American Heart Association Offers Guidance on Diabetes, Coronary Artery Disease

April 16, 2020

Recently, it has been shown that the mechanism by which glucose is managed can have a substantial impact on cardiovascular outcomes. For this reason, along with increasing prevalence of type 2 diabetes (T2D), effective, patient-centered management of coronary artery disease (CAD) in patients with diabetes is imperative to optimize patient outcomes, the American Heart Association said.

Recently, it has been shown that the mechanism by which glucose is managed can have a substantial impact on cardiovascular outcomes. For this reason, along with increasing prevalence of type 2 diabetes (T2D), effective, patient-centered management of coronary artery disease (CAD) in patients with diabetes is imperative to optimize patient outcomes.

In a statement published by the American Heart Association (AHA), authors outline the relationship between T2D and CAD in addition to the role glycemic management (both in intensity of control and choice of medications) plays in cardiovascular outcomes.

“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,” researchers said.

T2D, which is linked to increased risk of obesity, is projected to affect over 600 million individuals worldwide in the next 20 years. Cardiovascular disease and CAD in particular, are the leading causes of mortality and morbidity in this cohort. To reduce risks of cardiovascular complications and improve patients’ quality of life, prevention of ischemic events has become a key management priority.

In March, results from the phase 4 independent TWILIGHT trial found Brilinta (ticagrelor) monotherapy reduced bleeding complications with no increased risk of ischemic events in patients with diabetes undergoing percutaneous coronary intervention. Specifically, in high-risk coronary patients, Brilinta monotherapy reduced the risk of clinically relevant bleeding over 12 months, compared with aspirin plus Brilinta.

A separate trial, THEMIS (Effect of Ticagrelor on Health Outcomes in Diabetes Mellitus Patients Intervention Study), found “patients randomized to ticagrelor had a lower risk of the composite of cardiovascular death, myocardial infarction, or stroke over an average follow-up of 40 months (ticagrelor versus placebo: 7.7% versus 8.5%; P = .04)” according to AHA authors.

Results from the Vascular Outcomes Study of ASA Along with Rivaroxaban in Endovascular or Surgical Limb Revascularization for PAD (VOYAGER-PAD) trial showed “patients with peripheral artery disease (PAD) are 15% less likely to suffer a major cardiovascular event or death after undergoing a procedure for blocked arteries in their legs if they take rivaroxaban along with aspirin, instead of just aspirin,” The American Journal of Managed Care® reported.

In addition to reduction and prevention of ischemic events via medicinal treatment, researchers offer guidance on other management factors for T2D and CAD.

When it comes to optimal levels of blood pressure targeted to provide cardiovascular protection in patients with T2D and CAD, controversy persists. “The 2017 Hypertension Clinical Practice Guidelines recommended a goal blood pressure <130/80 mm Hg in patients with T2D,” authors said. However, according to results of several trials including CLARIFY, ONTARGET and TRANSCEND, these targets may not be optimal for all patients with T2D and CAD. “There appears to be heterogeneity in the impact of intensive blood pressure lowering on coronary versus cerebral events, and the effects can also vary based on comorbid conditions (recent acute coronary syndrome),” researchers said.

Similarly, the choice of antihypertensive agents must include a number of factors such as efficacy in blood pressure reduction, side-effect profile, cost, convenience and off-target effects. Authors note that in the absence of other considerations “ACE inhibitors/ARBs should be considered first-line treatment for hypertension in patients with T2DM and CAD.”

Trial data has also shown benefits from statin therapy in the primary and secondary prevention of CAD, despite a potential minimal increase in blood sugars. However, authors feel benefits outweigh risks of administering statins to people with T2DM and CAD.

In addition to treatments and procedures used to minimize risk of T2DM and CAD complications, authors highlight the importance of healthy lifestyle behaviors such as managing one’s weight, cessation of smoking, having a healthy diet, exercising, and effectively managing stress levels and sleep schedules.

Despite decades of diabetes guidelines instructing strict control of patients’ blood glucose levels to reduce complications, “3 major clinical trials of intensive glycemic control (lowering HbA1c levels to <6%-6.5%) demonstrated no reduction in major cardiovascular events compared with less intensive glycemic control in patients with T2DM,” authors said. However, other trials showed HbA1C lowering treatments had differing effects on cardiovascular outcomes, suggesting “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.”

As a result of new clinical trial data, advancements in research on risk factors, and continued investigation into lifestyle and behavioral changes, researchers note a “remarkable” transformation in the care of patients with T2D and CAD is taking place.

“Our understanding of diagnostic modalities to assess CAD burden in patients with T2DM has been refined, as well as the appropriate roles of lifestyle management, medical therapy, and percutaneous or surgical revascularization,” researchers said.

“The expanding knowledge base needed for the care of patients with T2DM necessitates a broad range of physicians to understand and apply the evidence that can directly improve clinical outcomes," they concluded.

Reference:

Arnold SV, Bhatt DL, Barsness GW, et al. Clinical management of stable coronary artery disease in patients with type 2 diabetes mellitus: A scientific statement from the American Heart Association [published online April 13, 2020]. doi: 10.1161/CIR.0000000000000766.