According to the authors, the advent of the newer classes of antihyperglycemic agents, including SGLT2i and GLP-1ra, has changed the landscape of therapeutic options for patients with CKD and T2D. It has also demonstrated a significant reduction in cardiovascular adverse events and progression to end-stage kidney disease.

The authors note that several potential mechanisms exist through which these beneficial effects are achieved in both drug classes, which may be independent of their antihyperglycemic effects.

Also in the statement, the authors list several practical steps that may be undertaken to encourage safe and effective use of evidence-based antihyperglycemic therapies to lower cardiovascular disease and CKD risks, including identification of at-risk patients, selection of therapy, adjustment of concomitant therapies and deprescribing, patient counseling, and longitudinal follow-up.

Finally, as the broad health implications of T2D are recognized, the authors explain that multispecialty care models help promote targeted and equitable integration of these evidence-based therapies in clinical care, especially with support from health care systems and payers.

"With multidisciplinary efforts from primary care physicians, cardiologists, nephrologists, endocrinologists, pharmacists, advanced practitioners and other allied health professionals toward providing targeted therapies for cardiovascular disease and CKD risk reduction in patients with T2D, there is opportunity to meaningfully reduce morbidity, mortality and health care expenditures for this vulnerable patient population," the authors conclude.

Rangaswami J, Bhalla V, de Boer IH, et al. Circulation 2020;142:e265-e286.

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The primary outcome was the time to first MACE. Secondary outcomes included the composite of hospitalization for heart failure (HF) or cardiovascular death and each component, all-cause mortality and a composite of kidney outcomes. Of the 46,969 patients included in the study, 66.2% had atherosclerotic cardiovascular disease (ASCVD). The mean age of patients was 63.7, 65.9% were male and 78.5% were white.

Results showed that SGLT2i were associated with reduced risk of MACE, hospitalization for HF, cardiovascular death and kidney outcomes, "with no significant heterogeneity of associations with outcome."

Researchers also found that associated risk reduction for hospitalization for HF was consistent across the trials and significant heterogeneity of associations with outcomes was observed for cardiovascular death. Further, they found the presence or absence of ASCVD had no effect on the association with outcomes for MACE, hospitalization for HF, cardiovascular death or kidney outcomes.

"Across the class, there are robust and consistent associations with reduction in risk for HF [hospitalization], independent of baselines ASCVD status or kidney function," write McGuire, et al. "These data support contemporary society recommendations to prioritize the use of SGLT2 inhibitors with demonstrated outcomes, independent of glucose control considerations, in patients with [T2D] with or at high risk for [cardiovascular] and kidney complications."

McGuire DK, Shih WJ, Cosentino F, et al. JAMA Cardiol 2020;Oct 7:[Epub ahead of print].

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The statement examines the minority stressors (intrapersonal, interpersonal and structural) and general life stressors that LGBTQ adults face because of their sexual orientation and gender identity and how understanding these stressors is essential to develop and tailor cardiovascular interventions for LGBTQ adults.

The statement also summarizes existing research on the cardiovascular health of LGBTQ adults by examining data on the population's tobacco use, physical activity, diet, body mass index, blood pressure, glycemic status, total cholesterol and lipids, additional risk factors and cardiovascular disease.

"[Future] research should use qualitative and mixed methods to identify and develop culturally appropriate interventions for [cardiovascular disease] risk reduction in LGBTQ adults," write the authors. They add that "LGBTQ health content should be incorporated into health professions curricula, and LGBTQ-related accreditation and licensure requirements are needed."

Caceres BA, Streed Jr CG, Corliss HL, et al. Circulation Oct 8:[Epub ahead of print].

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Srinath Adusumalli, MD, MSc, FACC, et al., evaluated the effect of passive choice and active choice interventions in the EHR to promote guideline-directed statin therapy with 82 cardiologists and 11,693 patients at 16 different cardiology practices.

In the passive choice option, cardiologists had to manually access an alert embedded in the EHR to select options to initiate or increase statin therapy. In the active choice option, an interruptive EHR alert prompted the cardiologist to accept or decline guideline-directed statin therapy.

This three-arm randomized clinical trial included a six-month preintervention period and six-month intervention, and data was analyzed between May 8, 2019, and Jan. 9, 2020.

Results showed that baseline statin prescribing rates at the optimal dose were 40.3% in the control arm, 39.1% in the passive choice arm and 41.2% in the active choice arm. In adjusted analyses, the authors found that change in statin prescribing rates at optimal dose over time was not significantly different from control for passive choice or active choice.

In adjusted analyses of the subset of patients with clinical atherosclerotic cardiovascular disease, the authors found that active choice intervention resulted in a significant increase in statin prescribing at optimal dose relative to control.

"Further study is needed to evaluate the active choice intervention among patients with clinical atherosclerotic cardiovascular disease, and future interventions could focus on ways to improve the design of active choice and combine it with other approaches to further improve statin prescribing," the authors conclude.

In an accompanying editorial comment, Thomas M. Maddox, MD, MSc, FACC, notes that "although the Adusumalli, et al., study did not result in improved statin prescription, it did provide another, equally important result: learning." He adds, "These insights are valuable contributions to our collective knowledge and move us closer to the EHR potential of effective clinical decision support."

Adusumalli S, Westover JE, Jacoby DS, et al. JAMA Cardiol 2020;Oct 7:[Epub ahead of print].

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The individual psychosocial resilience assessed environmental mastery, purpose in life, optimism, resilient coping and depressive symptoms. Neighborhood-level cardiovascular resilience was separately determined by the census tract-level rates of cardiovascular mortality/ morbidity events.

Results showed that higher individual psychosocial resilience was significantly associated with higher LS7 scores (β=0.38 [0.16 – 0.59] per 1 SD) after adjustment for sociodemographic factors.

Similarly, higher neighborhood-level cardiovascular resilience was significantly associated with higher LS7 scores (β=0.23 [0.02 – 0.45] per 1 SD).

When jointly examined, the authors found that high individual psychosocial resilience was independently associated with higher LS7 scores (β=0.73 [0.31 – 1.17]), whereas living in high-resilience neighborhoods was not.

The authors note the largest difference in LS7 scores was between those with high and low psychosocial resilience living in low-resilience neighborhoods (8.38 [7.90 – 8.86] vs. 7.42 [7.04 – 7.79]).

"Further research into the mechanistic links underlying our observed associations is needed to derive more specific insights into developing novel and effective intervention strategies to improve cardiovascular health of Black adults and other vulnerable populations," the authors conclude.

"Promoting resilience in Black people insinuates that injustice must be overcome without fully acknowledging any associated trauma," write Amber E. Johnson, MD, MS, MBA, FACC, and Jared W. Magnani, MD, MS, in a related editorial comment. "Instead, the goal should be to work with communities that have been historically marginalized or made vulnerable to restore agency for positive outcomes. We advocate for promoting health equity and social justice first, thereby rendering interventions to bolster resilience unnecessary."

Kim JW, Islam SJ, Topel ML, et al. Circulation Cardiovasc Qual Outcomes 2020;Oct 7:[Epub ahead of print].

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