetes, but the persistent hypertriglyceridemic state promotes LDL oxidation, and the concurrent hyperglycemia drives LDL glycation, all of which increase the atherogenicity of the LDL particles in type 2 diabetes,” Arnold and colleagues wrote.
Patients with type 2 diabetes often do not tolerate intensive statin therapy due to adverse effects or not being able to achieve adequate LDL lowering, according to the statement. Several trials have shown the benefits of simvastatin, ezetimibe and PCSK9 inhibitors like alirocumab (Praluent, Sanofi/Regeneron). However, not as much promise has been shown with non-LDL target therapies such as niacin, fibrates and fish oil when combined with statin therapy.
The foundation of clinical care for patients with type 2 diabetes and CAD is lifestyle and weight management, although randomized trial data are limited in this patient population, according to the statement. When caring for these patients, health care providers should focus on smoking cessation, diet, psychosocial factors and sleep, weight management and physical activity.
Glycemic control is important to reduce the risk for complications including heart disease, but the method in how it is done is important, according to the statement.
“The strategy used to achieve glycemic control matters because the total effect of a specific glucose-lowering agent is not conveyed by the degree to which it lowers glucose,” Arnold and colleagues wrote. “This evidence is shifting our previous glucocentric approach to type 2 diabetes care toward one that considers the actual method of glycemic management.”
Glycemic control may lower the risk for CV events if instituted soon after type 2 diabetes is diagnosed, although the effects are modest, according to the statement.
Several glucose-lowering drugs may have an effect on CAD outcomes one way or the other. For example, sulfonylureas and insulin should not be a first-line therapy for most patients with established CAD because it may lead to excess weight gain and hypoglycemia. In contrast, metformin may improve CV outcomes without the risk for excess weight gain and hypoglycemia. Thiazolidinediones may be another option for patients with CAD without known HF, although clinicians should be aware of any signs of fluid overload to reduce the risk for HF. Other glucose-lowering drug options for this patient population include dipeptidyl-peptidase IV inhibitors, SGLT2 inhibitors and GLP-1 receptor agonists.
Treatment of angina
Data are lacking in the management of stable angina in patients with type 2 diabetes and CAD, although there is some idea as to how to approach these patients, according to the statement. For example, CTA may be more beneficial than stress testing to manage patients with type 2 diabetes and stable angina, as it is capable of diagnosing nonobstructive CAD.
The treatment of angina in patients with type 2 diabetes remains a challenge because these patients often have more extensive and diffuse CAD that may not respond to revascularization. Selecting a treatment for these patients should focus on decreasing myocardial oxygen demand, increasing myocardial oxygen supply and other factors including adverse effects, glycemic effects, cost and effects on heart rate or BP, according to the statement.
If revascularization is to be considered, clinicians should take into consideration an individualized approach for these patients.
“The expanding knowledge base needed for the care of patients with type 2 diabetes necessitates a broad range of physicians to understand and apply the evidence that can directly improve clinical outcomes,” Arnold and colleagues wrote. – by Darlene Dobkowski
Disclosures: Arnold reports no relevant financial disclosures. Please see the scientific statement for all other authors’ relevant financial disclosures.
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