Highlights: 2020 Cardiometabolic Health Congress West Live Online
August 21, 2020
The 4th Annual CMHC West: Complexities in Cardiometabolic Care was held live online on Aug 7-9, 2020, and was chaired by top experts: Christie M. Ballantyne, MD; Robert H. Eckel, MD; George L. Bakris, MD; and Anne L. Peters, MD. Below are highlights from the meeting:
Translating Evidence to Practice Debate: Which comes first, GLP–1 RAs or SGLT–2 Inhibitors in Patients with T2D and Cardiovascular Disease?
With the progress in recent cardiovascular outcomes trials results with GLP-1 RA and SGLT-2 inhibitors, there is a profound shift in the treatment paradigm for patients with T2DM--from merely focusing on HbA1c to expanding treatment goals to minimize the risk of heart failure, adverse cardiovascular events, or prevent kidney disease progression. These developments have not only lead to updates in guidelines but have also influenced real-world practice. However, many lingering questions persist - how to interpret these trials to patient care, which agent should be used first (or whether they should be used simultaneously), and what patient clinical characteristics favor one approach over the other.
Our reputed faculty members came together to unravel these questions. Tracy Y. Wang, MD, Associate Professor of Medicine and Director of Health Services Research at the Duke University, commenced the debate by discussing the modification of cardiovascular disease risk with SGLT2is and presented a case study, she also mentioned that heart failure prevention and treatment strategies are critical in patients with type-2-diabetes and emphasized that SGLT2i have an established role in heart failure even without type-2-diabetes and therefore, should be routinely used for overall CV risk reduction. On the other end of the debate Vanita Aroda, MD, who is Director at Diabetes Clinical Research at Brigham and Women’s Hospital, emphasized the role of GLP-1 RAs in treating type-2-diabetes and cardiovascular diseases, also highlighted practical approach with a case example. She advocated the usage of GLP1-RAs by highlighting its glycemic efficiency with significant weight loss compared to an SGLT-2 inhibitor. At this point, our other esteemed faculty Anne L. Peters, MD, Robert H. Eckel, MD; Steven E. Kahn, MB, ChB; Leigh Perreault, MD; Athena Philis-Tsimikas, MD; Robert E. Ratner, MD, joined the debate and discussed their points of view and also answered several questions posed by our live participants. Overall, the debaters and the faculty panel emphasized that although guidelines make specific recommendations on when and how to use these therapies, clinicians should always individualize their approach and make the best decision to reflect the specific treatment goals.
Keynote: The Practical Management of Obesity
Obesity has truly become an epidemic and its prevalence is increasing at an alarming rate in people of all ages globally. It is also a significant risk factor for type 2 diabetes, dyslipidemia, cardiovascular disease (CVD), hypertension, and other cardiometabolic diseases. Unless we take steps to curb its impacts, it will continue to perpetuate the development of cardiometabolic disease, lower life expectancy, and have tremendous impacts on the economy. With this in mind, our keynote address, delivered by Robert Kushner, MD, FACP, a Distinguished Professor of Medicine and Medical Education at Northwestern University of Feinberg School of Medicine, Chicago, covered the multicomponent behavioral interventions that can be employed by clinicians for obesity management. During his remarkable talk, he emphasized that obesity treatment should be based on risk factors and complications and include a medical model of treatment --consisting of lifestyle modifications, which can be intensified to pharmacotherapy and bariatric surgery if indicated--must be developed to tackle this epidemic.
Improving Renal Outcomes with SGLT–2 Inhibitors and GLP–1 Ras
Recent evidences and clinical trials have elucidated the role of SGLT-2 inhibitors and GLP-1 Ras in patients with chronic kidney disease (CKD) and have the potential to reduce the current inevitable progression to end-stage kidney failure in CKD patients. George L. Bakris, MD, Professor of Medicine and Director of the ASH Comprehensive Hypertension Center at the University of Chicago Medicine, started by saying “there is a particularly important relationship between the heart and the kidney. If the heart does not do well then kidney will not also do well”. He discussed the results of recent clinical trials to assess the renal efficacy and safety of these drugs and their emerging role in the treatment of CKD. Dr. Bakris focused on the strong effects on renal outcomes observed with SGLT-2 inhibitors, particularly on the remarkable results with canagliflozin observed in the CREDENCE trial. Because of the strong clinical trial evidence, Dr. Bakris mentioned that “SGLT-2is are cardiorenal risk reducing drugs with glucose lowering as a side effect.”
While SGLT-2 inhibitors have grabbed most of the spotlight in renal outcomes, GLP1-RAssuch as liraglutide and semaglutide have also shown renal benefits. He also discussed the potential mechanism which may drive the effect of GLP-1RAs on renal outcomes, such has inhibition of NHE3, Inhibition of RAAS or indirect effects via neuronal pathways. He also discussed the latest updates of FLOW trial with semaglutide and summarized the ongoing renal trials to be completed in the near future, including DAPA-CKD (dapagliflozin), EMPA-KIDNEY (empagliflozin), and two ongoing trials with the novel non-steroidal MRA finerenone (FIGARO and FIDELIO-DKD).
He finished by highlighting the inclusion of the “renal factor” in diabetes guidelines and conveyed a very practical message, “if you have a patient with type-2-diabetes, then assess him or her for cardiovascular risks as well as renal risks”.
Opportunities for ASCVD Prevention and Treatment in Individuals of South Asian Ancestry
Pam R. Taub, MD, FACC, Associate Professor of Medicine at the University of California in San Diego, discussed ASCVD prevention specifically in individuals from South Asian ancestry. Many studies have now corroborated the fact that this ethnic group has a high burden of ASCVD, as well as higher hospitalization and mortality rates from ASCVD compared to other racial/ethnic minority groups. She started by saying that “this topic is very close to her heart” and gave a passionate presentation about the factors that clinicians have to consider while treating and managing the cardiovascular diseases in their South-Asian patients. She also talked about the dietary recommendation and introduced a very interesting “cardiometabolic slot” machine in which “jackpot” can be won if a patient is consuming a healthy diet with balanced calories coupled with regular exercise. She also outlined the details of the results of completed as well as ongoing clinical trials such as “MASALA” studies that are specifically devoted to studying the cardiometabolic shortcomings in South-Asian patients.
Complexities in Cardiometabolic Care Summit
The last yet fascinating one day summit of the congress explored the unique challenges faced by clinicians while comprehensively managing patients with cardiometabolic disease. The summit was kicked off with an intriguing talk by CMHC chair and current president of the American Diabetes Association Robert H. Eckel, MD, where he stressed on the formation of new cardiometabolic subspecialty in medical schools for achieving the entirely focused comprehensive treatment of patients with cardiometabolic diseases. Because cardiometabolic diseases or risk factors exist in a continuum, they can’t be addressed individually or in a vacuum, which is unfortunately what tends to happen in clinical practice. Dr. Eckel proposed that a potential solution to this gap is to create a whole new subspecialty of medicine altogether, which will aim to treat all these factors comprehensively. Although in its initial stages, Dr. Eckel outlined specific ideas about what training for the “cardiometabolic specialist” would look like and how it can help to better address patients’ needs. Our other esteemed faculty, Pamela B. Morris, MD, discussed and summarized the management strategies that can be undertaken by clinicians for primary and secondary prevention to optimize patient outcomes. She stressed upon the significance of risk discussion and the active involvement of patients in clinical decision making. The next compelling presentation by Martha Gulati, MD steered us to think about the increasing prevalence of metabolic syndrome and associated comorbidities, such as cardiovascular disease, obesity, and type 2 diabetes in women of reproductive age and beyond, and candidly reminded us the significance of the development of treatment regimens specifically designed for the management of cardiometabolic diseases for women. These talks set the stage and led to the panel discussion, which was also joined by George L. Bakris and Christie M. Ballantyne, who discussed many challenging cases and generated lots of questions form the audience.