Top Things to Know: Clinical Management of Stable Coronary Artery Disease in Patients With Type 2 Diabetes Mellitus
Published: April 13, 2020
- This statement summarizes the recent clinical trials have uncovered several new drugs not only to reduce glucose but also to improve cardiovascular and renal outcomes.
- There has been refinement in the understanding of diagnostic modalities to assess CAD burden in patients with T2D, as well as the appropriate roles of lifestyle management, medical therapy, and percutaneous or surgical revascularization. This statement expands the knowledge base needed for the care of patients with T2D and applies evidence that can directly improve clinical outcomes.
- Lifestyle and health behavior management, including smoking cessation, heart-healthy diet, weight loss (if overweight or obese), sleep and stress management, and exercise/physical activity, remains to be the cornerstone of clinical care both for patients with T2D and those with CAD.
- Long-term therapy with clopidogrel in addition to aspirin is an option in select patients with stable CAD and T2D, understanding there should be a balance between decreasing ischemic risks with increasing bleeding risks.
- A lower BP target might be appropriate in patients with diabetes who are at higher risk of stroke and other microvascular complications, if this can be done without harm.
- Beta blockers as antihypertensive agents should be targeted to patients with clear indications, such as angina or to those who require additional BP lowering beyond other agents. It is optimal to select a beta blocker with a concomitant vasodilatory effect (e.g., carvedilol, labetalol), which will have less adverse metabolic effects.
- The evidence to date supports an LDL-C lowering strategy to reduce the risk of subsequent cardiovascular events in individuals with T2D and CAD.
- As patients with both T2D and CAD represent a high-risk group, additional agents may be needed for LDL-C lowering beyond statin monotherapy. The addition of non-statin LDL-C lowering therapies, such as ezetimibe and PCSK9 inhibitors, should be considered based on the individual’s overall cardiovascular risk profile, personal preferences, and drug access.
- Metformin remains to be the most frequently recommended first-line therapy for patients with diabetes. Sulfonylureas and insulin can be used cautiously as glucose-lowering therapies in patients with stable CAD, but should be careful of hypoglycemia and excess weight gain.
- As both percutaneous and surgical revascularization outcomes are impaired in the presence of T2D, primary and secondary medical preventive therapy remains the foundation of care.
Citation
Arnold SV, Bhatt DL, Barsness GW, Beatty AL, Deedwania PC, Inzucchi SE, Kosiborod M, Leiter LA, Lipska KJ, Newman JD, Welty FK, on behalf of the American Heart Association Council on Lifestyle and Cardiometabolic Health and Council on Clinical Cardiology. Clinical management of stable coronary artery disease in patients with type 2 diabetes mellitus: a scientific statement from the American Heart Association [published online ahead of print April 13, 2020]. Circulation. doi: 10.1161/CIR.0000000000000766.