What is the management strategy for hyperglycemia and Atherosclerotic Cardiovascular Disease (ASCVD) in a 56-year-old obese male with Diabetes Mellitus (DM) and angina on exertion?

Management Strategy for Hyperglycemia and ASCVD in a 56-Year-Old Obese Male with Diabetes Mellitus

For this 56-year-old obese male with diabetes mellitus of 6 years duration presenting with angina on exertion, uncontrolled hypertension, poor glycemic control, and dyslipidemia, aggressive multitargeted therapy addressing hyperglycemia, hypertension, and dyslipidemia with medications that have proven cardiovascular benefits is essential.

Glycemic Management

• First-line therapy: Metformin should be continued or initiated as the cornerstone of treatment due to its established efficacy, safety profile, and cardiovascular benefits 1, 2
• Add an SGLT2 inhibitor with demonstrated cardiovascular benefit to reduce the risk of major adverse cardiovascular events and heart failure hospitalization 1
• Add a GLP-1 receptor agonist with proven cardiovascular benefit to further reduce the risk of major adverse cardiovascular events 1
• Consider combination therapy with both SGLT2 inhibitor and GLP-1 receptor agonist for additive reduction of cardiovascular and kidney events 1
• Target HbA1c <7% to improve glycemic control while avoiding hypoglycemia, with individualization based on comorbidities 1
• Monitor HbA1c every 3-6 months until target is achieved, then at least twice yearly 3

Lipid Management

• High-intensity statin therapy is recommended as first-line treatment to achieve LDL-C goal of <1.4 mmol/L (55 mg/dL) and >50% reduction from baseline 1
• Add ezetimibe if LDL-C target is not achieved with maximally tolerated statin therapy 1
• Consider PCSK9 inhibitor if LDL-C target is still not achieved after maximally tolerated statin and ezetimibe 1
• For statin-intolerant patients, consider bempedoic acid alone or in combination with a PCSK9 inhibitor 1
• Monitor lipid profile at initiation of statin therapy, 4-12 weeks after initiation or dose change, and annually thereafter 1

Blood Pressure Management

• Target blood pressure <130/80 mmHg for patients with diabetes and established cardiovascular disease 1, 3
• First-line therapy: ACE inhibitor or ARB to reduce cardiovascular events and mortality 1, 3
• Add a thiazide diuretic as second-line therapy 1
• Consider calcium channel blocker as third-line therapy, being mindful of potential peripheral edema in older adults 4
• Add a mineralocorticoid receptor antagonist (MRA) if blood pressure remains uncontrolled on three classes of antihypertensive medications including a diuretic 1
• Monitor serum creatinine and potassium after initiation of ACE inhibitor/ARB/MRA therapy and following dose adjustments 1, 3

Antiplatelet Therapy

• Aspirin therapy (75-162 mg daily) is recommended for secondary prevention in patients with established ASCVD 1
• Consider P2Y12 inhibitor in addition to aspirin for patients with recent acute coronary syndrome or percutaneous coronary intervention 1

Cardiac Evaluation and Management

• Cardiac stress testing is indicated for this patient with anginal symptoms to assess for obstructive coronary artery disease 1
• Consider coronary angiography based on stress test results and severity of symptoms 1
• Beta-blocker therapy should be initiated for angina control and secondary prevention if myocardial infarction is confirmed 1

Lifestyle Modifications

• Mediterranean or DASH eating pattern with reduced saturated and trans fats, increased n-3 fatty acids, viscous fiber, and plant stanols/sterols 1
• Regular physical activity: 30-60 minutes of moderate-intensity exercise most days of the week, as tolerated given anginal symptoms 1
• Weight loss goal: 5-10% of body weight through caloric restriction and increased physical activity 1
• Smoking cessation if applicable, with pharmacotherapy and behavioral support 1

Follow-up Plan

• Regular monitoring of glycemic control, blood pressure, and lipid parameters every 3 months until targets are achieved 3
• Screen for other diabetes complications including nephropathy, retinopathy, and neuropathy 1
• Evaluate for peripheral arterial disease with ankle-brachial index testing given the patient's age and diabetes status 1

Pitfalls and Caveats

• Avoid therapeutic inertia: This patient has multiple uncontrolled risk factors requiring prompt, aggressive intervention 5
• Monitor for medication interactions between antihyperglycemic, antihypertensive, and lipid-lowering therapies 1
• Watch for hypoglycemia when combining multiple glucose-lowering agents, especially if beta-blockers are added for angina 1
• Be alert for heart failure symptoms as patients with diabetes and ASCVD are at increased risk 1
• Consider kidney function when prescribing medications, particularly metformin, SGLT2 inhibitors, and certain antihypertensives 3