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07-05-2022 | Heart failure | News

Highest CV risk may warrant SGLT2 inhibitor rather than GLP-1 receptor agonist

Author: Eleanor McDermid

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medwireNews: The rate of heart failure hospitalization (HHF) rises more than the rate of major adverse cardiovascular events (MACE) as vascular risk increases in people with type 2 diabetes, report researchers.

This was “irrespective of whether the risk score applied was designed to predict MACE or HHF,” say Julian Sacre (Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia) and study co-authors.

The team used two scores –– the TIMI Risk Score for Secondary Prevention (TRS-2⁰P), which was designed to predict MACE, and the TIMI Risk Score for Heart Failure in Diabetes (TRS-HFDM).

When the TRS-2⁰P was applied to the populations of the SAVOR, DECLARE-TIMI 58, and EMPA-REG OUTCOME trials, the incidence rate of MACE rose from about 16 to 70 per 1000 person–years for people in the low versus the highest risk categories, respectively.

The incidence rate of HHF was lower overall, and in the low-risk group the HHF rate of around three per 1000 person–years represented just 19% of the MACE rate, so there were about five MACE for every HHF.

But the HHF rate rose steeply across the groups with intermediate, high, and highest MACE risk, increasing to 26%, 38%, and 51%, respectively, of the MACE rate.

“This translates to the observation, which may initially appear counterintuitive, that HHF appears relatively more frequently as the risk of MACE worsens,” write the researchers in Diabetes Care.

They say their findings “raise the question about the inherent feasibility of differentiating MACE from HHF risk in type 2 diabetes,” noting that there is a large overlap in risk factors for the two outcomes, and some overlap in the outcomes themselves, with death from HF being regarded as cardiovascular death and counted with MACE.

The same pattern was evident when using the TRS-HFDM score, with MACE rates being higher than HHF rates overall, but the latter increasing from 18% of the rate of MACE in the low-intermediate HHF risk category and rising to 31% and 61% across the high and highest HHF risk categories, respectively.

The team found that these high rates of HHF in people with the highest cardiovascular risk had implications for medication choice. Among people with low to high cardiovascular risk, sodium-glucose cotransporter (SGLT)2 inhibitors and glucagon-like peptide (GLP)-1 receptor agonists prevented similar numbers of clinical events (combined MACE and HHF).

But in those with the highest risk, SGLT2 inhibitors prevented approximately five more events per year per 1000 people treated than GLP-1 receptor agonists did, although this did not attain statistical significance.

Therefore, “people classified as highest MACE risk, and thus seemingly good candidates for treatment with a GLP-1 [receptor agonist], may actually benefit more from SGLT2 [inhibitor] therapy,” say Sacre and team.

But they stress that people with the highest MACE risk represented only 6% of the DECLARE-TIMI 58 participants, which they regard as the most generalizable to general clinical practice.

“[T]he two drug classes offer similar [cardiovascular] protection in people at low-intermediate MACE or HHF risk, which encompasses the majority of the population with type 2 diabetes,” says the team.

medwireNews is an independent medical news service provided by Springer Healthcare Ltd. © 2022 Springer Healthcare Ltd, part of the Springer Nature Group

Diabetes Care 2022; doi:10.2337/dc21-1929


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