Practice Update: Diabetes

19 / 24

With Aspirin and Statin
Use, Diabetics without CAD
Have Same Risk for MI as
Non-Diabetics
Diabetes Care
Take-home message
• In this population-based cohort study, researchers examined data from the Western
Denmark Heart Registry to determine if a diagnosis of diabetes increased risk of
death, cardiac death, and myocardial infarction (MI) in individuals without coronary
artery disease (CAD). After a median follow-up time of 4.1 years, no difference was
found in the rates of death, cardiac death, or MI in patients with or without diabetes
if no coronary artery disease was present at enrollment. Importantly, aspirin and
statin use was significantly higher in individuals with diabetes than in patients
without diabetes in the cohort with no CAD.
• The researchers conclude that, in this population of Danish patients without CAD,
diabetes does not raise the risk for death, cardiac death, or MI provided that
appropriate prophylactic medications are prescribed.
Abstract
OBJECTIVE The risk of myocardial infarction (MI) in
patients with diabetes is greater than for patients
without diabetes. Consequently, prophylactic
treatment is recommended for patients with
diabetes and risk factors for ischemic heart
disease. We aimed to estimate the risk of
adverse cardiac events in patients with and
without diabetes with and without coronary artery
disease (CAD) after coronary angiography (CAG).
RESEARCH DESIGN AND METHODS A population-
based cohort of patients registered in the
Western Denmark Heart Registry who underwent
CAG between 1 January 2003 and 31 December
2012 was stratified according to the presence
or absence of obstructive CAD and diabetes.
End points were death, cardiac death, and MI.
Unadjusted and adjusted rate ratios (RRs) were
calculated by using patients without diabetes
and without CAD as the reference group.
RESULTS We included 93,866 patients of whom
12,544 (13.4%) had diabetes at the time of CAG.
Median follow-up was 4.1 years. Patients with
and without diabetes without obstructive CAD
had the same adjusted risk of death (RR 1.03
[95% CI 0.92-1.15]), cardiac death (RR 1.21 [95%
CI 0.90-1.64]), and MI (RR 0.88 [95% CI 0.65-1.17]).
Patients with diabetes without CAD were more
often treated with statins (75.3% vs. 46.0%) and
aspirin (65.7% vs. 52.7%) than patients without
diabetes and CAD.
CONCLUSIONS In a real-world population, patients
with diabetes with high rates of statin and aspirin
treatment had the same risk of cardiovascular
events as patients without diabetes in the
absence of angiographically significant CAD.
Patients with and without diabetes without
significant angiographic coronary artery
disease have the same risk of myocardial
infarction in a real-world population receiving
appropriate prophylactic treatment. Diabetes
Care 2017 Jun 08;[EPub Ahead of Print], KKW
Olesen, M Madsen, G Egholm, et al.
should be reduced to 100 mg daily when
the eGFR is <60 mL/min/1.73 m2. Do the
cardiovascular benefits make using
these drugs worthwhile when the eGFR
is reduced even if the glycemic benefits
are small? In patients needing additional
glucose-lowering, perhaps it is not worth
starting them when the eGFR approaches
60 mL/min/1.73 m 2 as they will need to
be stopped when the eGFR reaches
<60 mL/min/1.73 m2 with dapagliflozin or
<45 mL/min/1.73 m2 with empagliflozin
and canagliflozin. On the other hand, if
patients are already taking these drugs,
then continuing them to these eGFR
limits would seem worthwhile. At present,
only empagliflozin has a cardiovascular
“indication” in the package insert, and the
CANVAS data are still pending. It is not clear
at this point whether these drugs should
be used solely for the cardiovascular/renal
outcomes when minimal glycemic benefit
is expected.
References
1. Petrykiv S, Sjöström CD, Greasley PJ, et al.
Differential effects of dapagliflozin on
cardiovascular risk factors at varying degrees
of renal function. Clin J Am Soc Nephrol
2017;12(5):751-759.
2. Barnett AH, Mithal A, Manassie J, et al. Lancet
Endocrinol Metab 2014;2(5):369-384.
3. Yamout H, Perkovic V, Davies M, et al. Efficacy
and safety of canagliflozin in patients with type 2
diabetes and stage 3 nephropathy. Am J Nephrol
2014;40(1):64-74.
4. Rajasekeran H, Lytvyn Y, Cherney DZI. Sodium-
glucose cotransporter 2 inhibition and
cardiovascular risk reduction in patients with
type 2 diabetes: the emerging role of natriuresis.
Kidney Intl 2016;89(3):524-526.
5. Anders H-J, Davis JM, Thurau K. Nephron
protection in diabetic kidney disease. N Engl J
Med 2016;375(21):2096-2098.
6. Zinman B, Wanner C, Lachin JM, et al.
Empagliflozin, cardiovascular outcomes, and
mortality in type 2 diabetes. N Engl J Med
2015;373(22):2117-2128.
7. Wanner C, Inzucchi SE, Lachin JM, et al.
Empagliflozin and progression of kidney
disease in type 2 diabetes. N Engl J Med
2016;375(4):323-334.
Dr Molitch is the Martha
Leland Sherwin Professor of
Medicine in the Division of
Endocrinology, Metabolism
and Molecular Medicine at
the Northwestern University
Feinberg School of Medicine.
CARDIOVASCULAR COMPLICATIONS 19
VOL. 1 • NO. 2 • 2017