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This medical industry feature, An Overview of the 2020 American College of Cardiology Expert Consensus Decision Pathway on Novel Therapies for CV Risk Reduction in Patients With T2D, is sponsored by Novo Nordisk. This program is intended for physicians.
Presenting is Dr. Joshua Stolker.
Dr. Joshua Stolker:
Hi, my name is Josh Stolker. I’m an interventional cardiologist practicing at Mercy Clinic Heart & Vascular in St. Louis, Missouri, and I’m an Adjunct Associate Professor of Medicine at St. Louis University School of Medicine. Today I’m going to walk through the 2020 ACC Expert Consensus Decision Pathway on novel therapies for cardiovascular risk reduction in patients with type 2 diabetes.
But before we focus on the subject of choosing the right glucose-lowering agent from a cardiologist’s standpoint, we first really have to acknowledge that these updated recommendations represent a complete change in mindset for the cardiology field. Until relatively recently, cardiologists, such as myself, deferred routinely to our primary care physicians and our endocrinologists for any glycemic control decisions in patients with type 2 diabetes. However, since cardiovascular disease is the leading cause of morbidity and mortality in patients with type 2 diabetes, we are always concerned with glycemic control for these patients due to the elevated risk of cardiovascular events in patients with type 2 diabetes, but in the end, avoiding major adverse cardiovascular events, or MACE, such as heart attacks or strokes or cardiovascular death, is our ongoing priority as cardiologists.
Despite that, the 2020 Consensus Pathway, the Decision Pathway, is creating an important opportunity for us to reexamine these traditional roles in the management of type 2 diabetes and allows us to become more active in prescribing cardioprotective diabetes therapies. More on that in a minute. First, let’s look over the Decision Pathway recommendations in more detail.
When we consider the summary graphic and its decision points, we first need to look at who the patients are and what we’re addressing, and here we’re talking about adult patients with type 2 diabetes who have either established atherosclerotic cardiovascular disease or are at high risk for atherosclerotic cardiovascular disease, or those patients who have heart failure or diabetic kidney disease.
So the next step is to simultaneously evaluate these patients for 2 important therapeutic considerations: No. 1, to optimize guideline-directed medical therapy for prevention of recurrent cardiovascular events or initial cardiovascular events. This includes lifestyle changes, blood pressure control, lipid-lowering agents, antiplatelet agents, as we’ve seen in our previous guidelines. But No. 2, it allows us to also recommend starting a cardioprotective diabetes therapy, so either an SGLT2 inhibitor or a GLP-1 receptor agonist with proven cardiovascular benefit depending on that patient’s specific risk factors and their comorbidities.
And remember, that when we talk about choosing the right glucose-lowering agent from a cardiologist’s standpoint, we’re still focusing on reducing cardiovascular events: heart attack, stroke, cardiovascular death, hospitalization for heart failure. I think this is the lens that we can and should be using to guide our glycemic control considerations for patients with type 2 diabetes.
So, heading back to the 2020 ACC Expert Decision Pathway, in the event of selecting a glucose-lowering agent, the next step is to talk with our patients to get a better understanding of their preferences and their priorities in relation to ours, and here we have 3 main options. First, if patients don’t want to take additional actions at this time based on our recommendation, we obviously can honor that preference while still encouraging them to have discussions with their endocrinologist or their primary care physician about choosing the right treatment strategy for them. Second, if we agree with the patient on advancing treatment, then we need to consider a GLP-1 receptor agonist for our patients with established atherosclerotic cardiovascular disease or those at high risk of atherosclerotic cardiovascular disease since specific agents in this class have demonstrated benefits for cardiovascular event reduction in patients with type 2 diabetes. On the other hand, we also could consider an SGLT-2 inhibitor for patients with established atherosclerotic cardiovascular disease or heart failure or diabetic chronic kidney disease or if they are at high risk for atherosclerotic cardiovascular disease since many of these agents have also been shown to reduce major adverse events in the setting of atherosclerotic disease and/or kidney disease and/or reduce the risk of hospitalization for heart failure.
And then finally, for those patients who do begin therapy on either an SGLT-2 inhibitor or a GLP-1 receptor agonist, the Decision Pathway recommends reassessment with our patients at any time throughout their treatment course to consider the addition of the alternative class—provided, of course, that the benefits outweigh the risks.
And that comes back to the heart of our mission with these treatments, which is to maximize the cardioprotective benefits of type 2 diabetes therapies in alignment with the patients’ wishes and with the treatment goals of their primary care physicians and their endocrinologists. This is clearly more than just an opportunity for us as cardiologists. It’s a responsibility that we all share together to both recognize and to recommend cardioprotective therapies for our patients with type 2 diabetes. Thank you very much.
That was Dr. Stolker from Mercy Clinic Heart and Vascular in Saint Louis. This program has been brought to you by Novo Nordisk. If you missed any part of this presentation, visit reachmd.com/heartoft2d. And to access the full 2020 ACC Expert Consensus Decision Pathway, visit acc.org and select Guidelines. This is ReachMD. Be part of the knowledge.
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US20DI00430 January 2021