Semaglutide and Cardiovascular Outcomes in Obesity without Diabetes

Cost-effectiveness of semaglutide in people with obesity and cardiovascular disease without diabetes

AIMS

The cardioprotective effects of semaglutide 2.4 mg reported in the SELECT cardiovascular (CV) outcomes trial (ClinicalTrials.gov NCT03574597) provide clinical benefit for subjects with overweight or obesity and established CV disease without type 2 diabetes (T2D). We assessed cost-effectiveness of semaglutide 2.4 mg in this population against the American College of Cardiology/American Heart Association value framework.

MATERIALS AND METHODS

A cohort-level Markov-state cost-effectiveness model using trial-derived data with outcomes from a healthcare sector perspective measured over a lifetime horizon was developed. Treatment costs were based on US list prices; scenario analyses used literature-reported estimated rebates. Healthcare costs and benefits were discounted at 3.0%. A simulated cohort of 100,000 subjects was aligned to the SELECT trial population baseline characteristics and time-on-treatment. Subjects received either semaglutide 2.4 mg or placebo in addition to standard of care (SoC). Modelled outcomes included clinical events (CV events, progression to T2D, chronic kidney disease [CKD]) and health economic measures, including direct costs and quality-adjusted life years (QALYs).

RESULTS

Mean semaglutide 2.4 mg treatment duration was 2.79 years. Per 100,000 subjects, treatment avoided 2,791 non-fatal myocardial infarctions, 3,000 coronary revascularizations, 487 non-fatal strokes, and 115 CV deaths over the modeled lifetime horizon. Average per-subject lifetime treatment costs were $47,353; savings arose from avoided T2D ($14,431), CKD ($2,074), and CV events ($1,512). Semaglutide 2.4 mg was associated with increased lifetime costs ($29,767), additional QALYs gained (0.218) and an incremental cost-effectiveness ratio of $136,271/QALY at list price; a scenario using an empirically estimated 48% rebate predicted $32,219/QALY.

LIMITATIONS

The generalizability of observations from SELECT to a broader US population is unknown. Our model does not capture all outcomes nor costs that may be affected by weight loss. Modeling assumptions may present limitations.

CONCLUSIONS

Semaglutide 2.4 mg use as in SELECT is cost-effective at list price, using a $150,000/QALY willingness-to-pay threshold.

Use of semaglutide and risk of non-arteritic anterior ischemic optic neuropathy: A Danish-Norwegian cohort study

AIMS

To investigate the putative association between semaglutide and non-arteritic anterior ischaemic optic neuropathy (NAION).

MATERIALS AND METHODS

Data from national health registries in Denmark (2018-2024) and Norway (2018-2022) were used to compare NAION risk in individuals with type 2 diabetes initiating semaglutide versus sodium-glucose co-transporter 2 inhibitors (SGLT-2is). A supplementary self-controlled analysis examined NAION risk among all semaglutide users. National estimates were pooled using a fixed-effects model.

RESULTS

We identified 44 517 users of semaglutide for the management of type 2 diabetes in Denmark and 16 860 in Norway, with a total of 32 NAION events observed. The unadjusted incidence rate of NAION was 2.19/10 000 person-years among Danish semaglutide initiators, compared to 1.18 among SGLT-2i initiators. In Norway, the corresponding rates were 2.90 and 0.92, respectively. After adjustment, the pooled hazard ratio (HR) was 2.81 (95% confidence interval [CI] 1.67-4.75), and the incidence rate difference (IRD) was +1.41 (95% CI +0.53 to +2.29) per 10 000 person-years. Estimates were consistent across both countries but higher and less precise in Norway (HR 7.25; 95% CI 2.34-22.4) compared to Denmark (HR 2.17; 95% CI 1.20-3.92). Results remained consistent across sensitivity and supplementary analyses, with a stronger association observed in a post hoc per-protocol analysis (HR 6.35; 95% CI 2.88-14.0). In the supplementary self-controlled study, symmetry ratios (SRs) for NAION were 1.14 (95% CI 0.55-2.36) in Denmark and 2.67 (95% CI 0.91-8.99) in Norway.

CONCLUSIONS

The use of semaglutide for managing type 2 diabetes is associated with an increased risk of NAION compared with the use of SGLT-2is. However, the absolute risk remains low.

Population-level impact of semaglutide 2.4 mg in patients with obesity or overweight and cardiovascular disease: A modelling study based on the SELECT trial

AIM

To estimate the impact of semaglutide 2.4 mg treatment on the risk of major adverse cardiovascular events (MACE) in adults with overweight/obesity in the United States based on the SELECT trial of patients with atherosclerotic cardiovascular disease.

MATERIALS AND METHODS

Using 2023 census projections and National Health and Nutrition Examination Survey data, we developed Markov population-based predictive models for US adults meeting SELECT inclusion criteria and, separately, for adults eligible for semaglutide 2.4 mg for its MACE risk reduction indication. The 10-year rate of recurrent MACE and deaths was estimated based on the Secondary Manifestations of ARTerial disease 2 risk calculator and estimated semaglutide 2.4 mg treatment effect as per the SELECT MACE hazard ratio.

RESULTS

Of 6 164 019 US adults meeting the SELECT criteria, 2 523 218 (40.9%) are estimated to have ≥1 new MACE in the next 10 years with no additional intervention. Semaglutide 2.4 mg may prevent 496 400 events, a 16% relative reduction. An estimated 2 103 630 deaths are predicted over the next 10 years, of which 332 597 deaths (any cause, 16% relative reduction) could be avoided with semaglutide 2.4 mg. Among the estimated 22 653 158 meeting the MACE risk reduction FDA label criteria, 42.7% could experience ≥1 new MACE; treatment could prevent 1 934 493 MACE and 1 231 295 deaths (16% relative reduction for both).

CONCLUSION

Four in 10 individuals in the United States meeting the SELECT criteria are estimated to experience a recurrent CV event without additional intervention. Semaglutide 2.4 mg can potentially prevent between half a million and up to 2 million MACE over the next 10 years in the population meeting SELECT and MACE risk reduction eligibility.

PLAIN LANGUAGE SUMMARY

What is the context and purpose of this research study? More than 7 in 10 US adults have overweight or obesity, which increases the risk of heart disease. Semaglutide is a medication used to treat type 2 diabetes and obesity. A clinical study called SELECT found that semaglutide reduces the risk of heart attack, stroke, or death by 20% in adults with overweight or obesity and heart disease. What was done? Our research estimated how many people in the United States would meet the criteria for participation in SELECT, how many heart disease events they might have with regular medical care over the next 10 years, and how many could be avoided with semaglutide 2.4 mg treatment in addition to regular medical care. We also estimated how many people would still be alive if they were treated with semaglutide. We estimated the same information for all people eligible for treatment with semaglutide based on the US Food and Drug Administration (FDA) indication of semaglutide 2.4 mg in patients with heart disease. These estimations were based on a large survey of US adults. What were the main results? We found that over 6 million people would meet the SELECT study criteria. Of these, 41% are estimated to have at least 1 new heart disease event in the next 10 years. If treated with semaglutide 2.4 mg, nearly 500 000 heart disease events and more than 300 000 deaths could be avoided. More than 22 million adults would qualify for semaglutide 2.4 mg, according to the FDA indication. If all of these people were treated with semaglutide 2.4 mg, nearly 2 million heart disease events and more than 1 million deaths might be prevented. What is the originality and relevance of this study? Treatment with semaglutide 2.4 mg can reduce the risk of new heart disease events and death in patients with existing heart disease, showing a substantial impact of semaglutide treatment in a real-world setting in the United States. Our study used different analyses to add to the existing research about reducing the risk of heart disease in people with overweight or obesity.

State of precision medicine for heart failure with preserved ejection fraction in a new therapeutic age

Heart failure with preserved ejection fraction (HFpEF) is defined by heart failure (HF) with a left ventricular ejection fraction (LVEF) of at least 50%. HFpEF has a complex and heterogeneous pathophysiology with multiple co-morbidities contributing to its presentation. Establishing the diagnosis of HFpEF can be challenging. Two algorithms, the 'Heavy, 2 or more Hypertensive drugs, atrial Fibrillation, Pulmonary hypertension, Elderly age >60, elevated Filling pressures' (H2FPEF) and the 'Heart Failure Association Pre-test assessment, Echocardiography and natriuretic peptide, Functional testing, Final aetiology' (HFA-PEFF), can help to determine the likelihood of HFpEF in individuals with symptoms of HF. Phenotype clusters defined largely by the total number and types of co-morbidities may delineate groups of patients with HFpEF with different management needs. It is important to recognize alternative diagnoses or HFpEF mimics such as infiltrative cardiomyopathies, coronary artery disease, lung disease, anxiety, depression, anaemia, severe obesity, and physical deconditioning, among others. Treatment with sodium-glucose co-transporter 2 inhibitors (dapagliflozin and empagliflozin) is recommended for all patients with HFpEF unless contraindicated. Future research should consider alternative approaches to guide the initial diagnosis and treatment of HFpEF, including phenotype clustering models and artificial intelligence, and consider whether LVEF is the most useful distinguishing feature for categorizing HF. Ongoing clinical trials are evaluating novel pharmacological and device-based approaches to address the pathophysiological consequences of HFpEF.

Obesity management in primary care: A joint clinical perspective and expert review from the Obesity Medicine Association (OMA) and the American College of Osteopathic Family Physicians (ACOFP) - 2025

Background

This collaboration from the Obesity Medicine Association (OMA) and the American College of Osteopathic Family Physicians (ACOFP) examines obesity management from a primary care perspective.

Methods

This joint perspective is based upon scientific evidence, clinical experience of the authors, and peer review by the OMA and ACOFP leadership. The goal is to identify and answer sentinel questions about obesity management from a primary care perspective, utilizing evidence-based publications, and guided by expert clinical experience.

Results

Obesity is a disease that contributes to both biomechanical complications and the most common cardiometabolic abnormalities encountered in primary care. Barriers that impede optimal care of patients with obesity in primary care include failure to recognize obesity as a disease, lack of accurate diagnosis, insufficient access to obesity treatment resources, inadequate training, insufficient time, lack of adequate reimbursement and the adverse impact of bias, stigma, and discrimination.

Conclusions

Family physicians are often the first line of treatment in the healthcare setting. This affords early intervention opportunities to prevent and/or treat overweight and/or obesity. Patient care is enhanced when primary care clinicians recognize the risks and benefits of anti-obesity medications and bariatric procedures, as well as long-term follow-up. Practical tools regarding the 4 pillars of nutrition therapy, physical activity, behavior modification, and medical interventions (anti-obesity medications and bariatric surgery) may assist primary care clinicians improve the health and lives of patients living with obesity.

Old and new anti-obesity drugs

Obesity is a pandemic problem that correlates with a cluster of metabolic factors leading to poor cardiovascular outcomes, morbidity, and an increased risk of overall mortality. It is necessary to approach obesity with a comprehensive treatment plan, which may involve lifestyle modifications (diet, exercise, and behavioral therapy) and pharmacological interventions. This article provides an overview of the mechanisms of action, efficacy, and safety of available long-term anti-obesity drugs and introduces other potential agents under investigation.

Cardiovascular-Kidney-Metabolic (CKM) Syndrome: A Case-Based Narrative Review

These 4 hypothetical cases highlight new features of the American Heart Association cardiovascular-kidney-metabolic (CKM) health construct. The cases incorporate the CKM staging system, estimates from the PREVENT risk calculator, and clinical approaches related to CKM stages and individual risk profiles. Topics include management considerations for (1) a patient with stage 1 obesity and impaired glucose tolerance, (2) a patient with metabolic risk factors and moderate-risk chronic kidney disease (CKD), (3) a patient with subclinical atherosclerotic cardiovascular disease and multiple comorbid conditions, and (4) a patient with metabolic risk factors, prior myocardial infarction, new-onset heart failure, atrial fibrillation, and CKD.

Onboarding obesity management in cardiovascular care: A cardiologist's guide to latest advances

In recent decades, the prevalence of obesity has escalated markedly, becoming a serious epidemic and public health crisis requiring urgent and sustained attention. Obesity is associated with a large number of health conditions, including cardiovascular diseases (CVDs), which contribute to an increase in mortality and overall global health challenge. Despite its high morbidity and mortality, most healthcare practitioners perceive obesity as an outcome of unhealthy lifestyle rather than a disease by itself. As such, obesity is either overlooked or considered a minor risk factor for CVD in clinical practice, among others. Since cardiovascular (CV) causes remain the leading cause of death in patients with obesity, cardiologists are among the most frequently visited healthcare professionals and can play an essential role in addressing this disease. Obesity is a complex, chronic, relapsing yet treatable disease that stems from the disruption in the body's homeostatic, hedonic, and cognitive systems, as a result of an interplay between genetic, metabolic, inflammatory, vascular, environmental and behavioral, and pharmacological factors. With early recognition and assessment, management of this disease can successfully improve life expectancy and reduce CV risk. In this review, a concise overview of obesity was provided, focusing on its pathophysiology, diagnosis, and management. The correlation between obesity and CVDs was further discussed, highlighting the significance of obesity education and management among cardiologists to improve patient outcomes and prevent the progression of obesity and its related comorbidities.

Disentangling the Impact of Adiposity From Insulin Resistance in Heart Failure With Preserved Ejection Fraction

BACKGROUND

Obesity, insulin resistance (IR), and diabetes are common in heart failure with preserved ejection fraction (HFpEF) and are associated with worsening heart failure, but their independent contributions remain unknown.

OBJECTIVES

In this study, we sought to determine the contribution of diabetes vs obesity to left heart abnormalities in HFpEF METHODS: Indices of adiposity (body mass index [BMI], bioimpedance fat mass, waist circumference) and IR (homeostasis-model assessment [HOMA]) were measured among PVDOMICS study participants with HFpEF. Rest and exercise pulmonary capillary wedge pressure (PCWP) responses were compared, stratified by obesity (BMI ≥30 kg/m2), IR status (HOMA-IR ≥2.6), and diabetes diagnosis. Findings were also tested in an independent HFpEF cohort.

RESULTS

Of 276 patients with HFpEF, 246 (89%) had increased waist/height ratio, and 166 (60%) had BMI ≥30 kg/m2, with 114 (69%) of the latter having IR and 75 (45%) having diabetes. Of 110 (40%) with HFpEF and BMI <30 kg/m2, 44 (40%) had IR and 27 (25%) had diabetes (both P < 0.0001 vs obesity phenotype). The presence of IR was not associated with worse left heart remodeling or PCWP. In contrast, obesity (regardless of IR status) was associated with greater biventricular enlargement, worse exercise performance, poorer quality of life, and higher rest and exercise PCWP (P < 0.01 for all). Obesity was associated with higher rest and dynamic PCWP responses (+4.4 mm Hg; 95% CI: +2.5 to +6.4 mm Hg; P < 0.0001), even after adjustment for HOMA-IR (+4.7 mm Hg; 95% CI: +2.7 to +6.7 mm Hg; P < 0.0001). Greater fat mass, BMI, and waist circumference were associated with higher PCWP at rest and exercise (P < 0.0009 for all), but HOMA-IR was not (+0.01 mm Hg; 95% CI: -0.13 to +0.16 mm Hg; P = 0.84). Findings were similar evaluating diabetes in place of IR, and were replicated in the independent HFpEF cohort (n = 254), where BMI remained independently associated with higher rest and exercise PCWP (+0.19 mm Hg [95% CI: +0.11 to +0.27 mm Hg] per kg/m2; P < 0.0001), but diabetes was not.

CONCLUSIONS

Excess adiposity is present in most patients with HFpEF, even among those not considered obese according to BMI, calling for further study of cardiometabolic therapies among patients with HFpEF and excess adiposity with BMI <30 kg/m2. Although excess body fat is associated with IR and diabetes, cardiac remodeling, hemodynamics, and functional impairment are independently correlated with body fat, but not IR. These findings suggest that diabetes is primarily a marker of greater adiposity in HFpEF, with less direct impact on heart failure severity. (Pulmonary Vascular Disease Phenomics Program [PVDOMICS]; NCT02980887).

Combining genetic proxies of drug targets and time-to-event analyses from longitudinal observational data to identify target patient populations

BACKGROUND

Human genetics is an important tool for identifying genes as potential drug targets, and the extensive genetic study of cardiovascular disease provides an opportunity to leverage genetics to match specific patient populations to specific drug targets to improve prioritization of patient selection for clinical studies.

METHODS

We selected well described genetic variants in the region of PCSK9 (rs11591147 and rs562556), ADRB1 (rs7076938), ACE (rs4968782 and rs4363), GLP1R (rs10305492) and ABCC8 (rs757110) for use as proxies for the effects of drugs. Time-to-event analyses were utilized to evaluate their effects on atrial fibrillation (AF) and heart failure (HF) death and/or re-hospitalization using real-world longitudinal dataset. To mitigate the effect of confounding factors for cardiovascular (CV) outcomes, we employed propensity score matching.

RESULTS

After matching, a genetic proxy for PCSK9 inhibition (rs11591147) improved survival from CV death/heart transplant in individuals following a diagnosis of ischemic heart disease (Hazard Ratio (HR) 0.78, P = 0.03). A genetic proxy for beta-blockade (rs7076938) improved freedom from rehospitalization or death in individuals with AF (HR 0.92, P = 0.001), and a genetic proxy of ACE inhibition (rs7076938) improved freedom from rehospitalization for HF or death (HR 0.8, P = 0.017) and AF (HR 0.85, P = 0.0014). A protective variant in GLP1R (rs10305492) showed decreased risk of developing HF or CV death after diagnosis of ischemic heart disease (HR = 0.82, P = 0.031) and a protective variant in ABCC8 (rs757110) showed decreased risk of CV mortality since ischemic disease diagnosis (HR = 0.88, P = 0.04) and decreased risk of AF in diabetic patients with ischemic heart disease (HR = 0.68, P = 0.001). Notably, despite smaller cohort sizes after matching, we often observed numerically smaller HRs and reduced P, indicating more pronounced effects and increased statistical association. However, not all genetic proxies replicated known treatment effects.

CONCLUSIONS

Genetic proxies for well-known drugs corroborate findings from clinical trials in cardiovascular disease. Our results demonstrate a useful analytical approach that leverages genetic evidence from a large cohort with longitudinal outcomes data to effectively select patient populations where specific drug targets may be most effective.

Clinical staging to guide management of metabolic disorders and their sequelae: a European Atherosclerosis Society consensus statement

Obesity rates have surged since 1990 worldwide. This rise is paralleled by increases in pathological processes affecting organs such as the heart, liver, and kidneys, here termed systemic metabolic disorders (SMDs). For clinical management of SMD, the European Atherosclerosis Society proposes a pathophysiology-based system comprising three stages: Stage 1, where metabolic abnormalities such as dysfunctional adiposity and dyslipidaemia occur without detectable organ damage; Stage 2, which involves early organ damage manifested as Type 2 diabetes, asymptomatic diastolic dysfunction, metabolic-associated steatohepatitis (MASH), and chronic kidney disease (CKD); and Stage 3, characterized by more advanced organ damage affecting multiple organs. Various forms of high-risk obesity, driven by maintained positive energy balance, are the most common cause of SMD, leading to ectopic lipid accumulation and insulin resistance. This progression affects various organs, promoting comorbidities such as hypertension and atherogenic dyslipidaemia. Genetic factors influence SMD susceptibility, and ethnic disparities in SMD are attributable to genetic and socioeconomic factors. Key SMD features include insulin resistance, inflammation, pre-diabetes, Type 2 diabetes, MASH, hypertension, CKD, atherogenic dyslipidaemia, and heart failure. Management strategies involve lifestyle changes, pharmacotherapy, and metabolic surgery in severe cases, with emerging treatments focusing on genetic approaches. The staging system provides a structured approach to understanding and addressing the multi-faceted nature of SMD, which is crucial for improving health outcomes. Categorization of SMD abnormalities by presence and progression is aimed to improve awareness of a multi-system trait and encourage a tailored and global approach to treatment, ultimately aiming to reduce the burden of obesity-related comorbidities.

What is the Role of Primary Prevention of Obesity in an Age of Effective Pharmaceuticals?

PURPOSE OF REVIEW

To examine the evidence and continuing role of strategies for the primary prevention and treatment of obesity in the context of effective obesity pharmacotherapies, through a narrative review.

RECENT FINDINGS

Global policies to improve nutritional labelling and reduce sugar-sweetened beverages consumption have been implemented worldwide (> 45 countries) with some success which varies by population and environment. Tailored behavioural interventions are effective and essential to reduce individual risk of progression from preclinical to clinical obesity. Pharmacotherapies are powerful treatment agents for clinical obesity but must consider nutritional and metabolic risks of use and discontinuation. The obesogenic environment continues to undermine individual agency to adopt healthier dietary and physical activity patterns. Population health informatics tools could inform tailored interventions based on real-time risk and contribute to obesity prevention and treatment. Efforts to rebalance investment towards obesity prevention must continue to improve population health and reduce healthcare burden.

Influence of glucagon-like peptide-1 receptor agonists on renal parameters: a meta-analysis of randomized controlled trials

AIMS

To verify the influence of glucagon-like peptide-1 receptor agonists (GLP-1 RA) on renal function parameters in type 2 diabetes based on well-known randomized controlled trials (RCTs).

METHODS

PubMed, Cochrane, Web of Science, Embase, and grey literature were searched for RCTs published until December 24, 2024. The quality of the RCTs was assessed using the Cochrane risk-of-bias tool. Weighted mean differences (WMD) and 95% confidence intervals (CIs) were calculated for continuous variables using meta-analysis. The primary outcomes were composite renal function parameters, including serum creatinine (Cr) levels, estimated glomerular filtration rate (eGFR), urinary albumin excretion (UAE), and urinary albumin-to-creatinine ratio (UACR).

RESULTS

Pooled data from 24 studies revealed that GLP-1 RA positively influenced renal outcomes in the type 2 diabetes group to some extent compared with that in the control group. GLP- 1 RA decreased serum creatinine levels (WMD=-0.10, 95%CI -0.19 to -0.01, I2 = 33%, P < 0.05), eGFR(WMD = 0.54, 95% CI 0.19 to 0.90, I2 = 27%, P < 0.05), UAE (WMD=-11.92, 95% CI - 23.50 to - 0.33, I2 = 0%, P < 0.05) and UACR (WMD: -1.01 mg/g, 95% CI:-1.68, -0.34, I2 = 15%, P < 0.05) in the type 2 diabetes group.

CONCLUSION

GLP-1 RA treatment significantly elevated eGFR, decreased the UACR, and positively influenced renal function outcomes in the type 2 diabetes group.

CLINICAL TRIAL NUMBER

Not applicable.

Heart failure and obesity: Translational approaches and therapeutic perspectives. A scientific statement of the Heart Failure Association of the ESC

Obesity and heart failure (HF) represent two growing pandemics. In the general population, obesity affects one in eight adults and is linked with an increased risk for HF. Obesity is even more common in patients with HF, where it complicates the diagnosis of HF and is linked with worse symptoms and impaired exercise capacity. Over the past few years, new evidence on the mechanisms linking obesity with HF has been reported, particularly in relation to HF with preserved ejection fraction. Novel therapies inducing weight loss appear to have favourable effects on health status and cardiovascular risk. Against the backdrop of this rapidly evolving evidence landscape, HF clinicians are increasingly required to tailor their preventive, diagnostic, and therapeutic approaches to HF in the presence of obesity. This scientific statement by the Heart Failure Association of the European Society of Cardiology provides an up-to-date summary on obesity in HF, covering key areas such as epidemiology, translational aspects, diagnostic challenges, therapeutic approaches, and trial design.

Weight-neutral interventions for people with obesity and the perspective of patients, carers and healthcare professionals: a mixed methods review

OBJECTIVES

This is a protocol for a Cochrane Review (prototype). The objectives are as follows: To assess the effects of weight-neutral interventions for managing obesity in children and adults (quantitative data). To explore the views, perspectives and experiences of children and adults receiving the intervention, their close family members or, if appropriate, carers, and healthcare personnel who recommend or deliver weight-neutral interventions to determine their feasibility and acceptability and any factors that create barriers and facilitators to optimal implementation (qualitative data). To determine whether the programme theories, components and delivery of interventions take account of the views, perspectives and experiences of intervention recipients and whether patient-centred interventions have greater effects.

Semaglutide and walking capacity in people with symptomatic peripheral artery disease and type 2 diabetes (STRIDE): a phase 3b, double-blind, randomised, placebo-controlled trial

BACKGROUND

Peripheral artery disease is a highly morbid type of atherosclerotic vascular disease involving the legs and is estimated to affect over 230 million individuals globally. Few therapies improve functional capacity and health-related quality of life in people with lower limb peripheral artery disease. We aimed to evaluate whether semaglutide improves function as measured by walking ability as well as symptoms, quality of life, and outcomes in people with peripheral artery disease and type 2 diabetes.

METHODS

STRIDE was a double-blind, randomised, placebo-controlled trial done at 112 outpatient clinical trial sites in 20 countries in North America, Asia, and Europe. Participants were aged 18 years and older, with type 2 diabetes and peripheral artery disease with intermittent claudication (Fontaine stage IIa, able to walk >200 m) and an ankle-brachial index of less than or equal to 0·90 or toe-brachial index of less than or equal to 0·70. Participants were randomly assigned (1:1) using an interactive web response system to receive subcutaneous semaglutide 1·0 mg once per week for 52 weeks or placebo. The primary endpoint was the ratio to baseline of the maximum walking distance at week 52 measured on a constant load treadmill in the full analysis set. Safety was evaluated in the safety analysis set. This trial is registered with ClinicalTrials.gov, NCT04560998 and is now completed.

FINDINGS

From Oct 1, 2020, to July 12, 2024, 1363 patients were screened for eligibility, of whom 792 were randomly assigned to semaglutide (n=396) or placebo (n=396). 195 (25%) participants were female and 597 (75%) were male. Median age was 68·0 years (IQR 61·0-73·0). The estimated median ratio to baseline in maximum walking distance at week 52 was significantly greater in the semaglutide group than the placebo group (1·21 [IQR 0·95-1·55] vs 1·08 [0·86-1·36]; estimated treatment ratio 1·13 [95% CI 1·06-1·21]; p=0·0004). Six serious adverse events in five (1%) participants in the semaglutide group and nine serious adverse events in six (2%) participants in the placebo group were possibly or probably treatment related, with the most frequent being serious gastrointestinal events (two events reports by two [1%] in the semaglutide group and five events reported by three [1%] in the placebo group). There were no treatment-related deaths.

INTERPRETATION

Semaglutide increased walking distance in patients with symptomatic peripheral artery disease and type 2 diabetes. Research implications include the need for future studies to further elucidate mechanisms of benefit and to assess the efficacy and safety in patients with peripheral artery disease who do not have type 2 diabetes.

FUNDING

Novo Nordisk.

New pharmacological agents and novel cardiovascular pharmacotherapy strategies in 2024

Despite substantial advances in cardiovascular pharmacotherapy and devices in recent years, prevention and treatment of many cardiovascular diseases (CVDs) remain limited, thus reflecting the need for more effective and safer pharmacological strategies. In this review, we summarize the most relevant studies in cardiovascular pharmacotherapy in 2024, including the approval of first-in-class drugs for the treatment of resistant hypertension and pulmonary arterial hypertension, label expansions for bempedoic acid and semaglutide, and the results of major randomized clinical trials (RCTs) that have met the pre-specified primary endpoints, thereby filling some gaps in knowledge and opening new perspectives in the management of CVD, and those RCTs whose results did not confirm the proposed research hypotheses. We also include a section on drug safety, where we describe the newest data on adverse reactions and drug-drug interactions that may complicate treatment and/or reduce drug adherence with the consequent decrease in drug effectiveness. Finally, we present the most important ongoing phase 2 and phase 3 clinical trials assessing the efficacy and safety of cardiovascular drugs for the prevention and treatment of CVD.

CVOT summit report 2024: new cardiovascular, kidney, and metabolic outcomes

The 10th Cardiovascular Outcome Trial (CVOT) Summit: Congress on Cardiovascular, Kidney, and Metabolic Outcomes was held virtually on December 5-6, 2024. This year, discussions about cardiovascular (CV) and kidney outcome trials centered on the recent findings from studies involving empagliflozin (EMPACT-MI), semaglutide (STEP-HFpEF-DM and FLOW), tirzepatide (SURMOUNT-OSA and SUMMIT), and finerenone (FINEARTS-HF). These studies represent significant advances in reducing the risk of major adverse cardiovascular events (MACE) and improving metabolic outcomes in heart failure with preserved ejection fraction (HFpEF), chronic kidney disease (CKD), and obstructive sleep apnea (OSA). The congress also comprised sessions on novel and established therapies for managing HFpEF, CKD, and obesity; guidelines for managing CKD and metabolic dysfunction-associated steatotic liver disease (MASLD); organ crosstalk and the development of cardio-kidney-metabolic (CKM) syndrome; precision medicine and person-centered management of diabetes, obesity, cardiovascular disease (CVD) and CKD; early detection of type 1 diabetes (T1D) and strategies to delay its onset; continuous glucose monitoring (CGM) and automated insulin delivery (AID); cardiovascular autonomic neuropathy (CAN) and the diabetic heart; and the role of primary care in the early detection, prevention and management of CKM diseases. The contribution of environmental plastic pollution to CVD risk, the increasing understanding of the efficacy and safety of incretin therapies in the treatment of CKM diseases, and the latest updates on nutrition strategies for CKM management under incretin-based therapies were also topics of interest for a vast audience of endocrinologists, diabetologists, cardiologists, nephrologists and primary care physicians, who actively engaged in online discussions. The 11th CVOT Summit will be held virtually on November 20-21, 2025 ( http://www.cvot.org ).

Dietary and pharmacological energy restriction and exercise for healthspan extension

Extending healthspan - the years lived in optimal health - holds transformative potential to reduce chronic diseases and healthcare costs. Dietary restriction (DR), particularly when combined with nutrient-rich diets and exercise, is among the most effective, evidence-based strategies for enhancing metabolic health and longevity. By targeting fundamental pathways, it mitigates the onset and progression of obesity, type 2 diabetes (T2D), cardiovascular disease (CVD), neurodegeneration, and cancer. This review synthesizes human data on the impact of DR and exercise on metabolic and age-related diseases, while emphasizing key biological mechanisms such as nutrient sensing, insulin sensitivity, inflammation, mitochondrial function, and gut microbiota. We also examine the emerging role of pharmacologically induced DR, focusing on glucagon-like peptide 1 (GLP-1) receptor agonists (RAs) that partially mimic DR and present opportunities for chronic disease prevention.

Semaglutide 2.4 mg in French people living with Class 3 obesity and comorbidities: Baseline characteristics and real-world safety data

AIM

- To describe baseline characteristics and safety data of real-world use of semaglutide 2.4 mg.

METHODS

- Patients with a body mass index (BMI) ≥40 kg/m2 and at least one of the following treated weight-related comorbidities (WRC: hypertension, dyslipidemia, obstructive sleep apnea, cardiovascular disease) were eligible to receive treatment through Temporary Utilization Authorization (TUA: March to June 2022) or Early Access Program (EAP: July 2022 to October 2023). Data were collected according to Health Authorities' requirements. Only descriptive statistics were used.

RESULTS

- Overall, 5,797 (62.8%) treatment requests were sent by sites specialized in obesity management. In total, 478 and 8,568 patients were treated within TUA and EAP cohorts respectively, with mean follow-up durations of 1.2 and 4.5 months, respectively. Mean (SD) BMI was 48.9 (9.7) and 47.0 (7.4) kg/m2, respectively. Age ranged from 18 to 81 years. In the EAP, 57.4%, 26.5%, 12.3% and 3.7% of patients had 1, 2, 3 and 4 WRC. In addition, 15.5% had type 2 diabetes, 18.1% reported depression and 15.4% had osteoarthritis. In the EAP, 247 (2.9%) patients discontinued treatment after a median time of 2.8 months (IQR: 1.2-5.1), mainly due to adverse events (AEs) (47.0%). During TUA, 3 patients discontinued due to AEs. Pancreatitis was reported in 7 cases overall.

CONCLUSION

- The high number of treatment prescriptions in a short period highlights the high unmet medical need. No new safety concerns were identified in this population with severe obesity treated in a real-world setting.

Cardiovascular outcomes of glucagon-like peptide-1 agonist in patients with obesity and hypertrophic cardiomyopathy

BACKGROUND

Obesity is highly prevalent in patients with hypertrophic cardiomyopathy (HCM) and associated with a more severe phenotype and worse outcomes. Glucagon-like peptide-1 (GLP-1) receptor agonists have recently been shown to improve cardiovascular outcomes in patients with obesity. However, their impact on patients with obesity and HCM is unclear. Therefore we sought to assess the safety and efficacy of GLP-1 agonists in patients with obesity and HCM.

METHODS

Using the TriNetX Global Research Network, patients with HCM and BMI ≥30 kg/m2 were identified from 2016 to 2024 and classified into those who received GLP-1 agonists and those who did not. Groups were propensity matched to control for baseline confounders and evaluated for outcomes including all-cause mortality, heart failure hospitalization and arrhythmias.

RESULTS

Of 29,521 patients with HCM, 1553 (5 %) received GLP-1 agonists. After propensity score matching, both groups (n = 1497 in each) had comparable baseline characteristics. Over a 2-year follow-up period, patients with HCM on GLP-1 agonists had a significant reduction in BMI and lower all-cause mortality and HF hospitalization rates compared to patients not on GLP-1 agonists. In contrast, there was no significant differences in new-onset atrial fibrillation or ventricular arrhythmia, nor was there a significant difference in safety events related to GLP-1 agonists use.

CONCLUSION

In this large real-world dataset, the use of GLP-1 agonists in patients with obesity and HCM was associated with improved survival and lower rates of HF hospitalization. These data support future large prospective clinical trials of GLP-1 agonists in patients with obesity and HCM.

Prescribing patterns of glucagon-like peptide-1 receptor agonists in the Swedish capital region-a register-based cross-sectional study

PURPOSE

Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) have gained considerable media attention, but there is limited knowledge about those receiving the drugs. This study aimed to assess demographic characteristics and previous diagnoses in patients dispensed GLP-1 RAs in Region Stockholm, Sweden, between 2019 and 2023, with a focus on off-label prescribing.

METHODS

This was a register-based cross-sectional study including all inhabitants in Region Stockholm, Sweden, who were dispensed a GLP-1 RA between 2019 and 2023. Patient characteristics were assessed through record linkage with administrative healthcare data on demographics, healthcare consultations, diagnoses, and other dispensed drugs.

RESULTS

The prevalence proportion of GLP-1 RA dispensations in Region Stockholm increased from 4.7 patients/1000 inhabitants in 2019 to 17.5 patients/1000 inhabitants in 2023, and the incidence proportion from 1.8 patients/1000 inhabitants in 2019 to 7.4 patients/1000 inhabitants in 2023. GLP-1 RAs have become more common among a younger and female population, with women constituting 47% of incident patients in 2019 compared to 53% in 2023. The most common diagnosis shifted from type 2 diabetes mellitus (T2DM) (82% in 2019) to obesity (47% in 2023). During the same period, obesity without T2DM notably increased from 10 to 31%. Almost one-third (31%) of all patients dispensed the drugs in 2023 had no recorded diagnosis of either diabetes or obesity, compared to 8% in 2019.

CONCLUSION

This study showed an increase in the dispensation of GLP-1 RA, with characteristics of patients changing towards a higher degree of off-label use. The effectiveness and safety of the increasing prescriptions warrant future studies.

The prevention and management of chronic kidney disease among patients with metabolic syndrome

Treatment of patients with chronic kidney disease (CKD) requires implementation of prevention and management strategies that reduce the risk of kidney failure and CKD-associated cardiovascular risk. Metabolic syndrome is characterized by obesity, high blood pressure, dyslipidemia, and hyperglycemia, and it is common among patients with CKD. Large-scale randomized trials have led to significant advances in the management of CKD, with 5 pharmacotherapies now proven to be nephroprotective and/or cardioprotective in certain types of patients. Renin-angiotensin system inhibitors and sodium-glucose cotransporter 2 inhibitors slow kidney disease progression and reduce heart failure complications for most patients with CKD. In addition, statin-based regimens reduce low-density lipoprotein cholesterol and lower the risk of atherosclerotic disease (with no clinically meaningful effect on kidney outcomes). For patients with type 2 diabetes and albuminuric CKD, the nonsteroidal mineralocorticoid receptor antagonist finerenone and the glucagon-like peptide-1 receptor agonist semaglutide also confer cardiorenal benefits, with semaglutide additionally effective at reducing weight. Together, these randomized data strongly suggest that metabolic syndrome mediates some of the cardiorenal risk observed in CKD. Considered separately, the trials help elucidate which components of metabolic syndrome influence the pathophysiology of kidney disease progression and which separately modify risk of atherosclerotic and nonatherosclerotic cardiovascular outcomes. As we predict complementary and different mechanisms of nephroprotection and cardioprotection for these different interventions, it seems logical that they should be deployed together to maximize benefits. Even when combined, however, these therapies are not a cure, so further trials remain important to reduce the residual cardiorenal risks associated with CKD.

Multifunctional incretin peptides in therapies for type 2 diabetes, obesity and associated co-morbidities

Recent studies with peptide-based incretin therapies have focussed mainly on the glucagon-like peptide-1 (GLP-1) receptor agonist semaglutide and the dual agonist tirzepatide that engages receptors for GLP-1 and glucose-dependent insulinotropic polypeptide (GIP). Randomised clinical trials and 'real-world' studies have confirmed the marked glucose-lowering and weight-lowering efficacy of these agents across diverse populations. These include different ethnic groups, young and elderly individuals with and without diabetes and/or overweight or obesity. Recent studies have also confirmed protections against the development and progression of cardiovascular and renal diseases that are additive to the benefits conferred by improved control of blood glucose and body weight. Emerging evidence suggests that incretin therapies could additionally ameliorate fatty liver disease, chronic inflammation, sleep apnea and possibly degenerative bone disorders and cognitive decline. New incretin-based peptide therapies in development include a long-acting glucagon receptor agonist (LY3324954), dual GLP-1/glucagon receptor agonists (survodutide, pemvidutide, mazdutide, G49), triple GLP-1/GIP/glucagon receptor agonists (retatrutide, efocipegtrutide), a combination of semaglutide with the amylin analogue cagrilintide (CagriSema), a unimolecular GLP-1/amylin receptor dual agonist (amycretin), and a GIP receptor antibody with GLP-1 receptor agonism (MariTide). The creation of multi-targeting incretin-based synthetic peptides provides opportunities for improved management of type 2 diabetes and obesity as well as new therapeutic approaches to an expanding list of associated co-morbidities. The aim of the review is to acquaint the reader with developments in the field from 2023 to the present (February 2025).

GLP-1 receptor agonists and cardiovascular events in metabolically healthy or unhealthy obesity

AIMS

The associations of glucagon-like peptide-1 receptor agonists (GLP-1RAs) and outcomes among patients with obesity according to the presence of cardiovascular risk factors (metabolically healthy obesity (MHO) or metabolically unhealthy obesity (MUHO)) remain unclear. We examined the associations of GLP-1RAs with mortality and adverse cardiovascular events in patients with MHO and MUHO.

METHODS

The TriNetX network was utilized to select a cohort of patients with MHO or MUHO, and use or non-use of GLP-1RAs with propensity score matching (1:1). Cardiovascular events were identified during follow-up.

RESULTS

A total of 2 983 151 patients with obesity (512 434 with MHO and 2 470 717 with MUHO) were included in the study. Among these, 416 713 (13.9%) were GLP-1RA users. After propensity score matching, GLP-1RA use in MUHO was associated with a significantly lower risk of mortality (HR 0.580 [95% CI, 0.566-0.595]), ischemic stroke (HR 0.921 [0.890-0.953]), AF (HR 0.913 [0.888-0.938]) and hospitalization for HF (HR 0.925 [0.900-0.949]) during follow-up compared with non-use of GLP-1RA. Patients with MHO had a markedly lower risk of clinical events than those with MUHO. A trend towards a lower risk of cardiovascular events associated with GLP-1RA was seen among patients with MHO. There was no statistical interaction in the risk of cardiovascular outcomes with GLP-1RA use for MHO and MUHO patients.

CONCLUSIONS

The use of GLP-1RAs was associated with lower rates of cardiovascular events than no use in patients with MUHO. Similar but non-statistically significant trends were seen in patients with MHO.

Μetabolic dysfunction-associated steatotic liver disease: a condition of heterogeneous metabolic risk factors, mechanisms and comorbidities requiring holistic treatment

Μetabolic dysfunction-associated steatotic liver disease (MASLD) comprises a heterogeneous condition in the presence of steatotic liver. There can be a hierarchy of metabolic risk factors contributing to the severity of metabolic dysfunction and, thereby, the associated risk of both liver and extrahepatic outcomes, but the precise ranking and combination of metabolic syndrome (MetS) traits that convey the highest risk of major adverse liver outcomes and extrahepatic disease complications remains uncertain. Insulin resistance, low-grade inflammation, atherogenic dyslipidaemia and hypertension are key to the mechanisms of liver and extrahepatic complications. The liver is pivotal in MetS progression as it regulates lipoprotein metabolism and secretes substances that affect insulin sensitivity and inflammation. MASLD affects the kidneys, heart and the vascular system, contributing to hypertension and oxidative stress. To address the global health burden of MASLD, intensified by obesity and type 2 diabetes mellitus epidemics, a holistic, multidisciplinary approach is essential. This approach should focus on both liver disease management and cardiometabolic risk factors. This Review examines the link between metabolic dysfunction and liver dysfunction and extrahepatic disease outcomes, the diverse mechanisms in MASLD due to metabolic dysfunction, and a comprehensive, personalized management model for patients with MASLD.

[Conservative Management of Chronic Coronary Syndrome]

CCS management, based on the 2024 ESC Guidelines, a cornerstone of contemporary cardiology, aims to prevent cardiovascular events, alleviate symptoms, and enhance quality of life through conservative and invasive strategies. Non-invasive approaches, encompassing patient education, lifestyle interventions, and optimized pharmacological treatments, have demonstrated significant benefits in prognosis and quality of life. The guidelines advocate for a patient-centered approach, tailoring therapies to pathophysiological mechanisms, comorbidities, and individual needs. Pharmacological strategies integrate antithrombotic, lipid-lowering, RAAS-blocking, anti-inflammatory, and antidiabetic agents for event prevention, alongside antianginal medications for symptom relief. Invasive interventions remain essential for high-risk patients with obstructive coronary artery disease (e.g., left main disease, three-vessel disease, or proximal LAD involvement) or refractory angina despite optimal medical therapy. However, the growing efficacy of medical management increasingly challenges the incremental benefits of early revascularization. The guidelines also highlight underdiagnosed conditions such as ANOCA (Angina with Non-Obstructive Coronary Arteries) and INOCA (Ischemia with Non-Obstructive Coronary Arteries). Recognizing diverse endotypes, including microvascular dysfunction and vasospastic angina, enables precise and individualized therapeutic approaches. Conservative therapy remains the foundation of CCS management, demanding a holistic, multidisciplinary, and patient-centered approach to optimize outcomes and improve quality of life.

Advances in the management of obesity and heart failure: latest evidence from clinical trials

PURPOSE OF REVIEW

Obesity is an important risk factor for heart failure with preserved ejection fraction (HFpEF). In patients who already have HFpEF, obesity contributes to high symptom burden and increased risk for heart failure (HF) hospitalization. This review examines the latest clinical trials assessing the efficacy of pharmacological interventions in the treatment of obesity-related HFpEF.

RECENT FINDINGS

Recent results from randomized clinical trials (RCTs) suggest that incretin-based therapies, including glucagon-like peptide-1 receptor agonists (GLP-1 RAs) (e.g., semaglutide) and dual glucose-dependent insulinotropic polypeptide (GIP)/GLP-1 RAs (e.g., tirzepatide), can improve quality of life, exercise tolerance, and markers of HF severity while promoting weight loss in patients with obesity and HFpEF. Some evidence also suggests that these therapies may reduce risk for HF hospitalizations. Additionally, exploratory analyses of the nonsteroidal mineralocorticoid receptor antagonist finerenone has been associated with reduced cardiovascular mortality and total worsening HF events across all body mass index (BMI) levels, with greater benefits observed in patients with higher BMIs.

SUMMARY

Antiobesity medications such as semaglutide and tirzepatide may represent important treatment options for patients with obesity-related HFpEF. Additional evidence suggests that certain other HF medications may have increased efficacy in patients with obesity.

Research priorities for peripheral artery disease: A statement from the Society for Vascular Medicine

Lower-extremity peripheral artery disease (PAD) affects approximately 236 million people worldwide and at least eight million people in the United States (US). Despite availability of new therapies that prevent major adverse cardiovascular events (MACE), these and major adverse limb events (MALE) remain common and occur more frequently in people with PAD, either with or without coronary artery disease (CAD), compared to people with CAD who do not have PAD. The most effective therapies to prevent cardiovascular events are not identical in people with PAD and those with CAD. Walking impairment and the risk of lower-extremity amputation are significantly greater in people with PAD compared to those without PAD. This report from the Society for Vascular Medicine (SVM) proposes and summarizes high-priority topics for scientific investigation in PAD, with the goal of improving health outcomes in people with PAD. To develop this report, a multidisciplinary team of scientists and clinicians reviewed literature, proposed high-priority topics for scientific investigation, and voted to rank the highest priority topics for scientific investigation. Priorities for clinical scientific investigation include: determine the current prevalence of PAD in the US by age, sex, race, and ethnicity; improve methods to diagnose PAD; develop new medical therapies to eliminate walking impairment; and improve implementation of established therapies to reduce rates of MACE and MALE in people with PAD. Priorities in basic science and translational science investigation include: developing animal models that closely resemble the vascular, skeletal muscle, and platelet pathology in patients with PAD and defining the genetic and epigenetic contributors to PAD and PAD-associated outcomes. Successful investigation of these research priorities will require more well-trained investigators focused on scientific investigation of PAD, greater and more efficient enrollment of diverse patients with PAD in randomized clinical trials, and increased research funding dedicated to PAD.

[Pharmacotherapy of obesity in Germany]

Pharmacotherapy is part of a comprehensive guideline-conform treatment concept for people with obesity. The foundation of obesity treatment is initially a conservative multimodal basic treatment and consists of a low-energy diet, increased physical activity and behavioral changes. If the individual treatment goals are not achieved with this approach, medications can support the basic treatment. The concept is that drugs should not only achieve weight reduction and stabilization of the reduced body weight but also provide better long-term treatment for the chronic multisystem disease obesity. The incretin-based pharmacotherapy with liraglutide, semaglutide and tirzepatide, which have been introduced in recent years, have not only pronounced weight-reducing but also beneficial cardiometabolic effects. These include improvements in obesity-related comorbidities, such as type 2 diabetes, hypertension, fatty liver disease, obstructive sleep apnea, cardiovascular risk factors, chronic kidney disease and others. In contrast, incretin-based pharmacotherapy is typically associated with mild to moderate gastrointestinal side effects. With the marketing launch of setmelanotide, a medication became available for the treatment of rare monogenic forms of obesity. In addition, numerous incretin-based active agents and new substance classes are in advanced phases of clinical development. Due to their favorable efficacy and side effect profiles and also with respect to the positive cardiometabolic effects, the new drugs have the potential to significantly increase the importance of pharmacotherapy of obesity in Germany.

Initiation and sequencing of guideline-directed medical therapy for heart failure across the ejection fraction spectrum

Strong evidence supports the importance of rapid sequence or simultaneous initiation of quadruple guideline-directed medical therapy (GDMT) for heart failure with reduced ejection fraction (HFrEF) for substantially reducing risk of mortality and hospitalization. Barring absolute contraindications for each individual medication, employing the strategy of rapid sequence, simultaneous, and/or in-hospital initiation at the time of HF diagnosis best ensures patients with HFrEF have the opportunity to benefit from proven medications and achieve large absolute risk reductions for adverse clinical outcomes. However, despite guideline recommendations supporting this approach, implementation in clinical practice remains persistently low, with less than one-fifth of eligible patients being prescribed the quadruple GDMT regimen. Additionally, for heart failure with mildly reduced or preserved ejection fraction (HFpEF), sodium-glucose co-transporter 2 inhibitors (SGLT2i) and non-steroidal mineralocorticoid receptor antagonists (MRA) constitute foundational therapy for all eligible patients with significant clinical benefits within just weeks of medication initiation. Nonetheless, the burden of symptoms, functional limitations, and hospitalizations remains substantial for many of these patients, even with SGLT2i and non-steroidal MRA therapy. Additional evidence supports consideration of adjunctive therapies for HF with EF > 40% that can be tailored to the patient phenotype, including glucagon-like peptide-1 receptor agonists (GLP-1 RA) for patients with obesity, as well as angiotensin receptor-neprilysin inhibitors (ARNI) for patients with EF below normal. This article reviews the evidence-based sequencing of GDMT for HF across the spectrum of EF, emphasizing the rationale and benefits of early up-front initiation of quadruple medical therapy for HFrEF, rapid initiation of SGLT2i for HF regardless of EF, and prompt phenotype-specific tailored approach to adjunctive therapies for HF with EF > 40%.

Glucagon-Like Peptide-1 Receptor Agonists in Patients With Durable Left Ventricular Assist Devices

BACKGROUND

GLP-1 RAs improve cardiometabolic outcomes in obese, diabetic, and heart failure patients. Data on the safety and efficacy of GLP-1 RA in advanced heart failure with durable LVAD is limited.

OBJECTIVES

To assess the safety and efficacy of GLP-1 RA in durable LVAD patients.

METHODS

We conducted a single-center retrospective analysis of patients on durable LVAD support treated with GLP-1 RA. Outcomes included cardiometabolic efficacy and LVAD and GLP-1 RA related adverse events up to 1 year post GLP-1 RA initiation.

RESULTS

Forty LVAD patients were treated with GLP-1 RA therapy between 2018 and 2023. At 1 year follow-up, the patient's weight was significantly reduced (116 (98-134) vs. 110 (91-129) kg, p-value < 0.001), HBA1C was improved (6.4 (5.8-8.1) vs. 5.7 (5.3-6.1), p-value 0.003), and NT-proBNP levels were significantly reduced (810 (594-1413) vs. 732 (354-1155) pg/mL, p-value 0.04). GLP-1 RA therapy was not associated with cannula position change (cannula coronal angle of 29.7° (15.0-42.0) vs. 23.1° (12.8-42.3), p-value 0.683), and LVADs complication rate was relatively low (12.5% of the patients had hemocompatibility adverse events, 15% had driveline infection, 12% had HF hospitalization, and 2.5% (1 patient) died due to HeartMate2 malfunction). There was no interruption of drug administration due to adverse events.

CONCLUSION

Durable LVAD patients treated with GLP-1 RA had improved cardiometabolic profiles and low major adverse events. GLP-1 RA therapy holds promise as a potential adjunctive treatment strategy in LVAD recipients, offering improved cardiometabolic profile, hemodynamics, and potential future transplant candidacy.

Kidney and Cardiovascular Outcomes Among Patients With CKD Receiving GLP-1 Receptor Agonists: A Systematic Review and Meta-Analysis of Randomized Trials

RATIONALE & OBJECTIVE

Glucagon-like peptide 1 (GLP-1) receptor agonists improve cardiac and kidney outcomes in patients with diabetes; however, their efficacy in individuals with reduced estimated glomerular filtration rate (eGFR) is uncertain. This study evaluated the effects of GLP-1 receptor agonists on kidney and cardiovascular (CV) outcomes in patients with chronic kidney disease (CKD).

STUDY DESIGN

Systematic review and meta-analysis of randomized controlled trials (RCTs) reported through May 25, 2024.

SETTING & STUDY POPULATIONS

Adult participants in RCTs with baseline eGFR<60mL/min/1.73m2.

SELECTION CRITERIA FOR STUDIES

RCTs including adults (≥18 years old) with varying degrees of kidney function, including individuals with CKD characterized by a baseline eGFR of<60mL/min/1.73m2, that compared GLP-1 receptor agonists with control treatments with respect to a composite kidney outcome, all-cause mortality, or a composite CV disease outcome. From among 212 screened studies, 12 trials involving that included participants with baseline eGFR<60mL/min/1.73m2 were included.

DATA EXTRACTION

Two independent investigators extracted the data.

ANALYTICAL APPROACH

Pooled odds ratios (ORs) for composite kidney outcome, all-cause mortality, and composite CV outcome were estimated using random-effects models. Evidence certainty was assessed using the GRADE system.

RESULTS

The analyses included 17,996 RCT participants with baseline eGFR<60mL/min/1.73m2. GLP-1 receptor agonists were significantly associated with a reduced risk of the composite kidney outcome (OR, 0.85 [95% CI, 0.77-0.94]; P=0.001) with low heterogeneity (I2<0.01%). GLP-1 receptor agonists were also associated with a reduced the risk of a>30% eGFR decline (OR, 0.78; P=0.004), a>40% decline (OR, 0.76; P=0.01), and a>50% decline (OR, 0.72; P<0.001). Risk of all-cause mortality was also lower in the GLP-1 receptor agonist group (OR, 0.77 [95% CI, 0.60-0.98], P=0.03), though there was high heterogeneity (I2=71.6%). Composite CV outcomes were also lower with the use of a GLP-1 receptor agonist (OR, 0.86 [95% CI, 0.74-0.99], P=0.03; I2=40.3%). Sensitivity analyses restricted to human GLP-1 backbone agents showed enhanced benefits.

LIMITATIONS

Inconsistent kidney outcome definitions, focus on diabetic populations in most studies, and potential publication bias.

CONCLUSIONS

GLP-1 receptor agonists improved kidney and CV outcomes, and survival in patients with CKD enrolled in an array of clinical trials.

REGISTRATION

Registered at PROSPERO with identification number CRD42023449059.

PLAIN-LANGUAGE SUMMARY

Glucagon-like peptide 1 (GLP-1) receptor agonists reduce body weight and improve glycemic control. They also have been shown to protect the heart and kidney in people with diabetes. However, the extrapolation of these findings to those with chronic kidney disease (CKD) is uncertain. This study meta-analyzed data from clinical trials focusing on patients with CKD and noted that GLP-1 receptor agonists may slow kidney disease progression and lower the risk of heart disease, stroke, and death. These findings suggest that GLP-1 receptor agonists offer multiple kidney and cardiovascular benefits to people with CKD.

Real-World Comparisons Between Glucagon-Like Peptide-1 Receptor Agonists and Other Glucose-Lowering Agents in Type 2 Diabetes: Retrospective Analyses of Cardiovascular and Economic Outcomes in England

INTRODUCTION

Clinical trials have demonstrated that glucagon-like peptide-1 receptor agonists (GLP-1RAs) reduce the risk of major adverse cardiovascular events (MACE) in adults with type 2 diabetes (T2D) who have established cardiovascular disease (CVD) or a high risk of CVD. Nevertheless, GLP-1RAs remain underutilized. This real-world, retrospective study compared cardiovascular and economic outcomes between individuals treated with GLP-1RAs and other glucose-lowering agents in England.

METHODS

Clinical Practice Research Datalink-registered people indexed on GLP-1RAs, dipeptidyl peptidase-4 (DPP4) inhibitors, or basal insulin between January 1, 2014 and December 31, 2018 for their fourth line of T2D treatment were stratified into six cohorts based on their: (1) cardiovascular risk (high or very high risk) and (2) indexed therapy. Cox proportional hazards regression was used to compare the risk of MACE and all-cause death between GLP-1RA and other treatment cohorts. Generalized linear regression was used to quantify differences in healthcare resource use (HCRU) and costs between groups.

RESULTS

Of 63,237 subjects, 10,607 were at high cardiovascular risk (GLP-1RA: 2709; DPP4 inhibitor: 2673; basal insulin: 5225) and 52,630 at very high cardiovascular risk (GLP-1RA: 14,692; DPP4 inhibitor: 18,461; basal insulin: 19,477). The crude incidence of all outcomes was lower in the GLP-1RA versus other treatment cohorts, regardless of cardiovascular risk. Among very-high-risk individuals treated with GLP-1RA, the adjusted risk of MACE was 33% (24-40%) and 23% (13-23%) lower versus DPP4 inhibitor and basal insulin cohorts, respectively. The adjusted total cardiovascular-related cost among very-high-risk individuals was £208.14 (£155.81-£260.47) and £151.74 (£110.69-£192.79) lower in the GLP-1RA versus DPP4 inhibitor or basal insulin cohorts, respectively.

CONCLUSIONS

In a real-world setting, GLP-1RAs may be associated with a lower risk of MACE and reduced HCRU and costs than DPP4 inhibitors or basal insulin in individuals with T2D, particularly among those at very high cardiovascular risk.

[Principles of obesity treatment: What has changed in the updated S3 guideline?]

A comprehensive update of the S3 guideline for the prevention and treatment of obesity was published in October 2024. In contrast to the former version, the literature search included not only data on weight reduction but also data on patient-reported outcomes and co-morbidity. The new recommendations for nutritional therapy, besides fat and carbohydrate reduction, now also include novel aspects like the Mediterranean diet and intermittent fasting. These will enable individualization and will avoid an unbalanced diet. Pharmacotherapy, especially incretin-based, is recommended in an adjuvant setting, especially since current clinical trials indicate beneficial effects on the heart, liver and kidney in addition to weight reduction. A novel chapter was included regarding eHealth strategies, since these are efficient as supportive measures for multidimensional treatment programs, including nutritional advice, behavioural coaching and exercise training. Finally, a novel aspect was incorporated: discrimination and stigmatization of subjects suffering from obesity. This is important not only for the general environment but also for the medical sector, including the handling of patients as well as the infrastructure of the medical institution (e.g. heavy-duty chairs). Hence, the novel guideline will guarantee high quality in the medical care of subjects suffering from obesity.

Advances in incretin therapies for targeting cardiovascular disease in diabetes

The global prevalence of obesity is skyrocketing at an alarming rate, with recent data estimating that one-in-eight people are now living with the disease. Obesity is a chronic metabolic disorder that shares underlying pathophysiology with other metabolically-linked diseases such as type 2 diabetes mellitus, cardiovascular disease and diabetic cardiomyopathy. There is a distinct correlation between type 2 diabetes status and the likelihood of heart failure. Of note, there is an apparent sexual dimorphism, with women disproportionately affected with respect to the degree of severity of the cardiac phenotype of diabetic cardiomyopathy that results from diabetes. The current pharmacotherapies available for the attenuation of hyperglycaemia in type 2 diabetes are not always effective, and have varying degrees of efficacy in the setting of heart failure. Insulin can worsen heart failure prognosis whereas metformin, sodium-glucose cotransporter 2 inhibitors (SGLT2i) and more recently, glucagon-like peptide-1 receptor agonists (GLP-1RAs), have demonstrated cardioprotection with their administration. This review will highlight the advancement of incretin therapies for individuals with diabetes and heart failure and explore newly-reported evidence of the clinical usefulness of GLP-1R agonists in this distinct phenotype of heart failure.

Incidence of new onset arterial hypertension after metabolic bariatric surgery: an 8-year prospective follow-up with matched controls

BACKGROUND

Metabolic bariatric surgery (MBS) reduces the risk of new-onset hypertension; however, it is unclear whether this effect varies according to patient sex, age, or socioeconomic background. This study aimed to assess the risk of new-onset arterial hypertension after MBS, with a special focus on these patient characteristics.

METHODS

This follow-up study with matched controls was nested in a large employee cohort, the Finnish Public Sector study, consisting of individuals with no hypertension at baseline. For each patient who underwent laparoscopic MBS between 2008 and 2016, two propensity-score matched controls were selected from individuals hospitalized with a diagnosis of obesity or individuals with self-reported severe obesity [body mass index (BMI) ≥ 35 kg/m 2 ] but no recorded history of MBS. Cases of new-onset hypertension were identified via linked electronic health records from the national health registries until December 31, 2016.

RESULTS

The study included 912 patients and 1780 matched controls. The rate of new-onset hypertension per 1000 person-years was 2.8 in the surgery group and 9.6 in the control group, with a rate ratio of 0.29 (95% confidence intervals 0.15-0.57) and a rate difference of -6.8 (95% confidence intervals -9.6 to -4.0) per 1000 person-years. No significant differences in rate reduction after MBS were observed to be associated with patient sex, age, or socioeconomic status.

CONCLUSION

Metabolic bariatric surgery reduces the risk of new-onset arterial hypertension across all age-, sex-, and socioeconomic subgroups.

Glucagon-like peptide-1 receptor agonists to improve cardiorenal outcomes: data from FLOW and beyond

PURPOSE OF REVIEW

Glucagon-like peptide-1 receptor agonists (GLP1RA), initially approved for glycemic control in type 2 diabetes mellitus (T2DM), have emerged as agents for weight loss, cardiovascular and kidney protection. This review summarizes the evidence supporting the benefits of these therapies on cardiorenal outcomes.

RECENT FINDINGS

Clinical trials have consistently demonstrated reductions in major adverse cardiovascular events with GLP1RA treatments. Recently, the FLOW trial revealed that semaglutide reduced the composite outcome of kidney failure, at least 50% decline in estimated glomerular filtration rate, kidney or cardiovascular mortality by 24% in patients with T2DM, thereby establishing GLP1RA as a pillar of therapy in this population. New evidence suggests favorable effects on kidney endpoints in nondiabetic individuals with overweight or obesity. Dedicated trials have also provided evidence for reduction in the risk for heart failure hospitalization and improvement in symptoms in individuals with heart failure with preserved ejection fraction. Subgroup analyses have suggested that GLP1RAs confer additive cardiorenal benefits irrespective of background medication use.

SUMMARY

There is increasing evidence that GLP1RA reduces the risk for cardiovascular events, chronic kidney disease progression, and heart failure hospitalizations. Further data on the effect of dual and triple GLP1-based therapies on cardiorenal outcomes is required.

Sex Differences in Obesity and Its Treatment

PURPOSE OF REVIEW

Researchers and clinicians have increasingly recognized the importance of investigating and considering sex differences in obesity treatment. In this narrative review, we first summarized sex differences in select obesity-related conditions that have been the focus of studies of second-generation anti-obesity medications (i.e., semaglutide and tirzepatide) including type 2 diabetes, obstructive sleep apnea, knee osteoarthritis, and heart failure. We next described sex differences related to obesity treatments with a focus on the second-generation anti-obesity medications, semaglutide and tirzepatide.

RECENT FINDINGS

Type 2 diabetes, obstructive sleep apnea, knee osteoarthritis, and heart failure demonstrated sex-specific pathways influenced by factors such as hormones and body composition. Lifestyle modification, on average, resulted in larger weight losses in males. In contrast, second-generation AOMs produced higher mean weight losses among females. Females reported more adverse events (e.g., nausea, vomiting) with second-generation anti-obesity medications. The few studies that have performed analyses of changes in obesity-related comorbidities stratified by sex have shown consistent improvements between males and females in heart failure and cardiovascular outcomes. Studies are needed to evaluate the effect of sex on the efficacy of anti-obesity medications including on mental health, investigate the mechanisms underlying these effects, and develop interventions to improve the availability and access of these medications.

Phase 3 Trial of Semaglutide in Metabolic Dysfunction-Associated Steatohepatitis

BACKGROUND

Semaglutide, a glucagon-like peptide-1 receptor agonist, is a candidate for the treatment of metabolic dysfunction-associated steatohepatitis (MASH).

METHODS

In this ongoing phase 3, multicenter, randomized, double-blind, placebo-controlled trial, we assigned 1197 patients with biopsy-defined MASH and fibrosis stage 2 or 3 in a 2:1 ratio to receive once-weekly subcutaneous semaglutide at a dose of 2.4 mg or placebo for 240 weeks. The results of a planned interim analysis conducted at week 72 involving the first 800 patients are reported here (part 1). The primary end points for part 1 were the resolution of steatohepatitis without worsening of liver fibrosis and reduction in liver fibrosis without worsening of steatohepatitis.

RESULTS

Resolution of steatohepatitis without worsening of fibrosis occurred in 62.9% of the 534 patients in the semaglutide group and in 34.3% of the 266 patients in the placebo group (estimated difference, 28.7 percentage points; 95% confidence interval [CI], 21.1 to 36.2; P<0.001). A reduction in liver fibrosis without worsening of steatohepatitis was reported in 36.8% of the patients in the semaglutide group and in 22.4% of those in the placebo group (estimated difference, 14.4 percentage points; 95% CI, 7.5 to 21.3; P<0.001). Results for the three secondary outcomes that were included in the plan to adjust for multiple testing were as follows: combined resolution of steatohepatitis and reduction in liver fibrosis was reported in 32.7% of the patients in the semaglutide group and in 16.1% of those in the placebo group (estimated difference, 16.5 percentage points; 95% CI, 10.2 to 22.8; P<0.001). The mean change in body weight was -10.5% with semaglutide and -2.0% with placebo (estimated difference, -8.5 percentage points; 95% CI, -9.6 to -7.4; P<0.001). Mean changes in bodily pain scores did not differ significantly between the two groups. Gastrointestinal adverse events were more common in the semaglutide group.

CONCLUSIONS

In patients with MASH and moderate or advanced liver fibrosis, once-weekly semaglutide at a dose of 2.4 mg improved liver histologic results. (Funded by Novo Nordisk; ClinicalTrials.gov number, NCT04822181.).

Evolving role of double and triple therapy with GLP-1 receptor agonists in obesity and cardiovascular disease

Glucagon-like peptide-1 receptor agonists (GLP-1RAs) have emerged as a transformative class of therapies, expanding their clinical utility far beyond glycemic control. Initially developed for the treatment of diabetes, these agents are now recognized as potent therapies for managing overweight and obesity, atherosclerosis, and heart failure. This review explores the evolution of GLP-1RA-based therapies, with a focus on novel advancements such as dual GLP-1 and glucose-dependent insulinotropic polypeptide (GIP) receptor agonists ("double G") and triple receptor agonists incorporating glucagon modulation ("triple G"). We also provide an overview of completed and ongoing clinical trials investigating the role of GLP-1RAs in atherosclerosis and heart failure. These developments underscore the expanding therapeutic landscape of GLP-1RAs and their growing significance in cardiometabolic medicine.

The landscape of novel antidiabetic drugs in diabetic HFpEF: relevant mechanisms and clinical implications

As a heterogeneous syndrome, heart failure with preserved ejection fraction (HFpEF) has become the leading form of heart failure worldwide. Increasing evidence has identified that diabetes mellitus (DM) increases the risk of HFpEF. Worse still, the coexistence of both diseases poses a great threat to human health by further worsening the cardiovascular system and accelerating the progression of diabetes. Although several studies have indicated that the novel antidiabetic drugs, including sodium glucose cotransporter 2 inhibitors (SGLT2i), glucagon-like peptide-1 receptor agonists (GLP-1 RA) and dipeptidyl peptidase 4 inhibitors (DPP4i) provide the cardiovascular benefits in T2DM patients with HFpEF, the elaborated roles and mechanisms are not fully understood. In this review, we summarize the state-of-the-art evidence regarding the epidemiology and pathophysiology of diabetic HFpEF, and the landscape of the novel antidiabetic drugs in the treatment of diabetic HFpEF, as well as discuss the relevant mechanisms, aiming to broaden the understanding of diabetic HFpEF and gain new insight into the treatment of this disease.