Cardiologists and diabetes.Target organs and action mechanism of antidiabetic drugs.Cardiovascular Outcome Trials
( CVOTs ) in Diabetes.Completed and ongoing CVOTs in type 2 diabetes.Diabetes Medications
and
Cardiovascular Impact.Recommendations for management of diabetes
Cardiovascular safety of anti-diabetic drugs.
SGLT2 inhibitors in Heart failure: A prized addition to HF treatment optionsahvc0858
Early Diabetes and Dyslipidaemia Treatment Optimisation.
Presentation by Dr Chan Wan Xian
Cardiologist, Echocardiologist
Heart Failure Intensivist
Asian Heart & Vascular Centre
www.ahvc.com.sg
SGLT2I The paradigm change in diabetes managementPraveen Nagula
Just like ARNI, SGLT2I have changed the face of diabetes management and they have a good profile in multimodality management because of pleiotropic effects
SGLT2 inhibitors in Heart failure: A prized addition to HF treatment optionsahvc0858
Early Diabetes and Dyslipidaemia Treatment Optimisation.
Presentation by Dr Chan Wan Xian
Cardiologist, Echocardiologist
Heart Failure Intensivist
Asian Heart & Vascular Centre
www.ahvc.com.sg
SGLT2I The paradigm change in diabetes managementPraveen Nagula
Just like ARNI, SGLT2I have changed the face of diabetes management and they have a good profile in multimodality management because of pleiotropic effects
DIABETES AND CARDIOVASCULAR DISEASE - THE CONTINUUMPraveen Nagula
DIABETES IS ONE OF THE MOST COMMON NONCOMMUNICABLE DISEASES WORLD WIDE.
EVERY 6 SECONDS ONE PERSON IS AFFECTED BY DIABETES..
THEME FOR 2014-2016
LETS UNITE FOR DIABETES
Anti-Diabetics For Cardiac Patients The Proper Selectionmagdy elmasry
Cardiovascular Disease and Type 2 Diabetes.Tight glycaemic control can reduce microvascular complications of T2DM, but does not lower CV risk sufficiently.
Multifactorial intervention, comprising of lowering lipid levels and BP, and use of aspirin, has been shown to reduce vascular complications and mortality.Shifting the Paradigm in Diabetes Care
Treating Diabetes Beyond A1C :Considerations for Cardiovascular Protection.
Do T2DM drugs have CV benefit for Type 1 Diabetes ?magdy elmasry
T1D Exchange , average A1C levels have not improved .How can adjunctive therapies ( added to insulin ) can help?
The Removal Trial.Three main clinical trials :
DEPICT with dapagliflozin ,
EASE with empagliflozin , and
inTANDEM with sotagliflozin.
DIABETES AND CARDIOVASCULAR DISEASE - THE CONTINUUMPraveen Nagula
DIABETES IS ONE OF THE MOST COMMON NONCOMMUNICABLE DISEASES WORLD WIDE.
EVERY 6 SECONDS ONE PERSON IS AFFECTED BY DIABETES..
THEME FOR 2014-2016
LETS UNITE FOR DIABETES
Anti-Diabetics For Cardiac Patients The Proper Selectionmagdy elmasry
Cardiovascular Disease and Type 2 Diabetes.Tight glycaemic control can reduce microvascular complications of T2DM, but does not lower CV risk sufficiently.
Multifactorial intervention, comprising of lowering lipid levels and BP, and use of aspirin, has been shown to reduce vascular complications and mortality.Shifting the Paradigm in Diabetes Care
Treating Diabetes Beyond A1C :Considerations for Cardiovascular Protection.
Do T2DM drugs have CV benefit for Type 1 Diabetes ?magdy elmasry
T1D Exchange , average A1C levels have not improved .How can adjunctive therapies ( added to insulin ) can help?
The Removal Trial.Three main clinical trials :
DEPICT with dapagliflozin ,
EASE with empagliflozin , and
inTANDEM with sotagliflozin.
Impact of sodium glucose cotransporter 2 (SGLT2) inhibitors on atherosclerosi...OlgaGoryacheva4
My student Joisy Aloor had presented this topic in our 22nd Student Scientific Society Conference in the department of Propaedeutic of Internal Diseases No.2
New Therapeutics in Diabetic Kidney Disease
Conjoint Meeting of the Iraqi Society of Nephrology and Renal Transplantation and The Iraqi Diabetes Association.
Pro / Con Debate on Central Blood Pressuremagdy elmasry
The Basis : Forward & Reflected Pulse Waves
Central BP - Pro Side of the Argument
Central BP - Con Side of the Argument
Central BP - Consensus on Clinical Application
FDA-cleared devices for central BP and arterial stiffness assessment
Value of measuring central BP in clinComparative effect of
anti-hypertensive drugs and nitrates
on central systolic BP
ical practice
isolated systolic hypertension in the young
The cardio-metabolic continuum.
Hypertension and global cardio-metabolic risk
Hypertension Continuum Stages
What is the total cardiovascular risk?
What is the residual cardiovascular risk?
Global “Cardio-metabolic” Residual Risk Reduction
Residual CV risk rising from obesity.Metabolic syndrome.From NAFLD (Non-Alcoholic Fatty Liver Disease)
to MAFLD (Metabolic dysfunction-Associated Fatty Liver Disease)
Diagnosis and Management of Cardiovascular Involvement in Friedreich Ataxia
GAA 7-34 times→Normal
GAA 100-1700 times→FRDA
Current Research
into Drug Treatments
for Friedreich ataxia
Best Practice in Rare Diseases
Although CNS involvement dominates the clinical presentation of FRDA ,
CV involvement dictates its prognosis, accounting for ~ 59% of deaths among FRDA patients .
The prognosis is particularly poor for those with progressive LV systolic dysfunction.
Should we screen for and treat childhood dyslipidemia?
The Rationale for ASCVD Prevention by Primordial and Primary Strategies
Pediatric guidelines
Selective Screening
2Treatment algorithm of childhood dyslipidemia
-8 years & 12-16 years
Dyslipidemia and lipid lowering-therapy {LLT}
in women through the course of life. Lipid loering drug safety profile .Aging is associated with an increasing burden of morbidity, especially for CVDs.
Elderly population should be screened for
Main CV risk factors :
T2D , HTN , Smoking , Dyslipidemia & Obesity
Comorbidities : CKD
Geriatric conditions: Functional Impairment
Linking HFpEF and Chronic kidney disease magdy elmasry
Cardio-renal interactions
Introducing nephro-cardiology
{ or cardio-nephrology }
Where are we in 2022 with HFpEF ?CKD in HFpEF { or HFpEF in CKD } Cardiorenal
Syndrome .Four-step
HFA-PEFF diagnostic algorithm
heterogeneity in patients with HFpEF.Phenotyping HFpEF :
Beyond EF.Management of HFpEF .patients with HF on dialysis
Drug Treatment of Chronic Coronary Syndrome: Focus Issue on Ranolazinemagdy elmasry
Chronic Coronary Syndromes .Old and New Anti-anginal Drugs.Sodium channel blocker(Ranolazine)Angina / ischaemiac relief .
Voltage-gated sodium channels (NaVChs).Patient profile to guide drug treatment of
chronic coronary syndromes .Therapeutic algorithm for chronic stable angina according to heart rate and blood pressure.Treatment Options for Microvascular angina / Vasospastic angina.Ranolazine in arrhythmias
Ranolazine in ischemic reperfusion injury
Ranolazine in pulmonary hypertension
Ranolazine in heart failure
Ranolazine in the prevention of chemotherapy‑induced cardiotoxicity
Role in diabetes mellitus
Ranolazine in peripheral arterial disease
Ranolazine in myotonia‑congenita
Ranolazine in hypertrophic cardiomyopathy.Antiarrhythmic properties of ranolazine.Amiodarone +Ranolazine
Strategies to improve adherence to antihypertensive medicationmagdy elmasry
Challenges in hypertension treatment.What is the definition of medication non-adherence?Who is at risk? How should
patients at risk be screened and identified?What are the negative impacts of non-adherence?What is the
practical approach for improving adherence? The ABC taxonomy for medication adherence
Adherence :3 quantifiable components: initiation , implementation , and discontinuationThe five dimensions
of non-adherence
.
Takotsubo syndrome diagnostic criteria.
position papers :Mayo clnic ,HFA and InterTAK Diagnostic Criteria.Takotsubo Syndrome and COVID-19.Noninvasive Multimodality Imaging
in the Diagnosis and Management
of Patients with Takotsubo Syndrome
CVD in cancer survivors.Screening of cancer survivors.Chest Radiotherapy .JACC Scientific Expert Panel
( J Am Coll Cardiol 2019;74:905–27 )manifestations of chest and mediastinal radiotherapy .
Connections Between Hepatic and Cardiovascular Disease,Diagnostic criteria for cirrhotic cardiomyopathy 2005 and 2019.New CCM criteria based
on contemporary CV imaging parameters
LV Systolic Function.
LV Diastolic Dysfunction.cardiac evaluation algorithm for liver transplant candidates
Peripartum Cardiomyopathy .BOARD scheme for the therapy of patients with acut...magdy elmasry
Definition of peripartum cardiomyopathy;Risk factors for the development of PPCM .Environmental Factors
Vasculohormonal (pregnancy).Genetic Factors Titin-truncating
Variants (TTNtv) .Secretion of prolactin by the anterior pituitary gland, upregulation of endothelial microRNA-146a (miRNA-146a), and placental secretion of soluble fms-like tyrosine kinase receptor 1 (sFlt-1) lead to endothelial dysfunction and cardiomyocyte death.Antisense therapy against microRNA-146a
Prolactin inhibition.bromocriptine .biomarkers in peripartum cardiomyopathy
Thyroid Hormones and Cardiovascular Function and Diseasesmagdy elmasry
Thyroid hormone system.
Thyroid hormone action on the CVS.
Thyroid hormones and cardioprotection.
How does thyroid disease affect the heart?
- Thyroid disease and CV risk factors.
- Thyroid dysfunction and CVD.
Thyroid hormones : a future therapeutic option?
New recommendations for a thyroid and CVD.
Thyroid and CV drugs.
Chronic Obstructive Pulmonary Disease and Heart Failure The challenges facin...magdy elmasry
Chronic Obstructive Pulmonary Disease and Heart Failure
The challenges facing cardiologists and pulmonologists,
prevalence of heart failure in COPD patients .Association of Cardiovascular Disease With Respiratory Disease,An atypical presentation of myocardial infarction (MI) should be considered in every patient presenting with COPD exacerbation ,Cardiovascular and pulmonary disease in the context of inflammation
(“CardioPulmonary Continuum”),The cornerstones of therapy are beta-blockers and beta-agonists ,which as their modes of action suggest oppose each other’s action
The main hemodynamic interactions that may impact on the diagnosis of multiple and mixed Multiple and Mixed Valvular Heart Diseases:HOW TO USE IMAGINGThe interplay of multiple valve pathology.The clinical challenge of concomitant aortic and mitral valve stenosis
.
.
Cancer-Associated Thrombosis.From LMWH to DOACsmagdy elmasry
Cancer-Associated Thrombosis.Risk factors for CAT. Certain types of cancer are associated with higher risk of CAT. Anticoagulant therapy for VTE in patients with cancer
Should You Use DOACs for Cancer-Associated VTE?.Criteria for DOAC use in cancer patients requiring anticoagulation .DOACs + AntiCancer agents
The Progression of Hypertensive Heart Disease.From hypertension to heart failuremagdy elmasry
Staging of Hypertensive Heart Disease.Precipitants and clinical sequelae related to LVH and myocardial fibrosis.Imaging in hypertensive heart disease .Differential diagnosis of LVH.Concentric LVH .Eccentric LVH . Concentric remodeling .linking hypertension and atrial fibrillation
Role of the Renin–Angiotensin–Aldosterone System Inhibition Beyond BP Reductionmagdy elmasry
Hypertension Mediated Organ Damage : How We Prevent It?The Role Of RAAS In Cardiovascular Continuum.Changes in Arterial Diameter in Patients with Arteriosclerosis or Atherosclerosis.Not All Angiotensin-Converting Enzyme Inhibitors Are Equal.Question : ACEIs vs. ARBsIs One Class Better For Cardiovascular Diseases?BP Variability .Central BP
.
Vascular Age &
Arterial Stiffness.Achieving BP Goals.
Cardio-Renal Protection Through Renin–Angiotensin–Aldosterone System Inhibitionmagdy elmasry
Physiological and detrimental roles of RAAS molecules in cardiac, vascular tissues and kidneys.‘cardiovascular continuum’ Barriers In Optimizing RAAS Inhibition.The effects of angiotensin II inhibition and improvement in bradykinin availability
HDL-cholesterol concentrations are inversely associated with CVD.When we consider cardiovascular mortality in women in terms of HDL.Causes of low HDL cholesterol.Lipoprotein subfractions suffer a shift after menopause towards a more atherogenic lipid profile.associations of HDL-C and HDL-P with cIMT and CHD.MESA (Multi-Ethnic Study of therosclerosis. Functional Versus Dysfunctional HDL. High concentrations of HDL - cholesterol are associated with high all-cause mortality in men and women.Improvement of HDL function without necessarily raising HDL-C
Fourth Universal Definition Of Myocardial Infarction (2018)magdy elmasry
Reasons for the elevation of cardiac troponin values
because of myocardial injury.
Spectrum of myocardial injury, ranging from no injury to myocardial infarction. Criteria For MI.Types of MI.Myocardial Infarction with Non-Obstructive Coronary Arteries(MINOCA)
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
3. The Triumvirate = triad = trio
Pathogenesis of type 2 diabetes: the triumvirate.
Insulin resistance in muscle and liver and impaired insulin secretion represent the core
defects in type 2 diabetes
1999 The Triumvirate
4.
5. The ominous octet. Multiple defects contribute to the development
of glucose intolerance in type 2 diabetes. HGP, hepatic glucose production.
2008 The ominous octet
6. Pathophysiological abnormalities targeted by currently available antidiabetic medications.
DPP4i, dipeptidyl peptidase-4 inhibitor; GLP1 RA, glucagon-like peptide-1 receptor agonist; HGP, hepatic glucose
production; MET, metformin; SGLT2i, sodium glucose co-transporter 2 inhibitor; TZD, thiazolidinedione.
The Ominous Octet : How Pathophysiology And Therapy Merge
14. Managing type 2 diabetes in the primary care setting:
beyond glucocentricity.
15. Glucocentricity
The irrational belief that lowering blood sugar using
virtually any pharmacological means will produce a
reliable reduction in adverse outcomes
glu-co-cen-tricity |ˈgloōkō senˈtrisitē
noun
Improving Diabetes Outcomes : Beyond Glucocentricity
20. Target organs and action mechanism of antidiabetic drugs.
Nature Reviews Endocrinology 12, 337–346 (2016)
The mechanism for metformin action remains uncertain: metformin might target the liver to reduce gluconeogenesis and skeletal muscles
to enhance peripheral glucose utilization, with a possible role in the gut to increase levels of glucagon-like peptide 1 (GLP-1) . Sulfonylureas
and meglitinides increase insulin secretion in the pancreas. Thiazolidinediones (TZDs) act as insulin sensitizers in skeletal muscle, adipose
tissue and the liver..GLP-1 receptor (GLP-1R) agonists (GLP-1RA) target the pancreas to increase insulin secretion and reduce glucagon
production, as well as act in the gut to reduce gastric emptying. Dipeptidyl peptidase 4 (DPP-4) inhibitors (DPP-4i) increase endogenous
incretin levels by blocking the action of DPP-4 . Sodium–glucose cotransporter 2 (SGLT-2) inhibitors (SGLT-2i) reduce renal glucose
reabsorption
21. Evolving concepts in the perception of safety issues related to anti-diabetic drugs.
(i.e., research priority and clinical implications )
30. 3-P MACE: 3 - point major adverse cardiac events (composite of cardiovascular death,
nonfatal stroke and nonfatal myocardial infarction)
4-P MACE: Composite of 3-P MACE plus unstable angina, ACS, hospitalization for HF.
31.
32.
33.
34.
35. Unknown = cardiovascular outcome data is currently unavailable.
Improves Outcomes = published data demonstrates cardiovascular
benefit with use in the treatment of type 2 diabetes.
Worsens Outcomes = published data demonstrates cardiovascular
harm with use in the treatment of type 2 diabetes.
Neutral = published data demonstrates neither benefit nor harm
in cardiovascular endpoints with use in the treatment of type 2
diabetes.
36. Biguanide
Metformin
Cardiovascular Impact
Improves Outcomes:
Metformin
Cardiovascular Outcomes Data
A subanalysis of the UKPDS trial found good glycemic
control with metformin with about 10 years of use MAY
reduce the risk of CV mortality , especially in obese
patients, NNT = 14 [Evidence level A; high-quality RCT].
Pooled data demonstrate possible reduced CV mortality
with a NNT = 56,compared to other DM medications or
placebo [Evidence level A; high-quality meta-analysis].
37. Sulfonylureas
( first generation )
Chlorpropamide
Tolazamide
Tolbutamide
Cardiovascular Impact
Unknown:
Chlorpropamide
Tolazamide
Worsens Outcomes:
Tolbutamide
Cardiovascular Outcomes Data
Tolbutamide: use has been associated with increased CV
mortality compared to diet alone or diet plus insulin.
39. Meglitinides
(Glinides)
Nateglinide
Repaglinide
Cardiovascular Impact
Unknown:
Nateglinide
Repaglinide
Cardiovascular Outcomes Data
Nateglinide: No outcome data for inpatients with T2D.
However, the NAVIGATOR trial found nateglinide use in
patients with impaired glucose tolerance and at high risk
for CV events had a neutral effect on cardiovascular
outcomes [Evidence level A; high-quality RCT]
40. Alpha-glucosidase
inhibitors
Acarbose
Cardiovascular Impact :
Unknown:
Acarbose
Cardiovascular Outcomes Data :
Acarbose: The ACE (Acarbose Cardiovascular Evaluation)
trial is ongoing to evaluate if acarbose reduces CV
morbidity and mortality in patients with impaired glucose
tolerance and established CHD or ACS.
41. Thiazolidinediones
( Glitazones )
Pioglitazone
Rosiglitazone
Cardiovascular Impact
Improves Outcomes:*
Pioglitazone
Neutral:*
Rosiglitazone
*based on CV morbidity and mortality
outcomes, but note increased risk of
heart failure associated with use.
Cardiovascular Outcomes Data
Pioglitazone and Rosiglitazone are known for their
associated risk of heart failure with a meta-analysis
determining an NNH of approximately 50 patients treated
with either agent for approximately two years [Evidence
level A; high-quality meta-analysis]
42. Cardiovascular Outcomes Data
Pioglitazone: The primary endpoint in the PROactive trial
was not improved with pioglitazone. A secondary endpoint
found use of pioglitazone for about three years in patients
with T2D and macrovascular disease (e.g., MI, stroke, PCI)
may reduce the risk of all-cause mortality, non-fatal MI,
and stroke (NNT = 50)[Evidence level A; high quality RCT].
Subgroup analysis found use of pioglitazone for about
three years in patients with T2D and a previous stroke
may reduce the risk of recurrent fatal or nonfatal stroke
(NNT = 22) [Evidence level A; high quality RCT].
43. Rosiglitazone: The RECORD trial found adding
rosiglitazone to metformin or a sulfonylurea for at least
five years did not affect overall CV morbidity or mortality
[Evidence level A; high-quality RCT].
Cardiovascular Outcomes Data
Pioglitazone: The IRIS trial found use of pioglitazone for
about five years in patients with prediabetes and a history
of stroke (with mild impairment) or TIA may reduce the
risk of a future stroke or MI (NNT = 36)[Evidence level A;
high-quality RCT].
45. Cardiovascular Outcomes Data
Alogliptin: The EXAMINE trial found alogliptin use in
patients with T2D and a history of a recent ACS, did not
increase major adverse CV events, compared to placebo
[Evidence level A; high-quality RCT].
Alogliptin is associated with an increased risk of heart
failure-related admissions, NNH = 167 [Evidence level A;
high-quality RCT].
46. Cardiovascular Outcomes Data
Saxagliptin: The SAVOR-TIMI 53 found saxagliptin use in
patients with T2D at high risk for CV events; neither
reduced nor increased the risk of CV death,
MI, or ischemic stroke, compared to standard therapy
[Evidence level A; highquality RCT].
Saxagliptin was associated with an increased risk of
heart failure-related admissions, NNH = 143 [Evidence
level A; high-quality RCT].
47. Sitagliptin: The TECOS trial found adding sitagliptin to
existing DM therapy did not increase the major adverse CV
events, hospitalization for heart failure, or other adverse
events compared to placebo [Evidence level A; high-quality
RCT].
Linagliptin: CAROLINA, CARdiovascular Outcome study of
LINAgliptin versus glimepiride in patients with type 2 DM
is ongoing to evaluate the long-term impact of linagliptin
versus glimepiride on CV morbidity and mortality
Cardiovascular Outcomes Data
49. Cardiovascular Outcomes Data
Albiglutide: HARMONY Outcomes is ongoing to evaluate
the effects of adding albiglutide to standard blood glucose
lowering therapies on MACE.
Dulaglutide: The REWIND (Researching Cardiovascular
Events with a Weekly Incretin in Diabetes) trial is ongoing
to evaluate if dulaglutide can reduce MACE in patients
with T2D.
Exenatide: The EXSCEL (Exenatide Study of Cardiovascular
Events Lowering Trial) trial is ongoing to evaluate if
exenatide added to usual care impacts CV outcomes in
patients with T2D.
50. Liraglutide: The LEADER trial [Evidence level A; high-quality
RCT] found adding liraglutide to standard care in patients
with T2D with CV disease or at high CV risk over almost
four years may reduce:
*Death from CV causes, nonfatal MI, or nonfatal stroke,
NNT = 53.
*Death from CV causes, NNT = 77.
*Death from any cause, NNT = 71.
*Liraglutide did not reduce the individual rates of MI,
nonfatal stroke, or hospitalization for heart failure.
Lixisenatide: The ELIXA trial found adding lixisenatide to
conventional therapy in T2D patients with a recent ACS had
a neutral effect on CV outcomes.
Cardiovascular Outcomes Data
51. Sodium-glucose cotransporter 2 (SGLT2) inhibitors “Flozins”
Canagliflozin Empagliflozin
Dapagliflozin
Cardiovascular Impact
Unknown:
Canagliflozin
Dapagliflozin
Improves Outcomes:
Empagliflozin
Cardiovascular Outcomes Data
Canagliflozin: CANVAS (CANagliflozin cardioVascular
Assessment Study) is ongoing to evaluate the impact of
canagliflozin on CV risk for MACEs
52. Dapagliflozin: DECLARE-TIMI58 is ongoing to evaluate
the impact of adding dapagliflozin to current DM
therapy on MI, ischemic stroke, and CV death
Empagliflozin: The EMPAG-REG OUTCOME trial [Evidence
level A; highquality RCT] found empagliflozin use for about
three years, when added to standard glucose-lowering
therapy in patients with T2D and underlying CV disease,
may reduce:
Hospitalization due to heart failure (NNT = 71).
CV death rates (NNT = 45).
Overall death rates (NNT = 39).
Empagliflozin did not reduce the individual rates of MI
or stroke.
Cardiovascular Outcomes Data
54. L I R A G L U T I D E
E M PA G L I F L O Z I N
M E T F O R M I N P I O G L I TA Z O N E
55.
56. Metformin, if not contraindicated and if tolerated, is the
preferred initial pharmacologic agent for the treatment of T2D. A
In patients with long-standing suboptimally controlled T2D and
established ASCVD , empagliflozin or liraglutide should be
considered as they have been shown to reduce cardiovascular
and all-cause mortality when added to standard care. Ongoing
studies are investigating the cardiovascular benefits of other
agents in these drug classes. B
57. In patients with symptomatic heart failure , thiazolidinedione
treatment should not be used. A
In patients with T2D with stable congestive heart failure ,
metformin may be used if eGFR remains >30mL/min but
should be avoided in unstable or hospitalized patients with
congestive heart failure. B
58.
59.
60.
61. Recommendations Class Level
Metformin is recommended as first-line
therapy, if tolerated and not contra-indicated,
following evaluation of renal function.
I B
In patients with type 2 DM and CVD, the use
of an SGLT2 inhibitor should be considered
early in the course of the disease to reduce
CV and total mortality.
IIa B
Recommendations for management of diabetes