Spotlight on cardiovascular risk in type 2 diabetes

Several recent articles focused on cardiovascular risk and outcomes in patients with type 2 diabetes.

First, the American Heart Association released a scientific statement updating its 2015 joint statement with the American Diabetes Association on preventing cardiovascular disease in adults with type 2 diabetes. The statement, published online on Jan. 10 by Circulation, reviewed the evidence and clinical utility of newer antihyperglycemic agents, such as dipeptidyl peptidase-4 inhibitors, sodium-glucose cotransporter-2 (SGLT-2) inhibitors, and glucagon-like peptide-1 receptor agonists, in improving glycemic control and reducing cardiovascular events, as well as other topics including health equity. It noted that several large randomized controlled trials of new antihyperglycemic agents have demonstrated cardiovascular safety and benefits but that clinical care and treatment account for only 10% to 20% of the modifiable contributors to healthy outcomes. The remaining contributors are social determinants of health, including health-related behaviors, socioeconomic factors, environmental factors, and racism, according to the statement. “We recommend a comprehensive approach to management of all cardiovascular risk factors in patients with [type 2 diabetes], including glycemia, [blood pressure], lipid abnormalities, thrombotic risk, obesity, and smoking, using lifestyle and pharmacological approaches with proven benefit using a patient-centered approach,” the authors wrote. “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.”

The second article, published Dec. 21 by Frontiers in Endocrinology, found that the presence of diabetes was associated with higher all-cause and cardiovascular mortality in patients with nonalcoholic fatty liver disease (NAFLD). Researchers used data from the third National Health and Nutrition Examination Survey (1988 to 1994) to assess mortality outcomes in 4,037 adults (55.9% female) with hepatic ultrasound-confirmed NAFLD. Overall, 483 patients self-reported a history of diabetes at baseline. During a median follow-up of 22.1 years, 1,517 patients died, including 332 from cardiovascular causes. In unadjusted analyses, the presence of diabetes was associated with increased all-cause mortality (hazard ratio [HR], 3.02; 95% CI, 2.67 to 3.41) and cardiovascular mortality (HR, 3.36; 95% CI, 2.61 to 4.32). The association remained significant after adjustment for confounders. Among other limitations, individuals were asked about diabetes at a single time point, the study authors noted.

The final study, a meta-analysis published Jan. 5 by JAMA Network Open, assessed the association of SGLT-2 inhibitors with cardiovascular outcomes in high-risk patients. Researchers looked at 10 placebo-controlled trials in which participants had atherosclerotic cardiovascular disease or risk factors for it, diabetes, or heart failure. They evaluated six efficacy outcomes of SGLT-2 inhibitor use: cardiovascular death and hospitalization for heart failure as the primary outcome and major adverse cardiovascular event, hospitalization for heart failure, cardiovascular death, acute myocardial infarction, and all-cause mortality as secondary outcomes. At a mean follow-up of 2.3 years, the 39,053 patients who received SGLT-2 inhibitors (out of 71,553) had a greater reduction in the primary outcome (8.10% vs. 11.56%; odds ratio, 0.67 [95% CI, 0.55 to 0.80]; P<0.001). In contrast, there was no difference in the rate of acute myocardial infarction in the SGLT-2 group compared with the placebo group (4.66% vs. 4.70%; P=0.22). Subgroup analyses favored SGLT-2 inhibitors for reducing the primary outcome across sexes, age groups, and racial and ethnic groups. The study authors lacked access to patient-level data to perform a propensity analysis or stratified analysis, they noted. They added that the definition of secondary outcomes was variable across studies, among other limitations.