Management
Glucose-Lowering Medications in Patients at High Cardiovascular Risk
Editors: Heather A. Ferris MD, Phd; Zbigniew Fedorowicz PhD, MSc, DPH, BDS, LDSRCS; Peter Oettgen MD
Background Information
Epidemiology
- STUDY SUMMARYestimated prevalence of adults aged 40-79 years at high cardiovascular risk is about 35% overall using 7.5% as 10-year risk cutoff and about 10% overall using 20% as 10-year risk cutoff in United States from 1999 to 2014CROSS-SECTIONAL STUDY: Am J Prev Med 2018 Sep;55(3):384
Possible Mechanisms Underlying Risk Reduction of Selected Glucose-Lowering Medications
- sodium-glucose cotransporter 2 (SGLT2) inhibitors
- SGLT2 inhibitors reported to decrease systolic blood pressure by about 4-6 mm Hg and decrease diastolic blood pressure by about 1-2 mm Hg (J Am Coll Cardiol 2018 Oct 9;72(15):1845)
- effects on blood pressure may be due to diuretic effects and possibly other mechanisms such as improved endothelial function, decrease in arterial stiffness, decrease in body weight, and nephron remodeling (J Am Coll Cardiol 2018 Oct 9;72(15):1845)
- natriuresis and glycosuria from SGLT2 inhibitors reduce plasma volume and reduce cardiac preload; reduced afterload may occur via reduced arterial pressure and reduced arterial stiffness (J Am Coll Cardiol 2018 Oct 9;72(15):1845)
- other reported mechanisms which may underlie cardiovascular benefits of SLGT2 inhibitors
- may provide alternative energy source for heart via increased ketone bodies and/or via increased glucagon secretion
- may inhibit cardiac fibrosis via inhibition of sodium/hydrogen exchanger in cardiac muscle
- PubMed31607208Journal of the American Heart AssociationJ Am Heart Assoc20191015820e013389e013389Reference - J Am Heart Assoc 2019 Oct 15;8(20):e013389
- glucagon-like peptide-1 (GLP-1) receptor agonists
- GLP-1 receptor agonists reported to improve lipids, reduce blood pressure, and reduce body weight
- other effects may include beneficial effects on endothelial cells via activation of endothelial nitric oxide synthase and inhibition of tumor necrosis factor alpha, plasminogen activator inhibitor-1, various growth factors, and adhesion molecules
- PubMed31422062The lancet. Diabetes & endocrinologyLancet Diabetes Endocrinol20191001710776-785776References - Lancet Diabetes Endocrinol 2019 Oct;7(10):776, Postgrad Med 2017 Nov;129(8):811
- biguanides (metformin)
- metformin reported to decrease triglycerides, total cholesterol, low-density lipoprotein cholesterol, and apolipoprotein B, while increasing high-density lipoprotein cholesterol
- metformin may also result in weight loss and may modulate endothelial function and oxidative stress
- PubMed28749197Postgraduate medicinePostgrad Med201711011298811-821811Reference - Postgrad Med 2017 Nov;129(8):811
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