LAUSR

At the 5 Annual Heart in Diabetes (HiD) Conference, held in New York from 10 to 12 September 2021, a variety of topics were addressed related to the cardiovascular (CV) risks and CV complications of diabetes. This is the second of a two-part summary of some of the presentations at the meeting, reviewing approaches to therapy. Michael Farkouh, Toronto, Ontario, Canada, discussed the interaction of optimal medical therapy and revascularization strategies in patients with diabetes and coronary artery disease (CAD). After percutaneous coronary intervention (PCI) for CAD, nontarget lesions are frequent sites of atherosclerotic cardiovascular disease (ASCVD) events, suggesting that stent placement alone may not be sufficient treatment for persons with CAD. Farkouh reviewed the Future Revascularization Evaluation in Patients with Diabetes Mellitus: Optimal Management of Multivessel Disease (FREEDOM) study, comparing stent placement with coronary artery bypass graft (CABG) surgery and showing over 5 years 18.7% of enrolled patients with multivessel disease had myocardial infarction, stroke, or mortality after CABG, while these outcomes occurred in 26.6% of those having PCI. He noted that this and other studies suggest the importance of optimized medical therapy of CAD and acknowledged that future studies will need to include sodium glucose cotransporter 2 inhibitors (SGLT2i) and glucagon-like peptide 1 receptor agonists (GLP-1RA), but pointed out that even in these clinical trials there is lack of uniformity in achieving diabetes, lipid, and blood pressure goals, so that a major clinical challenge is the delivery of appropriate treatment to the large number of persons with diabetes and CAD. Interestingly, his colleague Lucas Godoy, Toronto, reviewed a meta-analysis performed with Farkouh of patients with diabetes undergoing PCI or CABG, followed for 4 years, showing similar outcome with low-density lipoprotein (LDL) cholesterol <70 and 70 to <100 mg/dL, with both groups having 23% lower event rates than those with LDL cholesterol ≥100 mg/dL, although another study from the group showed that after PCI there is a gradient of adverse outcome from LDL cholesterol below 70 to LDL between 70 and <100 to LDL of 100 and over, supporting that the LDL cholesterol goal is below 70 mg/dL for diabetes with ASCVD. Peter Grant, Leeds, UK, discussed antiplatelet and anticoagulant treatment approaches for persons with diabetes. In a study of more than 15 000 persons with diabetes not having evidence of ASCVD randomized to aspirin 100 mg daily or placebo, serious vascular events occurred in 1.1% fewer persons over a mean 7.4-year follow-up, but major bleeding (primarily gastrointestinal) occurred in 0.9% more, leading Grant to suggest that the choice of whether or not aspirin should be given in such a primary prevention setting should be personalized. In acute coronary syndrome, aspirin combined with one of the P2Y12 platelet adenosine diphosphate receptor inhibitors clopidogrel, prasugrel, or ticagrelor is recommended, with evidence that prasugrel leads in general to optimal outcome. The combination can be continued for up to 3 years unless there is high bleeding risk, after which P2Y12 inhibitors alone may lead to better outcome. At age over 75 years, or with prior stroke or transient ischemic attack, prasugrel increases cerebrovascular event rates, and clopidogrel or ticagrelor may be preferable. With peripheral arterial disease, a different approach may be preferred with low-dose rivaroxaban and aspirin. Silvio Inzucchi, New Haven, CT, discussed stroke prevention in diabetes, pointing out the association of worse glycemic control with risk of fatal stroke in the United Kingdom Prospective Diabetes Trial, with metformin associated with lower risk of stroke than conventional treatment, and as well with lower risk of stroke than insulin or sulfonylurea treatment. Pioglitazone was associated with 50% reduction in stroke risk among persons with diabetes and prior stroke in the Prospective Pioglitazone Clinical Trial in Macrovascular Events (PROactive) and with 25% reduction in the combined endpoint of myocardial infarction and stroke among persons with insulin resistance (but not diabetes) and prior stroke in the Insulin Resistance Intervention After Stroke (IRIS) randomized clinical trial. Among newer glucoselowering agents, GLP-1RA are associated with 14% reduction in stroke rate in clinical trials of these agents. DOI: 10.1111/1753-0407.13251