As US Diabetes Rates Soar, AHA Urges CV Risk Factor Control

Management of cardiovascular risk factors should be a cornerstone of type 2 diabetes care, urges a new scientific statement from the American Heart Association (AHA) published today in Circulation. This effort is being boosted by new therapeutic options.

Use of these medications—specifically, sodium-glucose cotransporter 2 (SGLT2) inhibitors and glucagon-like peptide-1 (GLP-1) agonists–“has become the  most powerful therapeutic strategy to reduce risk of CVD in diabetes,” said Prakash Deedwania, MD (University of California at San Francisco School of Medicine, Fresno), the document’s vice chair.

He told TCTMD that much has changed since the AHA’s latest scientific statement on the topic, released in 2015. This includes growing awareness on the part of cardiologists, as well as emerging data.

“We used to say diabetes is a powerful risk factor for coronary artery disease, myocardial infarction, and stroke, but now we have learned that diabetes is also a powerful risk factor for heart failure, which was not very well recognized in the past,” Deedwania commented. Additionally, diabetes ups the risk of kidney disease, he added. “Something also that has become very clear . . . is that when [diabetic patients] develop kidney disease, they get a double whammy.”

Fully 34 million Americans have diabetes, Deedwania and colleagues note in their paper, citing numbers from the US National Health and Nutrition Examination Survey that suggest fewer than 20% meet targets for HbA1c, blood pressure, and cholesterol levels.

Thus, what’s most important in addressing type 2 diabetes is “comprehensive risk factor management,” stressed Deedwania. “It’s a multipronged approach. You can’t just control glucose and expect all things to go well. . . . There is not one shotgun therapy for reducing the risk of CV events in diabetic patients.”

In-depth Info on Comprehensive Care

Chaired by Joshua J. Joseph, MD, MPH (The Ohio State University Wexner Medical Center, Columbus), the document summarizes the most up-to-date advice on lifestyle management (physical activity, nutrition, obesity/weight management, alcohol, and smoking) and on glycemic targets and control in type 2 diabetes.

The newer antihyperglycemic agents—the SGLT2 inhibitors and GLP-1 agonists—offer not only traditional glucose-lowering but also have been shown to have “a significant number of favorable cardiometabolic effects” in randomized controlled trials. As reported by TCTMD, both the 2019 European Society of Cardiology diabetes guidelines and a 2020 American College of Cardiology decision pathway endorse these medications.

SGLT2 inhibitors include empagliflozin (Jardiance; Boehringer Ingelheim/Eli Lilly), canagliflozin (Invokana; Janssen Pharmaceuticals), and dapagliflozin (Farxiga; AstraZeneca), which were tested in EMPA-REG OUTCOME, CANVAS/CANVAS-R, DECLARE-TIMI 58, CREDENCE, and DAPA-HF.

GLP-1 receptor agonists include lixisenatide (Adlyxin; Sanofi), liraglutide (Victoza; Novo Nordisk), oral and subcutaneous semaglutide (Rybelsus/Ozempic; Novo Nordisk), exenatide (Byetta; AstraZeneca), and dulaglutide (Trulicity; Eli Lilly). In LEADER, liraglutide reduced the risk of cardiovascular death, MI, or stroke, as did semaglutide in SUSTAIN-6 and dulaglutide in REWIND.

Other sections of the scientific statement delve into the importance of blood pressure control and lipid-lowering, while another considers antithrombotic therapy, particularly aspirin use. For the latter, Joseph et al write, data from ASCEND and ASPREE merit a cautionary note. The document goes on to describe approaches to screening for renal disease and imaging tests for subclinical CVD.

Not Just the Individual Patient

But these developments do not occur in a vacuum, as the AHA statement makes clear. Key considerations are social determinants of health and the need for “health equity in cardiovascular risk factor management from the individual to the population level.”

As the document stresses: “Clinical care and treatment accounts for 10% to 20% of the modifiable contributors to healthy outcomes. The other 80% to 90% are the social determinants of health [such as] health-related behaviors, socioeconomic factors, environmental factors, and racism,” known to have a profound impact on patients with CVD and type 2 diabetes. Concurrent interventions must address these social factors when managing traditional CV risk factors (eg, food insecurity can impact glycemic control), the AHA statement advises, adding that policy changes are needed to tackle their root cause.

Broadly speaking, a comprehensive approach to CV risk factor management involves pharmacologic and lifestyle therapies with proven benefit and should focus on the patient’s needs, it concludes. “A patient-centered approach in this context means reframing our clinical encounters to think about patients as people who live in families, communities, and societies that must be considered in their cardiovascular risk management.”

Deedwania acknowledged that becoming expert in diabetes care lies outside the traditional purview of cardiology.

Practicing cardiologists may find it helpful to involve other healthcare professionals, such as nurse practitioners, registered dieticians, or physician assistants, on their team. Cardiodiabetology, a subspecialty that spans both worlds, also is on the rise, he said. “That’s probably going to flourish more and more.”

Regardless, multidisciplinary cooperation is required “to achieve the goals that we emphasize in this document,” Deedwania said.