Cardiovascular risk management

Prof Gerry McKay

Consultant Physician & Clinical Pharmacologist, Glasgow Royal Infirmary

MCN Conference

23rd February 2021

Disclosures

• Financial support for attending conferences/meetings from Astra Zeneca, Boehringer Ingelheim, Eli Lilly, MSD, Napp and Sanofi

• Speaker’s fees from Astra Zeneca, Boehringer Ingelheim, Eli Lilly, Sanofi, Bristol Myers Squibb, MSD, Novo Nordisk, Pfizer and Napp

• Consultancy fees from Boehringer Ingelheim, Eli Lilly, Sanofi, Bristol Myers Squibb, UCB Pharma, Pfizer and Napp

Case study

• 46 year old man T2D for 10 years

• PMH – ACS? 2013

• Meds –• metformin 1g x 2 daily

• gliclazide 80mg x2 daily

• bisoprolol 2.5mg daily

• Ramipril 2.5mg daily

• simvastatin 20mg nightly

• FH – IHD/T2D

• SH – ex smoker, non drinker, taxi driver

• Other information

• BP = 145/90 (p=76)

• Weight = 90kg (BMI= 33)

• HbA1c = 69mmol/mol

• Cholesterol = 4.8mmol/L

• HDL-C = 0.7mmol/L

• U&E Normal

• Urinary alb/creat = 86 (normal 0-2.5 mg/mmol creatinine)

How are you going to manage him?

Changes in Selected Risk Factors during the Interventional Study and Follow-up Period

Gaede P et al. N Engl J Med 2008;358:580-591

Steno study

NEJM 2008;358;580-91

Reality

NEJM 2017;376:1407–18

HR (95%CI)

Intensive (SU/Ins) vs. Conventional glucose control

HR (95%CI)

HR (95%CI)

NEJM 2008;359:1577-89

HR (95%CI)

Intensive (metformin) vs. Conventional glucose control

HR (95%CI)HR (95%CI)

HR (95%CI)HR (95%CI)

NEJM 2008;359:1577-89

CV outcome trials in T2DM

Cefalu WT, et al. Diabetes Care 2018;41:14-31

CV outcome trials: SGLT2 receptor blockers

NEJM 2015;373:2117-28

CV outcome trials: SGLT2 receptor blockers

NEJM 2017;377;644-57

CV outcome trials: SGLT2 receptor blockers

NEJM 2019;380:347-57

CV outcome trials: LEADER

NEJM 2016;375:311–22

CV outcome trials: SUSTAIN 6

NEJM 2016;375:1834–44

CV outcome trials: REWIND

Lancet 2019;394:121-30

SIGN and diabetes: 2017

Conclusion

NEJM 2017;376:1407–18

Conclusion – back to our case (6 months later)

• 46 year old man T2D for 10 years

• PMH – ACS? 2013

• Meds –• Metformin 1g x 2 daily• Empagliflozin 10mg/day• Semaglutide 1mg/weekly• Bisoprolol 5 mg daily• Ramipril 10 mg daily• Amlodipine 5 mg daily• Atorvastatin 80mg daily• Aspirin 75 mg daily

• FH – IHD/T2D

• SH – ex smoker, non drinker, taxi driver, has joined gym

• Other information

• BP = 128/74 (p=62)• Weight = 85 kg (BMI= 27)• HbA1c = 52 mmol/mol• Cholesterol = 2.8mmol/L• HDL-C = 0.9mmol/L• U&E Normal• Urinary alb/creat = 0.8 (normal 0-2.5

mg/mmol creatinine)

Conclusion – key points!

• Need to narrow the morbidity/mortality gap!

• How?• Lifestyle

• Appropriate statin treatment/targets?

• Appropriate management of BP

• Use of newer blood glucose lowering treatments with added value earlier