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Diabetes and Heart Failure: Truth and Consequences
1
Paul P. Doghramji, MD, FAAFP
Family Practice Physician
Collegeville Family Practice & Pottstown Medical Specialists, Inc.
Medical Director of Health Services, Ursinus College – Collegeville, PA
Attending Family Practice Physician, Pottstown Memorial Medical Center – Pottstown, PA
Diabetes and Heart Failure: Truth and Consequences
Learning Objectives
▪ Assess patients with type 2 diabetes mellitus for cardiovascular
(CV) risk, including heart failure
▪ Describe the results of cardiovascular outcomes trials of
glucose-lowering medications for type 2 diabetes mellitus,
focusing on heart failure
▪ Select glucose-lowering medication shown to be beneficial in
patients with type 2 diabetes mellitus at risk of heart failure
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Diabetes and Heart Failure: Truth and Consequences
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5
10
15
20
25
30
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Coronary HeartDisease
AtherothromboticBrain Infarction
IntermittentClaudication
Congestive HeartFailure
CardiovascularDeath
CardiovascularDisease
An
nu
al
ag
e-a
dju
ste
d e
ve
nt
rate
pe
r 1
00
0
Framingham Heart Study
Women without Diabetes Women with Diabetes
Men without Diabetes Men with Diabetes
Kannel WB, McGee DL. JAMA. 1979;241:2035-2038.
Diabetes Mellitus as a Cardiovascular Risk Factor
Linear Relationship Between Glycemic Control and HF
RR = relative risk
For every
1% increase
in A1c
15% increase in RR of
HF
Erqou S, et al. Eur J Heart Fail. 2013;15:185-193.
10 studies involving 178,929 patients with diabetes and 14,176 incident cases of HF
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Diabetes and Heart Failure: Truth and Consequences
3
Patients with T2DM are
2.5x more likelyto develop HF than people without T2DM1,2
Risk of hospitalization from HF is
33% higherin patients with T2DM3
Even with optimal glycemic management,
patients with T2DM have a high risk of
morbidity and mortality4
1. Nichols GA, et al. Diabetes Care. 2004;27(8):1879-1884.
2. Komanduri S, et al. J Community Hosp Intern Med Perspect. 2017;7(1):15-20.
3. Cavender MA, et al. Circulation. 2015;132:923-931.
4. Vijaykumar S, et al. Exp Rev Cardiovasc Ther. 2018;16(2):123-131.
Patients with T2DM are at greater risk of developing HF and being hospitalized due to HF
UKPDS = United Kingdom Prospective Diabetes StudyStratton IM, et al. BMJ. 2000;321:405-412.
43% 37% 19% 16% 14% 12%
Lower-extremity
amputation or fatal
peripheral vascular
disease(P<0.0001)
Microvascular
disease(P<0.0001)
Cataract
extraction(P<0.0001)
Heart failure(P<0.05)
Myocardial
infarction(P<0.0001)
Stroke(P<0.05)
Cardiovascular complications
UKPDS: 1% HbA1c Decrease and Reduced Risk of Complications
5
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Diabetes and Heart Failure: Truth and Consequences
4
Initial Presentation of Cardiovascular Disease in T2DM
2.98
1.72
1.64
1.62
1.58
1.56
1.54
1.53
1.45
1.43
0 0.5 1 1.5 2 2.5 3 3.5
Peripheral Arterial Disease
Ischemic Stroke
Stroke Not Further Specified
Stable Angina
Coronary Disease Not Further Specified
Heart Failure
Non-fatal Myocardial Infarction
Unstable Angina
Transient Ischemic Attack
Unheralded Coronary Death
Adjusted Hazard Ratio*
Shah AD, et al. Lancet Diabetes Endocrinol. 2015;3;105-113.*Adjusted for age, sex, body mass index, deprivation, HDL cholesterol, total cholesterol,
systolic blood pressure, smoking status, and statin and antihypertensive medications
*Excluding patients admitted for acute HF caused by acute coronary syndrome without evidence of systolic or diastolic dysfunction
van den Berge JC, et al. Diabetes Care. 2018;41(1):143-149.
American Diabetes Association. Short and long-term prognosis of patients with acute heart failure with and without diabetes: Changes over the last three
decades, American Diabetes Association, 2018. Copyright and all rights reserved. Material from this publication has been used with the permission of American
Diabetes Association.
Total Population 30-Day Event-Free Survivors
Worse Prognosis in Patients with HF and T2DM*
7
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Diabetes and Heart Failure: Truth and Consequences
5
Heart Failure with Preserved Ejection Fraction (HFpEF)
▪ Also referred to as “diastolic heart failure”
▪ Characterized by signs and symptoms of heart failure
and LVEF > 50%
▪ Heart failure associated with intermediate reductions
in LVEF (40% to 49%) is also commonly grouped into
this category
Pathophysiology of HFpEF
▪ Abnormalities of active ventricular relaxation and passive
ventricular compliance, resulting in ventricular stiffness and
higher diastolic pressures
▪ These pressures are transmitted through atrial and pulmonary
venous systems, reducing lung compliance
▪ A combination of decreased lung compliance and cardiac
output leads to symptoms
▪ Physiologic stressors, such as a hypertensive crisis, can
overcome compensatory mechanisms and result in
pulmonary edemaBorlaug BA, Paulus WJ. Heart failure with preserved ejection fraction: pathophysiology, diagnosis, and treatment. Eur Heart J. 2011;32(6):670–679.
9
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Diabetes and Heart Failure: Truth and Consequences
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Epidemiology
▪ ~5 million persons in the United States have been diagnosed
with heart failure, with an incidence of more than 650,000 new
diagnoses per year
▪ Almost one-half of patients with heart failure have preserved
ejection fraction
▪ Risk factors: older age, female sex, obesity, hypertension,
tobacco use, diabetes mellitus, coronary artery disease (CAD),
valvular heart disease, and atrial fibrillation
Lee DS, Gona P, Vasan RS, et al. Relation of disease pathogenesis and risk factors to heart failure with preserved or reduced ejection fraction: insights from the
Framingham Heart Study of the National Heart, Lung, and Blood Institute. Circulation. 2009;119(24):3070–3077.
Chronic Kidney
Disease
Coronary Heart
Disease
AnemiaDyslipidemia
Advanced
Age
Sleep ApneaHypertension
Obesity
Thomas MC. Curr Cardiol Rev. 2016;12:249-255.
Heart Failure Diabetes Mellitus
All of the Major Risk Factors for HF are Associated with Diabetes
11
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Diabetes and Heart Failure: Truth and Consequences
7
How Heart Failure Is Diagnosed
▪ History & Physical examination
▪ Risk scoring - Seattle Heart Failure Model, ADHERE
Clinical Evaluation
▪ CBC, lytes, urinalysis, BUN, SCr, glucose, fasting lipids, LFTs, TSH
▪ Biomarkers - BNP, NT-proBNP
▪ Chest X-ray
▪ 12-lead ECG
▪ 2-dimensional echocardiogram with Doppler
▪ Angiogram
Testing
Yancy CW, et al. J Am Coll Cardiol. 2013;62(16):e147-e239.
Signs and Symptoms of HFpEF
▪ Fatigue
▪ Weakness
▪ Dyspnea
▪ Orthopnea
▪ Paroxysmal nocturnal dyspnea
▪ Jugular venous distention on exam
▪ S3 heart sound
▪ Displaced apical impulse
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Diabetes and Heart Failure: Truth and Consequences
8
Framingham Criteria for Diagnosis of Heart Failure
Major criteria
▪ Acute pulmonary edema
▪ Cardiomegaly
▪ Hepatojugular reflux
▪ Neck vein distention
▪ Paroxysmal nocturnal
dyspnea/orthopnea
NOTE: Heart failure is present in patients with at least two major criteria or one major and two minor criteria (positive
likelihood ratio = 10; negative likelihood ratio = 0.4)
Minor criteria ▪ Ankle edema
▪ Dyspnea on exertion
▪ Hepatomegaly
▪ Nocturnal cough
▪ Pleural effusion
▪ Tachycardia (pulse > 120)
McKee PA, Castelli WP, McNamara PM, Kannel WB. The natural history of congestive heart failure: the Framingham study. N Engl J Med. 1971;285(26):1441–1446.
Diagnostic Tests
▪ Brain natriuretic peptide (BNP)
▪ IN ER: <100 pg per mL (100 ng per L) rules out acute heart failure
▪ In primary care setting: <35 rules out heart failure in low risk patients
▪ N-terminal pro-BNP (NT pro-BNP)
▪ IN ER: <300 pg per mL (300 ng per L) can reliably rule out acute heart failure
▪ In primary care setting: <125 rules out heart failure in low risk patients
▪ EKG: reduced likelihood of heart failure when normal
▪ CXR: moderately helpful when abnormal, not so much when normal
Mant J, Doust J, Roalfe A, et al. Systematic review and individual patient data meta-analysis of diagnosis of heart failure, with modelling of implications of different
diagnostic strategies in primary care. Health Technol Assess. 2009;13(32):1–207.
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Diabetes and Heart Failure: Truth and Consequences
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Diagnostic Tests (cont’d)
▪ Trans-thoracic echocardiogram (TTE)
▪ Preferred test to confirm HFpEF
▪ The combined finding of normal left ventricular systolic
function and diastolic dysfunction confirms HFpEF
▪ Transesophageal echocardiography is not recommended
for routine evaluation of HFpEF
Chinnaiyan KM, Alexander D, Maddens M, McCullough PA. Curriculum in cardiology: integrated diagnosis and management of diastolic heart failure. Am Heart J.
2007;153(2):189–200.
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Diabetes and Heart Failure: Truth and Consequences
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Exercise Capacity is diminished in patients with HFpEF and T2DM
328
297
0
100
200
300
400
Mete
rs
Exercise Capacity(6-minute walk test)
P<0.001
Lindman BR, et al. J Am Coll Cardiol. 2014;64(6):541-549.
HFpEF without Diabetes HFpEF with Diabetes
HFpEF, heart failure with preserved ejection fraction, ie, ejection fraction ≥50%
MacDonald MR, et al. Eur Heart J. 2008;29:1377-1385.
MacDonald MR, et al for the CHARM Investigators. Impact of diabetes on outcomes in patients with low and preserved ejection fraction heart failure.
Eur Heart J. 2008;29(11):1377-1385 by permission of the European Society of Cardiology.
Patients with T2DM and HFpEFhave worse outcomes
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Diabetes and Heart Failure: Truth and Consequences
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STAGE RECOMMENDATION
A: Heart failure risk factorsGuideline-directed treatment of hypertension and
hyperlipidemia
B: Diastolic dysfunction without symptoms
Treat hypertension with thiazide diuretics, ACE
inhibitors, or nondihydropyridine calcium channel
blockers
C: Symptomatic heart failure with preserved
ejection fraction and hypertension
Treat volume overload with diuretics; consider use of
beta blockers, ACE inhibitors
D: Symptomatic heart failure with preserved
ejection fraction without hypertensionTreat volume overload with diuretics
Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology
Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013;62(16):e147–e239.
AHA/ACC Recommendations for Treatment
Mechanick JI, et al. Endocr Pract. 2018;24(11):995-1011.
Type 2 Diabetes Mellitus
Insulin Resistance
Prediabetes
Type 2 Diabetes Mellitus
Vascular Complications
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Diabetes and Heart Failure: Truth and Consequences
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There’s also
• Antiplatelet therapy ● Cholesterol ●Exercise
• Blood pressure ● Dietary
And let’s not forget
• Smoking ● Regular examination of:
• Weight -Eyes, mouth/teeth, feet/skin, kidneys
Plus
• Diabetes distress
• Quality of life
And now
• Choose glucose-lowering medication shown to reduce cardiovascular risk (when possible)
Treating Patients with T2DM is more than Glucose Control
▪ 62 yo man diagnosed
with T2DM 10 y ago
(A1c 8.6%)
▪ 3-y history of mixed
dyslipidemia
▪ Complains of
occasional SOB,
fatigue
▪ Currently▪ A1c 7.5%
▪ BMI 30.6 kg/m2
▪ BP 160/95 mmHg
▪ LDL-C 125 mg/dL
▪ Triglycerides 364 mg/dL
▪ Non-HDL-C 156 mg/dL
▪ Medications▪ Metformin 1 g BID
▪ Losartan 100 mg QD
▪ Simvastatin 40 mg QD
▪ ASA 81 mg QD
Exam findings:
▪ JVD
▪ S3
▪ Ankle edema
Case Study: David
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Diabetes and Heart Failure: Truth and Consequences
13
▪ BNP =75, NTBNP = 150
▪ EKG normal
▪ CXR normal
▪ TEE: reveals David has heart failure with preserved
ejection fraction
▪ Ejection fraction 60%
Case Study: David (cont)
US Food and Drug Administration.
http://www.fda.gov/downloads/drugs/guidancecomplianceregulatoryinformation/guidances/ucm071627.pdf.
Accessed February 10, 2020.
FDA Diabetes Mellitus Guidance - 2008
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Diabetes and Heart Failure: Truth and Consequences
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The goal of cardiovascular safety trials is to demonstrate that the CV safety of the new glucose-lowering therapy is
SIMILAR TO PLACEBO.
▪ Primary vs secondary prevention
▪ Primary end point:
▪ Composite of CV death, non-fatal MI, and
non-fatal stroke
Nomenclature
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Diabetes and Heart Failure: Truth and Consequences
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Diabetes Medication CV Outcomes/Safety Trials
DPP-4i GLP-1RA SGLT-2i
Alogliptin EXAMINE Albiglutide* HARMONY
Canagliflozin
CANVAS
Linagliptin
CARMELINA Dulaglutide REWIND CANVAS-R
CAROLINA Exenatide QW EXSCEL CREDENCE
Saxagliptin SAVOR-TIMI53 Liraglutide LEADER DapagliflozinDECLARE-TIMI
58
Sitagliptin TECOS
Lixisenatide ELIXA EmpagliflozinEMPA-REG
OUTCOME
Semaglutide SUSTAIN 6 Ertugliflozin VERTIS CV
NOTE: All trials are randomized, double-blind, parallel, placebo-controlled, multi-center
*Will no longer be available as of December 2019.
Results of CV Outcomes Trials
CV Safety▪ Non-inferiority
▪ No increase in CV risk compared to placebo as part of standard therapy
CV Benefit▪ If non-inferiority is demonstrated,
can look for superiority
▪ Superiority - CV risk significantly reduced compared to placebo as part of standard therapy
CV Safety CV Benefit
Dipeptidyl peptidase-4 inhibitors
Alogliptin
Linagliptin
Saxagliptin
Sitagliptin
Glucagon-like peptide-1 receptor agonists
Albiglutide*
Dulaglutide
Exenatide BID Not required
Exenatide QW
Liraglutide
Lixisenatide
Semaglutide
Sodium glucose cotransporter-2 inhibitors
Canagliflozin
Dapagliflozin
Empagliflozin
Ertugliflozin*Will no longer be available as of December 2019.
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Diabetes and Heart Failure: Truth and Consequences
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Antihyperglycemic Medications Demonstrating Cardiovascular Benefit: SGLT-2 Inhibitors
Canagliflozin(1◦ & 2◦ Prevention)
Endpoint
Rate/100 patient -
years
Hazard
Ratio
(95% CI)Canagliflozin Placebo
CV death, nonfatal MI, nonfatal strokea 2.69 3.15 0.86 (0.75-0.97)
HF hospitalization 0.55 0.87 0.67 (0.52-0.87)
CV death or HF hospitalization 1.63 2.08 0.78 (0.67-0.91)
Progression of albuminuria 8.94 12.87 0.73 (0.67-0.79)
40% reduction eGFR, renal dialysis or
transplantation, renal death0.55 0.90 0.60 (0.47-0.77)
Neal B, et al. N Engl J Med. 2017;377(7):644-657.
Independent of prior stroke at baseline
CV = cardiovascular; eGFR = estimated glomerular filtration rate;
HF = heart failure; MI = myocardial infarctionaPrimary endpoint
Antihyperglycemic Medications Demonstrating Cardiovascular Benefit: SGLT-2 Inhibitors (cont)
Dapagliflozin(1◦ & 2◦ Prevention)
Endpoint
Rate/100 patient -
years
Hazard
Ratio
(95% CI)Dapagliflozin Placebo
CV death, nonfatal MI, nonfatal strokea 2.26 2.42 0.93 (0.84-1.03)
CV death or HF hospitalizationa 1.22 1.47 0.83 (0.73-0.95)
HF hospitalization 0.62 0.85 0.73 (0.61-0.88)
≥40% decrease in eGFR to <60
mL/min/1.73 m2, ESRD, or death from
renal or CV cause
1.08 1.41 0.76 (0.67-0.87)
Consistent across multiple groups,
including history of ASCVD or heart failure
ESRD = end-stage renal diseaseaPrimary endpoint
Wiviott SD, et al. N Engl J Med. 2018;doi:10.1056/NEJMoa1812389.
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Diabetes and Heart Failure: Truth and Consequences
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Antihyperglycemic Medications Demonstrating Cardiovascular Benefit: SGLT-2 Inhibitors (cont)
Empagliflozin(2◦ Prevention)
Endpoint
Rate/100 patient -
years
Hazard
Ratio
(95% CI)Empagliflozin Placebo
CV death, nonfatal MI, nonfatal strokea 3.74 4.39 0.86 (0.74-0.99)
All-cause deathb 1.94 2.86 0.68 (0.57-0.82)
CV death 1.24 2.02 0.62 (0.49-0.77)
HF hospitalization 0.94 1.45 0.65 (0.50-0.85)
HF hospitalization or CV death
(excluding fatal stroke)1.97 3.01 0.66 (0.55-0.79)
Independent of prior MI and/or stroke at baselineaPrimary endpoint bNNT=39 over 3 years
Zinman B, et al. N Engl J Med. 2015;373(22):2117-2128.
Antihyperglycemic Medications Demonstrating Cardiovascular Benefit: GLP-1 Receptor Agonists
Dulaglutide(1◦ & 2◦ Prevention)
Endpoint
Rate/100 patient -
years
Hazard
Ratio
(95% CI)
P
Dulaglutide Placebo
CV death, nonfatal MI, nonfatal
strokea 2.35 2.66 0.88 (0.79-0.99) 0.026
Nonfatal stroke 0.52 0.69 0.76 (0.61-0.95) 0.017
New macroalbuminuria, sustained
decline in eGFR ≥30% or chronic
renal replacement therapy
3.47 4.07 0.85 (0.77-0.93) 0.0004
aPrimary endpoint
Gerstein HC, et al. Lancet. 2019;doi:10.1016/S0140-6736(19)31149-3.
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Diabetes and Heart Failure: Truth and Consequences
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Antihyperglycemic Medications Demonstrating Cardiovascular Benefit: GLP-1 Receptor Agonists (cont)
Liraglutide(1◦ & 2◦ Prevention)
Endpoint
Rate/100 patient -
years
Hazard
Ratio
(95% CI)Liraglutide Placebo
CV death, nonfatal MI, nonfatal strokea,b 3.4 3.9 0.87 (0.78-0.97)
CV death, nonfatal MI, nonfatal stroke,
coronary revascularization, or
hospitalization for UA or HF
5.3 6.0 0.88 (0.81-0.96)
All-cause deathc 2.1 2.5 0.85 (0.74-0.97)
CV death 1.2 1.6 0.78 (0.66-0.93)
Microvascular event 2.0 2.3 0.84 (0.73-0.97)
Nephropathy 1.5 1.9 0.78 (0.67-0.92)
aPrimary endpoint bNNT=66 over 3 years cNNT=98 over 3 years
Marso SP, et al. N Engl J Med. 2016;375(4):311-322.
Antihyperglycemic Medications Demonstrating Cardiovascular Benefit: GLP-1 Receptor Agonists (cont)
Semaglutide(1◦ & 2◦ Prevention)
Endpoint
Rate/100 patient -
years
Hazard
Ratio
(95% CI)Semaglutide Placebo
CV death, nonfatal MI, nonfatal strokea,b 3.24 4.44 0.74 (0.58-0.95)
CV death, nonfatal MI, nonfatal stroke,
revascularization, hospitalization for UA
or HF
6.17 8.36 0.74 (0.62-0.89)
All-cause death, nonfatal MI, nonfatal
stroke3.66 4.81 0.77 (0.61-0.97)
Nonfatal stroke 0.80 1.31 0.61 (0.38-0.99)
Revascularization 2.50 3.85 0.65 (0.50-0.86)
New or worsening nephropathy 1.86 3.06 0.64 (0.46-0.88)
aPrimary endpoint bNNT=45 over 2 years
Marso SP, et al. N Engl J Med. 2016;375(19):1834-1844.
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Diabetes and Heart Failure: Truth and Consequences
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Effect of Selected Glucose-Lowering Medications on Heart Failure Hospitalization
Rate/100
Patient - years
Hazard
Ratio
(95% CI)Active Placebo
SGLT-2 Inhibitor
Canagliflozin 0.55 0.87 0.67 (0.52-0.87)
Dapagliflozin 0.62 0.85 0.73 (0.61-0.88)
Empagliflozin 0.94 1.45 0.65 (0.50-0.85)
GLP-1 Receptor Agonist
Dulaglutidea 0.83 0.89 0.93 (0.77-1.12)
Liraglutide 1.2 1.4 0.87 (0.73-1.05)
Semaglutide 1.76 1.61 1.11 (0.77-1.61)
aHF hospitalization or urgent visit
MACE FDA Labeling Regarding CV Risk
GLP-1 Receptor Agonists
Albiglutide* –
Dulaglutide –
Exenatide
once-weekly
Liraglutide …to reduce the risk of major adverse CV events (CV death, non-fatal myocardial infarction, or
non-fatal stroke) in adults with T2DM and established CV disease
Lixisenatide
Semaglutide –
SGLT-2 Inhibitors
Canagliflozin
…to reduce the risk of major adverse CV events in adults with T2DM and established CV
disease
…to reduce the risk of end-stage kidney disease (ESKD), doubling of serum creatinine, CV
death, and hospitalization for heart failure in adults with T2DM and diabetic nephropathy with
albuminuria ˃ 300 mg/d
Dapagliflozin…to reduce the risk of hospitalization for heart failure in adults with T2DM and established CV
disease or multiple CV risk factors
Empagliflozin …to reduce the risk of CV death in adults with T2DM and established CV disease
Ertugliflozin
Updated Prescribing
Information to Reflect CV Outcomes
Trials
*No longer available as of
December 2019
Tanzeum [package insert]. Research Triangle, NC: GlaxoSmithKline; December 2017. Trulicity [package insert]. Indianapolis, IN: Eli Lilly and Co.; January 2019. Bydureon [package
insert]. Wilmington, DE: Astrazeneca Pharmaceuticals LP; February 2019. Victoza [package insert]. Plainsboro, NJ: Novo Nordisk Inc.; September 2019. Adlyxin [package insert].
Bridgewater, NJ: Sanofi-aventis U.S., LLC; January 2019. Ozempic [package insert]. Plainsboro, NJ: Novo Nordisk Inc.; April 2019. Invokana [package insert]. Titusville, NJ: Janssen
Pharmaceuticals, Inc.; October 2019. Farxiga [package insert]. Wilmington, DE: Astrazeneca Pharmaceuticals LP; October 2019. Jardiance [package insert]. Ridgefield, CT: Boehringer
Ingelheim Pharmaceuticals, Inc.; January 2019. Steglatro [package insert]. Whitehouse Station, NJ: Merck Sharp & Dohme Corp.; October 2018.
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Diabetes and Heart Failure: Truth and Consequences
20
Summary & Implications for Primary Care
▪ Reducing cardiovascular risk is the key treatment objective for
patients with diabetes
▪ Available evidence shows that medications from 3 classes do not
pose an increased risk of major adverse cardiovascular events
▪ Available evidence shows that the following medications reduce
the risk of key cardiovascular outcomes
▪ SGLT-2 inhibitors: canagliflozin, dapagliflozin, empagliflozin
▪ GLP-1 RAs: albiglutide, dulaglutide, liraglutide, semaglutide
New Paradigm in Diabetes Treatment
American Diabetes Association.
Diabetes Care. 2019;42(Suppl
1):S90-S102.
American Diabetes Association.
Standards of medical care in
diabetes-2019, American
Diabetes Association, 2019.
Copyright and all rights
reserved. Material from this
publication has been used with
the permission of American
Diabetes Association.
39
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Diabetes and Heart Failure: Truth and Consequences
21
Patients with T2DM and Established ASCVD or CKD
American Diabetes Association. Diabetes Care. 2019;42(Suppl 1):S90-S102.
American Diabetes Association. Standards of medical care in diabetes-2019,
American Diabetes Association, 2019. Copyright and all rights reserved. Material from
this publication has been used with the permission of American Diabetes Association.
▪ 62 yo man diagnosed with
T2DM 10 y ago (A1c 8.6%)
▪ 3-y history of mixed
dyslipidemia
▪ Complains of occasional
SOB, fatigue
▪ Currently▪ A1c 7.5%
▪ BMI 30.6 kg/m2
▪ BP 160/95 mmHg
▪ LDL-C 125 mg/dL
▪ Triglycerides 364 mg/dL
▪ Non-HDL-C 156 mg/dL
▪ Medications▪ Metformin 1 g BID
▪ Losartan 100 mg QD
▪ Simvastatin 40 mg QD
▪ ASA 81 mg QD
Case Study: David
Diagnosed with HFpEF
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