Cardiovascular risk and lifetime benefit from preventive treatment in type 2 diabetes: A post hoc analysis of the CAPTURE study

AIM

To assess the potential gain in the number of life-years free of a (recurrent) cardiovascular disease (CVD) event with optimal cardiovascular risk management (CVRM) and initiation of glucose-lowering agents with proven cardiovascular benefit in people with type 2 diabetes (T2D).

MATERIALS AND METHODS

9,416 individuals with T2D from the CAPTURE study, a non-interventional, cross-sectional, multinational study, were included. The diabetes lifetime-perspective prediction model was used for calculating individual 10-year and lifetime CVD risk. The distribution of preventive medication use was assessed according to predicted CVD risk and stratified for history of CVD. For the estimation of absolute individual benefit from lifelong preventive treatment, including optimal CVRM and the addition of glucagon-like peptide-1 receptor agonists (GLP-1 RAs) and sodium-glucose co-transporter-2 inhibitors (SGLT-2is), the model was combined with treatment effects from current evidence.

RESULTS

GLP-1 RA or SGLT-2i use did not greatly differ between patients with and without CVD history, while use of blood pressure-lowering medication, statins and aspirin was more frequent in patients with CVD. Mean (standard deviation [SD]) lifetime benefit from optimal CVRM was 3.9 (3.0) and 1.3 (1.9) years in patients with and without established CVD, respectively. Further addition of a GLP-1 RA and an SGLT-2i in patients with CVD gave an added mean (SD) lifetime benefit of 1.2 (0.6) years.

CONCLUSIONS

Life-years gained free of (recurrent) CVD by optimal CVRM and the addition of a GLP-1 RA or aSGLT-2i is dependent on baseline CVD status. These results aid individualizing prevention and promote shared decision-making in patients with T2D.

Distribution of cardiovascular risk in type 2 diabetes: results of an analysis using data from the CAPTURE study

Introduction

Cardiovascular disease (CVD) is the leading cause of mortality in people with type 2 diabetes (T2D). CAPTURE, a non-interventional, cross-sectional study conducted across 13 countries in 2019, collected demographic and clinical characteristics in almost 10,000 adults with T2D in primary or secondary care. Less than 25% of patients with established CVD treated with a glucose-lowering agent received an agent with demonstrated benefit in cardiovascular (CV) risk reduction, such as a glucagon-like peptide-1 receptor agonist (GLP-1 RA) or a sodium–glucose co-transporter-2 inhibitor (SGLT-2i).1 It is not known whether this is linked to estimated 10-year and lifetime CV risk.

Purpose

To estimate the CV risk distribution in the CAPTURE population using the Diabetes Lifetime-perspective prediction (DIAL) model, and to assess treatment patterns by CV risk.

Methods

The DIAL model is an externally validated competing risk adjusted model for predicting CV risk in patients with T2D, calculating absolute 10-year and lifetime risk of myocardial infarction, stroke or cardiovascular death, and life-expectancy free of a CVD event. Patient-level data from CAPTURE (age, sex, body mass index, smoking status, HbA1c, CVD history, T2D duration, clinical parameters and treatment history) were used in the DIAL model. Missing data were imputed by region using predicted mean matching. High risk was defined as 10-year risk >10%, and lifetime risk >50%.

Results

Data from 9457 patients with T2D aged 30–85 years were included in the analyses. There was a wide distribution of both 10-year and lifetime risk, with higher risk in patients with a history of CVD (n=2914) than in those without (n=6543). Among patients with a history of CVD, 96% had a 10-year risk of CVD >10% and 81% had a lifetime risk of CVD >50% (Figure). In patients with CVD and a high 10-year risk of recurrent CVD, 81% had a lifetime risk of recurrent CVD >50%. In patients without history of CVD, 14% had a 10-year risk >10% and only 1% had a lifetime risk >50% (Figure). Among patients without previous CVD but with a high 10-year risk of CVD, only 4% had a lifetime risk >50%. Of the patients with CVD, 10% received a GLP-1 RA and 18% received an SGLT-2i. Similarly, of patients with CVD and a high 10-year risk of recurrent CVD, 10% received a GLP-1 RA and 17% received an SGLT-2i. Among patients without CVD, 11% received a GLP-1 RA and 16% received an SGLT-2i, and among patients without current CVD but at a high 10-year risk of CVD, 12% received a GLP-1 RA and 16% received an SGLT-2i.

Conclusion

There is a wide distribution of CVD risk in the CAPTURE population, and only a minority of patients at high risk of CVD received a glucose-lowering agent with demonstrated benefit in CV risk reduction. Discussing with patients the 10-year and lifetime risks, and the CV benefit to be gained from interventions, can enhance shared decision making.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Funded by Novo Nordisk A/S

Inherited predisposition to colorectal adenomas caused by multiple rare alleles of MUTYH but not OGG1, NUDT1, NTH1 or NEIL 1, 2 or 3

BACKGROUND

MUTYH-associated polyposis (MAP) is a recessive trait characterised by multiple colorectal adenomas and a high risk of colorectal cancer. MUTYH functions in the DNA base excision repair pathway and has a key role in the repair of oxidative DNA damage.

OBJECTIVES

To assess the contribution of inherited variants in genes involved in base excision repair and oxidative DNA damage including MUTYH, OGG1, NEIL1, NEIL2, NEIL3, NUDT1 and NTH1 to the multiple colorectal adenoma phenotype.

METHODS

Inherited variants of MUTYH, OGG1, NEIL1, NEIL2, NEIL3, NUDT1 and NTH1 were sought in 167 unrelated patients with multiple colorectal adenomas whose family histories were consistent with recessive inheritance. These variants were also characterised in approximately 300 population controls.

RESULTS

Thirty-three patients (20%) and no controls were MUTYH homozygotes or compound heterozygotes (ie, carried two mutations) and therefore had MAP. Eight different pathogenic MUTYH mutations were identified, of which four were novel. MAP cases had significantly more adenomas than non-MAP cases (p = 0.0009; exact test for trends in proportions) and presented earlier (p = 0.013; analysis of variance). Twenty-four protein-altering variants were identified upon screening of OGG1, NEIL1, NEIL2, NEIL3, NUDT1 and NTH1. However, all combinations of two (or more) variants that were identified at an individual locus in patients were also seen in controls, and no variants were significantly over-represented (or under-represented) in cases.

CONCLUSION

Multiple rare alleles of MUTYH are associated with autosomal recessive MAP, while OGG1, NEIL1, NEIL2, NEIL3, NUDT1 and NTH1 do not contribute significantly to autosomal recessive polyposis.

Effect of luteinizing hormone (LH), pregnancy specific protein B (PSPB), or arachidonic acid (AA) on ovine endometrium of the estrous cycle or placental secretion of prostaglandins E2 (PGE2) and F2alpha (PGF2alpha) and progesterone in vitro

The objective of this experiment was to determine the effect of AA, LH, or PSPB on secretion of PGE2, PGF2alpha, or progesterone by ovine caruncular endometrium of the estrous cycle or placental tissue of pregnancy in vitro. Ovine caruncular endometrium of the estrous cycle (days 8, 11, 13, and 15) or caruncular/placental tissue on days 8, 11, 13, 15, 20, 30, 40, 50, 60, and 90 postbreeding were incubated in vitro with vehicle, AA, LH, or PSPB in M-199 for 4 and 8 h. Secretion of PGF2alpha by caruncular endometrium of non-bred ewes on days 13 and 15 and by caruncular/placental tissue of bred ewes on days 13, 15, 20, 30, and 40 was increased (P < or = 0.05) when incubated with vehicle and declined (P < or = 0.05) after day-40 in bred ewes. Secretion of PGF2alpha by day-15 caruncular endometrium of non-bred ewes and bred ewes was increased (P < or = 0.05) by AA on days 13 and 15 and by LH on day-15. Secretion of PGF2alpha by caruncular/placental tissue from bred ewes was (P < or = 0.05) by AA on days 13, 15, 20, 30, and 40 and by LH on days 15, 20, 30, and 40, after which the response decreased (P < or = 0.05). Secretion of PGF2alpha by caruncular endometrium of non-bred ewes during the estrous cycle or by caruncular/placental tissue of bred ewes during the first trimester was not affected by PSPB (P > or = 0.05). Secretion of PGE2 by caruncular endometrium of non-bred ewes did not change (P > or = 0.05) and was increased (P < or = 0.05) by caruncular/placental tissue on days 13-90 from bred ewes when incubated with vehicle. Secretion of PGE2 by endometrium from non-bred ewes was not affected (P > or = 0.05) by AA, LH, or PSPB, but was increased (P < or = 0.05) by AA or LH on days 13-50 and by PSPB on days 60 and 90 when incubated with caruncular/placental tissue from bred ewes. Secretion of progesterone by placental tissue of bred ewes increased (P < or = 0.05) on day-50 and continued to increase through day-90. In summary, uterine/placental tissue secretion of PGF2alpha is not reduced until the end of the first trimester of pregnancy in ewes. In addition, LH appears to play a role in luteolysis of non-bred ewes by stimulating caruncular endometrial secretion of PGF2alpha and on day-5 postbreeding to prevent luteolysis during early pregnancy by stimulating caruncular/placental secretion of PGE2 throughout the first trimester of pregnancy in sheep. Secretion of PGE2 by caruncular/placental tissue after day-50 of pregnancy appears to be regulated by PSPB, not LH.