Cardiovascular risk reduction in type 2 diabetes: Study urges better use of life-saving therapies

By Bhavana KunkalikarReviewed by Benedette Cuffari, M.Sc.May 10 2023

In a recent study published in the American Heart Journal, researchers explore the efficacy of current approaches to reduce the risk of cardiovascular events in patients with type 2 diabetes (T2D).

Study: Contemporary Use of Cardiovascular Risk Reduction Strategies in Type 2 Diabetes. Insights from The Diabetes Collaborative Registry. Image Credit: siam.pukkato / Shutterstock.com

T2D and cardiovascular health

T2D patients are at an increased risk of hospitalization, decreased quality of life, and financial costs due to cardiovascular complications. These complications are responsible for more than 50% of deaths in T2D patients, with their incidence continuing to rise.

Glucagon-like peptide-1 receptor agonists (GLP-1RA) and sodium-glucose cotransporter-2 inhibitors (SGLT2i), both of which were developed to lower glucose levels, have been shown to improve kidney and cardiovascular health, as well as mortality rates, among high-risk T2D patients.

About the study

In the present study, researchers analyze the trend of evidence-based therapies usage to lower cardiovascular risk in T2D patients over time. 

The study involved adult patients aged 18 years and above who had T2D and were prescribed at least one glucose-lowering therapy from a list of medication classes, including insulin, sulfonylurea, metformin, thiazolidinedione (TZD), GLP1RA, DPP-4i, and SGLT2i.

The study focused on several subgroups of patients, including those with heart failure (HF), atherosclerotic cardiovascular disease (ASCVD), and chronic kidney disease (CKD). Within the ASCVD subgroup, patients had various conditions, such as peripheral artery disease, coronary artery disease (CAD), and cerebrovascular disease. The cerebrovascular disease subgroup comprised patients with transient ischemic attack, prior stroke, and carotid artery intervention.

The researchers calculated a diabetes cardiovascular composite score (DCCS) to determine the effectiveness of cardiovascular risk reduction techniques for individual patients. This score indicated the percentage of medications recommended to the patient for optimal cardiovascular risk reduction.

Five potential medications were evaluated for eligibility for a patient, including GLP-1RA, SGLT2i, statin, antithrombotic treatment, as well as angiotensin-converting enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs), and angiotensin receptor neprilysin inhibitor (ARNI).

Results

A total of 1,001,542 patients from 391 sites were included in the current study. The cohort had an average age of about 66 years and included 512,807 men.

Over 627,146 patients had at least one high-risk condition, including documented ASCVD, heart failure, or CKD. More specifically, 518,270 patients had reported ASCVD, 177,518 noted an HF diagnosis, and 230,519 had CKD. In addition, the average systolic blood pressure was almost 130 mmHg, whereas the average body mass index (BMI) was approximately 33 kg/m2, and average hemoglobin A1C (HbA1C) was 7.4%.

Metformin was the most commonly prescribed glucose-lowering medication, with a usage rate of 73.1%. Insulin was used by 36.6% of patients, while 12.5% used SGLT2i and 12.9% used GLP-1RA.

The use of SGLT2i or GLP-1RA among patients increased from 4.1% to 28.8% from 2013 to 2019. However, DCCS decreased from 72% to 52% from 2013 to 2019 due to the increase in eligible medication options in the DCCS.

Approximately 18% of the 627,146 patients diagnosed with ASCVD, HF, or CKD were given SGLT2i or GLP-1RA medication. Younger male patients without reported HF, ASCVD, or CKD who were prescribed insulin were more frequently prescribed SGLT2i medications. GLP-1RA drugs were frequently prescribed to younger patients, women, those without documented ASCVD or HF, and those taking insulin.

The male sex and an ASCVD diagnosis were associated with a greater likelihood of using GLP-1RA or SGLT2i. Comparatively, those older or with an HF or CKD diagnosis were less likely to be prescribed these medications.

Older patients, men, those with certain medical conditions such as ASCVD, CKD, or HF, and those on insulin exhibited higher DCCS. The hierarchical linear model revealed that the male sex and a CKD diagnosis were linked to higher DCCS, whereas an ASCVD or HF diagnosis correlated with lower DCCS.

Conclusions

The study findings revealed a positive trend in the utilization of glucose-lowering medications with respect to a reduction in cardiovascular risk over time. However, despite the potential benefits, the utilization of these agents is not optimal, especially among patients with high-risk conditions.

The current study highlights the importance of educating both cardiologists and patients about the additional benefits of therapies beyond glucose reduction. Educating healthcare providers on the advantages of SGLT2i and GLP-1RA medications, as well as providing guidance on prescribing these agents and adopting team-based care models, can aid in changing the perception of these drugs from glucose-lowering agents to instruments for reducing cardiovascular risks in T2D patients.