The epidemic of obesity, metabolic syndrome, and type 2 diabetes shows no sign of remission. Although each individually are costly important medical outcomes, it is the relationship of these metabolic maladies to cardiovascular disease that is graded, strong, and almost certainly responsible for reversing the decades-long temporal trends of reduced cardiovascular disease mortality.1
Importantly, the landscape of drug therapies to treat these metabolic conditions has expanded dramatically.2 For example, 3 cardiovascular outcome trials using glucagon-like peptide-1 (GLP-1) receptor agonists, which also serve as effective weight loss drugs, have shown improvements in multiple cardiovascular risk factors as well as important cardiovascular outcomes and total mortality.3 Three sodium-glucose co-transporter 2 (SGLT2) inhibitors have shown benefits on cardiovascular risk factors and important cardiovascular outcomes including heart failure and cardiovascular mortality. Although the mechanisms for these cardiovascular benefits remain unclear, they extend well beyond glycemic lowering,4 and therefore are probably best considered diverse “cardiometabolic” pharmaceuticals rather than simply type 2 diabetes drugs.
Yet to be clarified is who becomes the physician of record when patients who are obese, have type 2 diabetes mellitus treated with metformin, and glycosylated hemoglobin (HbA1c) of 8.2% are hospitalized for acute coronary syndrome.
At discharge, there are several medications to be managed, including high-intensity statin, angiotensin-converting enzyme inhibitor or angiotensin receptor blocker, beta blocker, and a dual antiplatelet regimen. In follow-up, nonstatin therapies may need to be added for further low-density lipoprotein cholesterol (LDL-C) or triglyceride lowering, and anti-hypertensive titrations may be needed to achieve stricter blood pressure goals.5., 6. A cardiologist, who may not have been the inpatient attending physician of record, is most commonly the first outpatient visit. Does this physician have time, bandwidth, and capacity to manage traditional cardiovascular medications yet also consider GLP-1 receptor agonist or SGLT2 inhibitor therapy?
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-Robert H. Eckel, MDa, Michael J. Blaha, MD, MPHb
This article originally appeared in the July 2019 issue of The American Journal of Medicine.
