An Update for Cardiologists Who See Patients With Type 2 Diabetes

For years, cardiologists who worried about preventing heart attacks and strokes and endocrinologists or primary care physicians who kept tabs on blood sugar were in separate camps. A decade ago, only 13% of patients treated for coronary artery disease by cardiologists were screened for type 2 diabetes (T2D), and the idea that a drug developed to lower blood sugar would be prescribed to treat heart failure was unthinkable.

But a revolution in care has changed things. Today, the American College of Cardiology issued an update to a 2018 guidance for its members, who treat heart and vascular conditions, on how to prescribe two classes of drugs first approved by FDA for diabetes: the sodium glucose co-transporter 2 (SGLT2) inhibitors and glucagon-like peptide-1 (GLP-1) receptor agonists.

When these drugs were approved, FDA required large studies to demonstrate their safety. And starting nearly 5 years ago, those studies started showing that patients who take them have fewer heart attacks and strokes, have lower rates of cardiovascular death or renal failure, and are less likely to be hospitalized for heart failure.

Called the 2020 Expert Consensus Decision Pathway (ECDP) on Novel Therapies for Cardiovascular Risk Reduction With Type 2 Diabetes, the document covers all the studies that have come in just the past two years—which have added to the data about what these drugs can do. It appears today in the Journal for the American College of Cardiology.

“An important paradigm shift in the care of patients with diabetes and cardiovascular disease is underway,” Sandeep R. Das, MD, MPH, FACC, co-chair of writing committee for the ECDP, said in a statement. “Patients and physicians can now choose from a number of medications that have important proven benefits on cardiovascular and renal outcomes, in addition to their effects on blood glucose.”

While the studies that fueled the 2018 document were designed to show that the two drug classes wouldn’t cause harm when they lowered blood sugar, the more recent wave of trials—including one that shows benefits for the SGLT2 inhibitor Farxiga in heart failure and Invokana in preventing renal decline—were designed to show benefits. And the new ACC document doesn’t single out a “preferred” therapy in each class as it did two years ago.

Among the recommendations in this new guidance:

1. Cardiologists should consider screening patients with heart failure, diabetic kidney disease, or atherosclerotic cardiovascular disease (ASCVD) for T2D once a year if they meet the criteria for prediabetes.

• Because patients leaving the hospital are more likely to stick with a medication prescribed at discharge, this “must be weighed” by hospitals in deciding whether to put SGLT2 inhibitors or GLP-1 RAs on formulary.
• An SGLT2 inhibitor with demonstrated CV benefit is recommended for patients with T2D and heart failure, especially with reduced ejection fraction (HFrEF).
• When a patient is diagnosed with T2D or ASCVD, and when the other condition or a risk factor such as kidney disease or HFrEF is present, this “offers the opportunity” to talk to patients about taking an SGLT2 inhibitor.
• GLP-1 RAs are recommended for those patients with established or very high risk ASCVD.
• If a cardiologist wants to prescribe an SGLT2 inhibitor or GLP-1 RA for CV or kidney risk reduction, this “should not be contingent” on a patient’s A1C level.

For several years, ACC leaders have tried to promote the value of prescribing SGLT2 inhibitors and GLP-1 RAs for T2D patients with heart failure or demonstrated ASCVD. However, some cardiologists have balked at using “diabetes” drugs, in part because they have not traditionally been tasked with managing a patient’s glycated hemoglobin, or A1C. But those who advocate using these drugs for CV conditions say that these benefits must be separated from their effects on glycemic control, and this latter responsibility should remain with the endocrinologist, or more typically, the primary care physician.

Collaboration between cardiologists and those who treat patients with T2D has increased in recent years, and the ACC has worked closely with the American Diabetes Association (ADA) to jointly adopt guidelines that affect patients with diabetes and cardiovascular conditions or risk.

“Cardiologists play an integral role in preventing and treating cardiovascular disease in patients with type 2 diabetes, said Brendan M. Everett, MD, MPH, FACC, co-chair of the writing committee. “We should consider thesenew medications important tools to reduce cardiovascular morbidity and mortality in patients with type 2 diabetes. We can work together with our patients and other members of the care team to decide whether the patient would benefit from these therapies, and to initiate therapy if appropriate.”