Source:ajmc.com
Nihar Desai, MD, MPH, is an assistant professor of medicine in the Cardiovascular Medicine Section of the Yale School of Medicine and an investigator in the Center for Outcomes Research & Evaluation. His interests include the identification of opportunities to improve outcomes and the evaluation of the impact of novel care delivery systems on cost and quality. He has served in leadership positions in several organizations and is passionate about the need for strong physician leaders to advocate for patients and for the profession.
An editor from The American Journal of Managed Care® recently conducted a question-and-answer session with Desai to discuss strategies for improving cardiovascular outcomes among patients with type 2 diabetes.
Nihar Desai, MD, MPH: A body of literature demonstrates that diabetes increases the risk of developing CV disease, including coronary heart disease and congestive heart failure. Although there has been some disagreement about whether diabetes is a coronary heart disease equivalent, it clearly is a risk factor for CV disease, and patients with both conditions face considerable morbidity and mortality. More recently, we have come to a more global management paradigm of CV risk factors among patients with diabetes. Because CV disease is a leading cause of morbidity and mortality, optimizing blood pressure, lipids, and the use of antithrombotic therapies and other medications that reduce CV risk plays a central role in the management of patients with type 2 diabetes.
Desai: Ideally, it is the entire care team. Sure, there is an endocrinologist and a cardiologist, but there is also the primary care physician, the advanced practice provider, the pharmacist, and the diabetes educator, among others. The patient expects and deserves the entire care team to be coordinated in their approach and unified in their goal—to improve the patient’s health. I think there is always room for improvement. The system is too often siloed and fragmented, uncoordinated and opaque. We desperately need more multidisciplinary team–based models of care for all our patients, in particular those with diabetes, given all the issues at play.
Desai: I think all cardiologists—regardless of practice setting, geographic area, or number of years in practice—can benefit from educational materials highlighting the optimal management of patients with diabetes and CV disease. Issues related to blood pressure control, antithrombotic therapy, lipid management, and use of other CV-risk reducing therapies are of such critical importance that they deserve to be highlighted and reemphasized. The use of more novel therapies, such as SGLT2 [sodium-glucose cotransporter 2] inhibitors and GLP-1 [glucagon-like peptide 1] receptor agonists, also needs focused educational outreach. These are agents that were historically deemed outside the purview of cardiologists, as they were traditionally thought of as diabetes medications. However, as evidence of their CV benefits continues to emerge, they are increasingly and appropriately viewed as CV risk–reducing medications just like statins. However, this is a paradigm shift, and therefore, education, feedback, and encouragement are required.
Desai: This has been an incredibly important shift. Moving away from diabetes management that focused almost exclusively on glycemic control to a much broader and more patient-centered approach around reducing morbidity and mortality by addressing CV risk has happened over years and decades. I would say the clinical practice environment was [previously more] siloed and fragmented. Each provider had their sphere of influence, and for diabetes, that was glycemic control. However, results from epidemiologic and clinical research compelled a reevaluation. Analyses highlighting the CV risk of patients with diabetes and other [analyses] highlighting the importance of blood pressure, lipid, and antithrombotic therapy to address CV risk in this population helped catalyze a change in focus. More recently, the arrival of therapies that have only modest effects on HbA1c [glycated hemoglobin] levels, including SGLT2 inhibitors and GLP-1 receptor agonists, but have substantial benefits in terms of CV risk have further emphasized the need to look broadly at addressing CV risk.
Desai: A number of clinical trials [have evaluated] diabetes medications of varying mechanisms. The DPP-4 inhibitors have been shown to reduce HbA1c without increasing CV risk, though there may be a signal for increasing the risk of heart failure. More recently, [results of] clinical trials of SGLT2 inhibitors across patients of varying risk suggest that these [medications] can reduce the risk of MACE, particularly among patients with established CV disease. The data for GLP-1 receptor agonists are also consistent [in] showing a reduction in MACE. The newest data to emerge have been the dramatic reductions in the development of heart failure among patients with diabetes but no prior history of heart failure, as well as reductions in morbidity and mortality among patients with heart failure who receive SGLT2 inhibitors. Dapagliflozin has strong data in patients with heart failure, specifically patients with reduced ejection fraction heart failure, though clinical trials with several other SGLT2 inhibitors are ongoing. A very interesting aspect of the most recent data from DAPA-HF [NCT03036124] is that the benefit was consistent regardless of whether the patients had diabetes. Several other SGLT2 inhibitors, including empagliflozin, canagliflozin, and ertugliflozin, are also being studied in clinical trials of heart failure including for both heart failure with reduced and preserved ejection fraction. Secondary analyses of completed trials would suggest that the improvements in outcomes among patients with heart failure will be a class effect, but we eagerly await the results of the dedicated heart failure trials with these other agents.