From the Guidelines
The patient with Acute Coronary Syndrome (ACS) and three-vessel disease, Type 2 Diabetes Mellitus (DM 2) with uncontrolled hyperglycemia (HbA1c 9.5) may benefit from Farxiga (dapagliflozin) before Coronary Artery Bypass Grafting (CABG), as it is recommended in patients with T2DM and CVD, or at very high/high CV risk, to reduce CV events 1.
Benefits and Considerations
The benefits of using Farxiga in this patient include:
- Improved glycemic control without hypoglycemia risk
- Potential cardioprotective effects
- Possible reduction in heart failure risk The SGLT2 inhibitor mechanism reduces glucose reabsorption in the kidneys, promoting urinary glucose excretion while offering cardioprotection through multiple pathways including reduced cardiac preload, improved myocardial energetics, and anti-inflammatory effects. Important considerations include:
- Monitoring for genital infections, urinary tract infections, and volume depletion, especially in the perioperative period
- Renal function should be assessed before initiation, and the medication should be used cautiously if eGFR is below 45 ml/min/1.73m²
Dosage and Timing
The medication should be started at 10 mg once daily, ideally at least 3-5 days before surgery if the clinical situation allows. However, Farxiga should be discontinued 24-48 hours before the CABG procedure to minimize perioperative risks.
Guideline Recommendations
According to the 2024 ESC guidelines for the management of chronic coronary syndromes, CABG is recommended over medical therapy alone to improve symptoms and outcomes in patients with significant three-vessel disease and diabetes 1.
Additional Considerations
Aspirin and other antiplatelet therapies are also important considerations in the management of patients with ACS and three-vessel disease, as they can reduce the risk of mortality, MI, stroke, renal failure, and bowel infarction 1. ACE inhibitors and angiotensin-receptor blockers are also recommended before CABG to improve outcomes 1.
From the Research
Patient Profile
- The patient has Acute Coronary Syndrome (ACS) and three-vessel disease.
- The patient also has Type 2 Diabetes Mellitus (DM 2) with uncontrolled hyperglycemia (HbA1c 9.5).
Treatment Considerations
- The patient is scheduled to undergo Coronary Artery Bypass Grafting (CABG).
- The question is whether the patient would benefit from Farxiga (dapagliflozin) before CABG.
Relevant Studies
- A study published in 2024 2 found that early initiation of sodium-glucose cotransporter-2 inhibitors (SGLT2i) in patients with type 2 diabetes who experienced ACS and underwent CABG was not associated with a reduction in Major Adverse Cardiovascular Events (MACE).
- However, another study published in 2016 3 discussed the clinical evidence and rationale for the use of dapagliflozin as add-on therapy in type 2 diabetes, highlighting its benefits in improving glycemic control, weight loss, and low risk of hypoglycemia.
- A multicenter retrospective study published in 2020 4 found that the use of dapagliflozin was associated with significant improvement in glycemic control, body weight, and blood pressure in patients with type 2 diabetes.
- A study published in 2012 5 examined the safety and efficacy of dapagliflozin added on to pioglitazone in type 2 diabetes inadequately controlled on pioglitazone, and found that dapagliflozin further reduced HbA1c levels and mitigated the pioglitazone-related weight gain without increasing hypoglycemia risk.
CABG Considerations
- A study published in 2022 6 discussed the use of CABG for Acute Coronary Syndrome, highlighting its benefits in complete revascularization, especially for patients with multiple vessel disease, and its comparable operative mortality and better long-term survival rate compared to percutaneous coronary intervention (PCI).
Potential Benefits of Dapagliflozin
- Dapagliflozin may help improve glycemic control and reduce the risk of hypoglycemia in patients with type 2 diabetes.
- It may also have benefits in terms of weight loss and blood pressure reduction.
- However, its effect on MACE in patients with ACS and three-vessel disease undergoing CABG is unclear, as the study published in 2024 2 found no association between early initiation of SGLT2i and reduction in MACE.