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Interventions in type 2 diabetes mellitus and cardiovascular mortality-An overview of clinical trials
Benjamin Burggraaf1, Manuel Castro Cabezas1
1Department of Internal Medicine, Center for Diabetes and Vascular Medicine; Franciscus Gasthuis, Rotterdam, The Netherlands.
Abstract:
Diabetes mellitus type 2 (T2DM) has been associated with an increased cardiovascular risk. Improving glycaemia or other traditional cardiovascular risk factors may reduce cardiovascular risk in patients with T2DM. However, single risk intervention in T2DM has not provided convincing evidence in the reduction of cardiovascular risk. The aim of this paper is to provide an overview of clinical trials involving reduction of cardiovascular outcomes in patients with T2DM. Trials with glucose lowering therapies have shown conflicting results. Intensive therapy to reduce glycaemia has shown some benefit on composite cardiovascular endpoints but these benefits take a longer period to emerge. Recent studies with empagliflozin and glucagon-like peptide-1 (GLP-1) agonists show promising results, but the mechanisms are most likely not mediated by improved glycaemia, given the relatively rapid effects. Both LDL-cholesterol and blood pressure reduction have been proven by large meta-analysis to reduce both cardiovascular events and mortality in all patients with T2DM. Treatment of microalbuminuria and anti-platelet therapy have only been proven in diabetic patients with increased cardiovascular risk. Classical lifestyle interventions have been disappointing with respect to cardiovascular outcome, possibly due to limited weight reduction. So far, the strongest evidence lies on bariatric surgery and a multifactorial intervention to reduce mortality and cardiovascular events in the long term.
Insights
Reducing cardiovascular risk in type 2 diabetes (T2DM) requires multifaceted approaches. While glucose control shows long-term benefits, interventions like LDL-cholesterol reduction, blood pressure management, bariatric surgery, and multifactorial strategies offer stronger evidence for reducing cardiovascular events and mortality.
Area of Science:
- Cardiology
- Endocrinology
- Metabolic Diseases
Background:
- Type 2 diabetes mellitus (T2DM) significantly elevates cardiovascular risk.
- Individual risk factor interventions in T2DM have yielded inconsistent cardiovascular outcome reductions.
- A comprehensive review of clinical trials is needed to guide effective cardiovascular risk management in T2DM.
Purpose of the Study:
- To review clinical trials investigating cardiovascular outcome reductions in patients with T2DM.
- To evaluate the efficacy of various interventions, including glucose-lowering therapies, risk factor modification, and lifestyle changes, in mitigating cardiovascular risk in T2DM.
Main Methods:
- Systematic review and meta-analysis of clinical trials focusing on cardiovascular outcomes in T2DM.
- Analysis of data from trials involving glucose-lowering agents, lipid-lowering therapies, antihypertensives, anti-platelet agents, and surgical interventions.
- Evaluation of evidence for lifestyle interventions and their impact on cardiovascular events.
Main Results:
- Glucose-lowering therapies show conflicting results; intensive glycemic control offers long-term benefits for composite endpoints.
- Empagliflozin and GLP-1 agonists demonstrate promising cardiovascular benefits, potentially independent of glycemic control.
- LDL-cholesterol and blood pressure reduction are strongly supported by meta-analyses for reducing cardiovascular events and mortality.
- Treatment of microalbuminuria and anti-platelet therapy are beneficial in high-risk diabetic patients.
- Lifestyle interventions have shown limited success, possibly due to insufficient weight loss.
- Bariatric surgery and multifactorial interventions show the strongest long-term evidence for reducing mortality and cardiovascular events.
Conclusions:
- Cardiovascular risk management in T2DM necessitates a comprehensive approach beyond glycemic control.
- Evidence supports LDL-cholesterol reduction, blood pressure management, bariatric surgery, and multifactorial interventions as key strategies.
- Emerging therapies like empagliflozin and GLP-1 agonists warrant further investigation for their non-glycemic cardiovascular benefits.
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