Uptake of novel evidence-based therapies in patients with type 2 diabetes after a cardiovascular event: insights from CANHEART

Background — A cardiovascular (CV) hospitalization is a seminal opportunity to implement guideline-directed medical therapy (GDMT). Sodium-glucose transporter 2 inhibitors (SGLT2is) and glucagon-like peptide-1 receptor agonists (GLP1RAs) can improve outcomes among those with type 2 diabetes mellitus (T2DM) and CV disease.

Methods — We conducted a population-based cohort study among patients aged ≥ 66 years with T2DM in Ontario hospitalized for a CV event (myocardial infarction, heart failure, peripheral arterial disease, ischemic stroke) from June 2015 to March 2022, who were followed until March 2023. We examined use of GDMT before vs after the index event, including use of SGLT2is, GLP1RAs, statins, and others medications.

Results — We identified 75,869 people aged ≥ 66 years with T2DM (median age 78 years; 43% female). The proportion receiving SGLT2is was 9% before index hospitalization and 29% during the follow-up period. GLP1RA was used for 1% before vs 9% after, compared with 65% before and 86% after for statins. Use of novel GDMT increased across the follow-up period. The incidence of SGLT2i use 1-year posthospitalization was 4% in 2016 vs 39% in 2021; for GLP1RA use, the incidence was 0% in 2016 vs 11% in 2021.

Conclusions — A rise in the use of novel GDMT suggests increasing adoption of therapies to optimize secondary prevention in patients with T2DM and CV disease after index CV events.

Cardiovascular (CV) disease (CVD) remains the leading cause of death and morbidity among patients with type 2 diabetes mellitus (T2DM), and T2DM continues to be an independent predictor of hospitalization for ischemic heart disease, stroke, heart failure, and lower-extremity amputation.1 Costs related to diabetes in the US increased 26% from 2012 to 2017, comprising an estimated $327 billion,2 compared with around $30 billion in Canada in 2019.3 CVD accounts for approximately 20%-49% of the total direct costs of diabetes care.4,5 Novel pharmacotherapies, including sodium-glucose co-transporter 2 inhibitors (SGLT2is) and glucagon-like peptide-1 receptor agonists (GLP1RAs), have demonstrated CV outcome benefits among patients with T2DM and established CVD.6-11 These therapies improve CV outcomes in ways that reach beyond their glucose-lowering effects.12 In Canada, SGLT2is and GLP1RAs were recommended for the first time for people with T2DM who had CV disease and uncontrolled glycemia, in the 2018 clinical practice guideline, and these agents continue to be reflected in contemporary Canadian and US guidelines, which recommend use of either a GLP1RA or an SGLT2i in people with diabetes and CVD, independent of their hemoglobin A1c level.13,14 Given the impact these therapies could have on advancing the care for patients with T2DM and CVD, assessing their contemporary real-world utilization will contextualize the need for interventions aimed at improving care performance and CV outcomes in this population. A CV hospitalization is a seminal opportunity to consider initiation of guideline-direct medical therapy (GDMT). This study examined uptake of SGLT2i and GLP1RA use, compared to established CV pharmacotherapies, after a hospital admission for a major CV event.