Practice Update: Diabetes

CARDIOVASCULAR COMPLICATIONS 19

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.

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 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

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 should be reduced to 100 mg daily when the eGFR is <60 mL/min/1.73 m 2 . 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 m 2 with dapagliflozin or <45 mL/min/1.73 m 2 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

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.

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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.

VOL. 1 • NO. 2 • 2017