The American Heart Association (AHA) issued a scientific statement on the clinical management of stable coronary artery disease (CAD) in patients with type 2 diabetes.
Factors that have led the cardiology community to reconsider the role of diabetes in CAD include mounting evidence that the mechanism by which glucose is managed can have a substantial impact on cardiovascular outcomes, the authors said. The statement, which is intended to provide a comprehensive summary of effective, patient-centered management, was published April 13 by Circulation.
Regarding antithrombotics, the statement says that aspirin alone poses the lowest risk of bleeding, but high residual platelet reactivity increases cardiovascular risk. Clopidogrel alone decreases cardiovascular risk without meaningfully increasing risk of bleeding compared to aspirin alone. Aspirin plus clopidogrel/ticagrelor decreases cardiovascular risk with increased risk of bleeding, as does aspirin plus low-dose rivaroxaban.
The statement recommends a target blood pressure of less than 140/90 mm Hg in most patients but consideration of a target of 130/80 mm Hg if there are additional risk factors for stroke or microvascular complications. Angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers should be first-line therapy. Long-acting thiazide diuretics offer good cardiovascular risk reduction but a slight increase in glucose levels. Calcium-channel blockers offer good cardiovascular risk reduction and are an effective antianginal agent. Aldosterone antagonists are particularly effective in patients with prior myocardial infarction or left ventricular dysfunction. Beta-blockers do not reduce mortality in uncomplicated patients with stable CAD, the statement said.
High-intensity statins should be the cornerstone of lipid therapy and secondary prevention, the AHA recommended. Ezetimibe and PCSK9 inhibitors offer additional cardiovascular risk reduction when LDL levels are above 70 mg/dL (1.8 mmol/L) despite maximally tolerated statins. Niacin is not recommended. Fibrates are recommended when triglyceride levels are very high, more than 500 mg/dL (5.7 mmol/L), to reduce the risk of pancreatitis. Icosapent ethyl can be considered for further cardiovascular risk reduction when triglyceride levels remain above 135 mg/dL (1.5 mmol/L) despite maximally tolerated statins.
Hyperglycemia increases cardiovascular risk, but impact of glucose-lowering therapies on outcomes is complex, and therapy needs to be individualized, the statement said.
“A remarkable transformation in the care of patients with [type 2 diabetes mellitus] is occurring,” the authors concluded. Improvements include drugs that not only reduce glucose levels but also improve cardiovascular and renal outcomes, new treatments for other risk factors such as elevated cholesterol levels and hypertension, expanded antithrombotic options, and refinements in both diagnostic modalities to assess CAD burden in patients with diabetes and the roles of lifestyle management, medical therapy, and revascularization.