DPP‐4 inhibitors, GLP‐1 receptor agonists & SGLT‐2 inhibitor | Figure 1

%27%3e%3cg%20id=%27Group-14%27%20transform=%27translate(13.000000,%20103.176124)%27%3e%3cg%20id=%27Group-Copy-5%27%20transform=%27translate(0.000000,%20182.676124)%27%3e%3crect%20id=%27Rectangle-8%27%20fill=%27%23E2E0DE%27%20x=%270%27%20y=%270%27%20width=%2736%27%20height=%2736%27%20rx=%2718%27%3e%3c/rect%3e%3cpath%20d=%27M28,27.6503435%20C28,22.127496%2023.5228474,17.6503435%2018,17.6503435%20C12.4771525,17.6503435%208,22.127496%208,27.6503435%20M18,16.3472505%20C20.8165136,16.3472505%2023.099749,14.0640151%2023.099749,11.2475015%20C23.099749,8.43098783%2020.8165136,6.1477524%2018,6.1477524%20C15.1834863,6.1477524%2012.9002509,8.43098783%2012.9002509,11.2475015%20C12.9002509,14.0640151%2015.1834863,16.3472505%2018,16.3472505%20Z%27%20id=%27Combined-Shape%27%20fill=%27%23FFFFFF%27%20fill-rule=%27nonzero%27%3e%3c/path%3e%3c/g%3e%3c/g%3e%3c/g%3e%3c/g%3e%3c/svg%3e)

Deleted account

Some actions are only available when you log in.

Report case

Report this to our moderators

DPP‐4 inhibitors, GLP‐1 receptor agonists & SGLT‐2 inhibitors for people with cardiovascular disease

You can view up to 4 cases without signing up Sign up for unlimited access

Key messages

‐ GLP‐1RA and SGLT2i (two new diabetes medicines) are likely to reduce the risk of death from cardiovascular disease and death from any cause in people with both diabetes and established cardiovascular disease (diseases of the heart and blood vessels).

‐ SGLT2i medicines are likely to reduce the risk of hospitalisation for heart failure and GLP‐1RA medicines may reduce fatal and non‐fatal stroke.

‐ We need further studies to find out if these medicines also have a positive effect on cardiovascular health in people without diabetes or if the effects seen in people with diabetes are due only to these medicines’ ability to control blood sugar.

Cardiovascular disease is a general term for conditions that affect the heart and blood vessels. Fatty substances in the blood can build up and block blood vessels, leading to problems such as heart failure – when the heart cannot pump blood around the body properly – stroke and heart attacks.

Some new types of diabetes medicines, DPP4i, GLP‐1RA and SGLT2i, have been designed to control blood sugar. They may also prevent cardiovascular complications in people with diabetes who also have cardiovascular disease.

We wanted to know if DPP4i, GLP‐1RA and SGLT2i medicines are effective treatments for cardiovascular disease in people with established cardiovascular disease, both with and without diabetes. We also wanted to know whether these medicines cause unwanted effects.

We found 31 studies. We were able to combine and analyse the evidence from 20 studies, with 129,465 participants. Six of the 20 studies investigated DPP4i, 7 studied GLP‐1RA and 7 investigated SGLT2i medicines, all compared with placebo. People in the studies were aged between 60 and 71 years and most people had diabetes.

What are the limitations of the evidence?

We are confident or moderately confident in the evidence for deaths from cardiovascular disease or any cause, heart attack, stroke and hospitalisation due to heart failure. We are less confident in the evidence for unwanted effects because few studies provided information on unwanted effects and they did not report many. Most studies included people with diabetes only so these results could be due to better control of their diabetes, rather than the medicines’ effect on cardiovascular disease.

How up‐to‐date is this evidence?

The evidence is current to 16 July 2020.

Read the full Cochrane Review:

Comment

Sign up to add a comment

More about this case

Unresolved

Why you should join Figure 1

Sign up to explore now

Similar cases

\ \ Are glucose‐lowering medications effective and safe in people with diabetes and chronic kidney disease (CKD)?\ Cochrane Review; 44 studies (13,036 people).\ Key findings\ SGLT2 inhibitors probably reduce glucose levels, blood pressure, heart failure and high potassium levels but increase genital infections and slightly reduce kidney function. SGLT2 inhibitors may reduce weight. Their effect on the risk of death, hypoglycaemia, acute kidney injury, urinary tract infection, end‐stage kidney disease, low blood volume, bone fractures, diabetic ketoacidosis is uncertain.\ DPP‐4 inhibitors may reduce glucose levels. Their effect on the risk of death due to heart attacks and strokes, heart failure, upper respiratory tract infections, liver problems, kidney function, hypoglycaemia, pancreatitis and pancreatic cancer is uncertain.\ GLP‐1 agonists probably reduce glucose levels and may reduce weight. Their effect on kidney function, hypoglycaemia, gastrointestinal symptoms and pancreatitis is uncertain.\ Compared to glipizide, sitagliptin probably has a lower risk of hypoglycaemia.\ Conclusions\ Evidence concerning the efficacy and safety of glucose‐lowering agents for people with diabetes and CKD is limited.\ More studies are required.](https://app.figure1.com/case-detail/3cfd9228-1c6a-4b41-a499-0ff589fb612d)

\ \ Background\ This is the first update of a review originally published in 2017. Hypertension (high blood pressure) is a long‐term condition that increases the risk of health problems such as heart attack, stroke, or kidney disease. Several types of medicines are used to treat hypertension. It is frequently the case that over time a person with hypertension will need more than one type of medicine to control their blood pressure. A doctor prescribing medicines to reduce the blood pressure for the first time in a patient has two options: using only one medicine (monotherapy) or using two medicines (combination therapy). Combination therapy can be in the same tablet or in different tablets. The potential advantage of using combination therapy is that blood pressure may fall faster, however it is unclear if this is better or worse in terms of avoiding health problems.\ Study characteristics\ We searched for clinical studies that compared starting treatment of hypertension in adults with monotherapy versus starting with combination therapy. Studies had to report results in terms of deaths, events due to diseases of the heart or the vessels (heart attack, stroke, or heart failure), deaths due to diseases of the heart or the vessels, or any health‐related serious side effects. We only selected studies with 50 or more people per group and that lasted at least 12 months. The evidence is current to April 2019.\ Key results and certainty of the evidence\ In this update we included one new study, for a total of four studies in the review involving 349 people treated with combination therapy and 419 treated with monotherapy. However, data were insufficient to answer our review question. There is a need for more and larger studies that compare monotherapy with combination therapy as the initial treatment of hypertension.](https://app.figure1.com/case-detail/47c9693c-94fc-4206-b090-bd4382da2f34)

\ \ Review question\ We wanted to see if natriuretic peptide (NP)‐guided treatment is better than usual care for preventing death and cardiovascular events among patients with risk factors for heart disease but without heart failure.\ Background\ Cardiovascular diseases (CVDs) are a group of conditions that affect the heart and blood vessels. They are the leading causes of avoidable death worldwide. Risk factors that increase a person's likelihood of developing CVD include diabetes, high blood pressure, high cholesterol, and obesity. Natriuretic peptides (NPs) are hormones produced by the heart that are measured in the blood. They help the body to eliminate fluids, relax the blood vessels, and funnel sodium into the urine. When the heart is damaged, the body releases more NPs to try to ease strain on the heart. By measuring a person's blood NP levels, we can identify those who have established damage to their heart and who are at higher risk of death and cardiovascular events such as heart attack and stroke. We can then use this information to reduce a person's cardiovascular risk by guiding decisions about their cardiovascular care (NP‐guided treatment), such as what medication they should take, what investigations they need, and what adjustments they should make to their lifestyle.\ Study characteristics\ Evidence in this review is current to July 2019. We included two randomised controlled trials (where participants have an equal chance of being assigned to either treatment) including 1674 adult participants who had one or more risk factors for developing CVD, which compared NP‐guided treatment with standard care. We excluded patients with symptoms of heart failure. The mean age of participants varied between 64.1 and 67.8 years. Patients were followed‐up for between 2 years and a mean of 4.2 years.\ Key results\ Effects of NP‐guided treatment on death due to CVD or for any other reason remain uncertain as our results were imprecise. Moderate‐quality evidence suggests that NP‐guided treatment probably reduces the number of hospitalisations due to cardiovascular events and due to all causes in patients with cardiovascular risk factors. We would expect that of 1000 patients who received standard care, 163 would be admitted to hospital as the result of a cardiovascular event, compared to between 65 and 111 patients who received NP‐guided treatment. Out of 1000 patients with cardiovascular risk factors who received standard care, 601 would be admitted to hospital for any reason, compared to between 457 and 553 patients who received NP‐guided treatment.\ High‐quality evidence indicates that NP‐guided treatment reduces the risk of ventricular dysfunction (a condition that often leads to heart failure) compared to standard care. Our results suggest that of 1000 patients with cardiovascular risk factors who received standard care, 87 would develop ventricular dysfunction, compared to between 36 and 79 patients who received NP‐guided treatment. No evidence suggests that NP‐guided treatment affected NP level at completion of the studies.\ Quality of the evidence\ The quality of evidence ranged from low to high across outcomes. Key reasons for concern about the quality of the evidence included risk of bias, as patients and medical staff caring for patients knew whether they were in the control or intervention group and this may have affected the care they received; some results obtained were imprecise, and it is unclear if the intervention was beneficial or harmful. As we identified only two studies that were suitable for inclusion in this review, the generalisability of the review is limited.](https://app.figure1.com/case-detail/69b46bac-0c99-4bdd-9f77-e59c22ba0366)

\ \ Antiarrhythmics for maintaining sinus rhythm (normal heartbeat) after reversing atrial fibrillation (correcting an irregular heartbeat)\ Review question\ We reviewed the evidence about the effect of antiarrhythmic medicines on mortality (death), stroke, side effects that cause people to stop taking the medicine and recurrences of irregular heartbeat, in people who had recovered normal heart rhythm after having atrial fibrillation (a type of irregular heartbeat).\ Background\ Atrial fibrillation is a disease where the heart rhythm is irregular (called arrhythmia) and often, but not always, too fast. Atrial fibrillation may produce complications, either in the heart (heart failure, fainting) or in other organs by causing embolisms. Embolisms are blood clots that form in the cavities of the heart which may then travel to other places, for example the brain.\ Atrial fibrillation can be reverted, restoring normal heart rhythm, by using medicines or a controlled electrical shock. However, a major problem is that atrial fibrillation frequently recurs. A variety of medicines have been used to avoid these recurrences and keep the normal heart rhythm.\ Study characteristics\ This is an update of a review previously published in 2006, 2012 and 2015, and includes results of a search for new studies in January 2019. We found 59 studies testing various antiarrhythmic drugs and involving 20,981 participants. The average age of participants was 65 years. The most frequent diseases were hypertension (high blood pressure) and diseases of the arteries and valves of the heart. We found studies for nine medicines: quinidine, disopyramide, propafenone, flecainide, metoprolol, amiodarone, dofetilide, dronedarone and sotalol.\ Key results and certainty of the evidence\ High‐certainty evidence from five studies found that deaths from any cause were twice as high in people taking sotalol compared with people taking a placebo (dummy treatment) or no treatment. We calculated that one extra person would die for every 102 people taking sotalol for one year. Evidence for quinidine was low certainty, but the average effect across six studies suggested that people who took quinidine may have a higher risk of death compared with people taking no treatment or placebo. However, the evidence was not strong enough to rule out the possibility that there was no increased risk of death with quinidine. We found few data on mortality for disopyramide, flecainide and propafenone, meaning that we are uncertain of the effect of these drugs on mortality. We found no clear evidence that the other medicines we studied had any effect on risk of death.\ We found that people taking any of these medicines were more likely to stop taking them due to side effects, compared with people not taking them. We are less certain of the results for disopyramide, amiodarone, dofetilide and flecainide because the low‐certainty evidence mostly came from small studies with design limitations. Evidence was moderate or high for the other medicines.\ One particular side effect of antiarrhythmic medications is proarrhythmia, which means that people have new or more frequent problems with irregular heartbeats. We found high‐certainty evidence that people taking quinidine or metoprolol had a higher risk of proarrhythmia than people taking no treatment or placebo. Moderate‐certainty evidence indicated a similar increased risk for flecainide, amiodarone, dofetilide, dronedarone and sotalol. Evidence from these studies was moderate certainty due to problems with study limitations, smaller size or imprecise results. We are uncertain of the effect of propafenone on proarrhythmia as we only had very low‐certainty evidence for this medicine. None of the disopyramide studies reported how many people had proarrhythmia.\ We found high‐certainty evidence that dronedarone may reduce the risk of stroke. There was no evidence of an effect of sotalol (moderate‐certainty evidence); amiodarone, flecainide, quinidine (all low‐certainty evidence) or disopyramide (very low‐certainty evidence) on risk of stroke. No studies reported risk of stroke with propafenone, metoprolol or dofetilide.\ Moderate‐ to high‐certainty evidence, except disopyramide which was low certainty, showed that all the medicines we assessed reduced recurrence of atrial fibrillation, compared with not taking any treatment or taking a placebo. However, atrial fibrillation still recurred in about half of participants (43% to 67%) treated with antiarrhythmics.\ Overall, It is unclear whether long‐term treatment with antiarrhythmic medicines carries benefits that outweigh their risks for this group of people.](https://app.figure1.com/case-detail/915d8871-0cf0-49ae-8fc5-c17cf375961e)

Trending now

\ \ A 52-year-old man presented with a 20-minute history of chest pain radiating to the left shoulder and neck, associated with dyspnea and diaphoresis.\ He had a history of hypertension, long-term smoking, and a sedentary lifestyle.\ On physical examination, bibasilar crackles were noted on lung auscultation. An electrocardiogram (ECG) was performed in the primary care setting, and the patient was promptly referred to the emergency department.](https://app.figure1.com/case-detail/ae0fe999-6875-4474-94f0-ad823dbb9b3a)

\ \ A 28-year-old woman presented with a 3-day history of intense pruritus over the lower back. She reported no recent travel or exposure to new environments. She cares for a small kennel with approximately eight dogs rescued from the streets.\ Physical examination revealed multiple small vesicles, some clustered and others scattered, predominantly involving the lumbar region and the left gluteal area.](https://app.figure1.com/case-detail/c271070f-2bc7-4052-9895-635277e1a7d5)

\ \ A 4-month-old male infant presented with skin lesions localized to the chin for the past 3 days. Physical examination revealed multiple small pustules with surrounding inflammatory signs on the chin, along with a few scattered papules on the chest.](https://app.figure1.com/case-detail/48f41642-b9db-4089-b120-a94ee52328de)

\ \ patient in late teens presenting after a collapse, no chest pain, no previous cardiac history, no history of sudden death in family, are there any features in this ekg that would warrant further work-up or is this just a pediatric ekg?](https://app.figure1.com/case-detail/2af390e1-ace8-40ed-ba1c-98fb2d72f4c5)