Source: Yimaitong Clinical Guidelines
In recent years, new glucose-lowering drugs glucagon-like peptide-1 receptor agonists (GLP-1 RA, such as liraglutide, semaglutide, and dulaglutide) and sodium-glucose cotransporter 2 inhibitors (SGLT2i, such as empagliflozin, dapagliflozin, and canagliflozin) have been shown to have clear cardiovascular benefits in patients with type 2 diabetes and further reduce the risk of cardiovascular events. The Expert Consensus on Blood Glucose Management in Patients with Coronary Heart Disease and Type 2 Diabetes Mellitus provides standardized guidance for blood glucose management and comprehensive disease management in patients with coronary heart disease and type 2 diabetes mellitus.
Six hypoglycemic drugs had clear cardiovascular benefits
Glucose-lowering agents with clear cardiovascular benefits
Some glucagon-like peptide-1 receptor agonists (GLP-1 RAs), such as liraglutide, semaglutide, and dulaglutide, and some sodium-glucose cotransporter 2 inhibitors (SGLT2i), such as empagliflozin, dapagliflozin, and canagliflozin.
➤ Glucose-lowering drugs with potential cardiovascular benefits: metformin and pioglitazone.
➤ Hypoglycemic drugs with good cardiovascular safety but unclear cardiovascular benefit: dipeptidyl peptidase-4 inhibitors (DPP-4i), sulfonylureas (glimepiride, gliclazide), insulin glargine or insulin degludec, α-glycosidase inhibitors (acarbose), and other GLP-1RA (lisinatide, exenatide).
➤ Hypoglycemic drugs that have not been evaluated for cardiovascular safety: other insulins and other sulfonylureas.
Table 1 Antidiabetic drugs and cardiovascular benefits
Recommendation 1: All patients with coronary heart disease should be screened for diabetes
The consensus recommends that all patients with coronary heart disease be screened and evaluated for type 2 diabetes, and that fasting blood glucose and glycosylated hemoglobin (HbA1c) are preferred for diabetes screening indicators, and if both are not yet confirmed, oral glucose tolerance test (OGTT) should be considered.
糖尿病的诊断标准为：典型糖尿病症状（烦渴多饮、多尿、多食、不明原因体重下降）合并随机血糖≥ 11.1 mmol/L；或空腹血糖≥ 7.0 mmol/L；或 OGTT 2 h 血糖≥ 11.1 mmol/L；或 HbA1c ≥ 6.5%；无糖尿病典型症状者，需改日复查确认。
If screening for diabetes is not emphasized, a large proportion of patients will be missed. In patients with acute coronary syndrome (ACS), elevated blood glucose during hospitalization is common, regardless of whether diabetes is present or not, and is partly related to stress.
Table 2 Classification of glucose metabolism status
Core Recommendation 2: "Individualized" Glycemic Management Goals - 6.5%, 7%, 8.5%
➤ It is recommended that the HbA1c control target for most patients with coronary artery disease and diabetes mellitus be <7%, but the principle of individualization should be followed.
➤ In the absence of risk of hypoglycemia or other adverse effects, patients with type 2 diabetes who are younger, have a shorter course of illness, and have a longer life expectancy may be treated with a more stringent HbA1c control target (eg, < 6.5%).
➤ Patients with older age, longer course of disease, history of severe hypoglycemia, and short life expectancy can adopt a relatively relaxed HbA1c control target (which can be relaxed to <8.5%).
➤ For perioperative patients with ACS or coronary intervention (PCI) and diabetes mellitus, a tight glycemic control strategy has not been shown to be beneficial, but rather increases the risk of hypoglycemia, so a more lenient glycemic control range is recommended. The more severe the disease, the more lenient the goal should be. If the patient can tolerate it, it is recommended to control the blood glucose at 7.8~10.0 mmol/L on a fasting or preprandial basis.
Recommendation 3: Glycemic management for acute coronary syndrome (ACS).
Figure 1 Blood glucose management process for ACS patients
In the acute phase of glycemic management, we follow the core principle of effective control of hyperglycemia levels, while being vigilant and preventing the occurrence of hypoglycemia.
During hospitalization, patients should have their HbA1c levels checked regularly and blood glucose changes monitored closely to help distinguish between diabetes and stress hyperglycemia.
When a patient's blood glucose level exceeds 13.9 mmol/L, health care providers should pay special attention to measuring glucose and ketone levels in the urine to assess the patient's metabolic status.
For patients who are clinically stable, who eat regularly, and who do not contraindicate the use of oral glucose-lowering drugs, continuation of previous oral glucose-lowering drugs or glucagon-like peptide-1 receptor agonists (GLP-1 RAs) may be considered after admission. However, in other cases, treatment with subcutaneous insulin is preferred.
Patients with established diabetes mellitus and no contraindications to drug use should be treated with GLP-1 RA (e.g., liraglutide, semaglutide, and dulaglutide) and/or sodium-glucose cotransporter 2 inhibitors (SGLT2i, such as empagliflozin, dapagliflozin, and canagliflozin) with demonstrated cardiovascular benefits in addition to lifestyle interventions after stabilization.
Prevent hypoglycemia by combining other hypoglycemic drugs with other hypoglycemic drugs based on blood glucose levels. If the patient has only stress hyperglycemia or has not previously diagnosed diabetes mellitus, it is recommended that blood glucose and HbA1c be reassessed 2 weeks after stabilization to determine the presence of diabetes.
Recommendation 4: Chronic coronary syndrome (CCS) glycemic management
Figure 2 Blood glucose management process in patients with CCS
For patients with chronic coronary syndromes with diabetes mellitus, regardless of whether they meet criteria for HbA1c, initiation of drugs with a clear cardioprotective effect, such as glucagon-like peptide-1 receptor agonists (GLP-1 RAs, such as liraglutide, semaglutide, and dulaglutide), and/or sodium-glucose cotransporter 2 inhibitors (SGLT2i, such as empagliflozin, dapagliflozin, and canagliflozin), is recommended in the absence of contraindications.
For patients with heart failure, priority SGLT2i, including dapagliflozin, empagliflozin, and canagliflozin, is recommended to reduce the risk of hospitalization for heart failure. If further glycemic control is required despite SGLT2i therapy, a combination of GLP-1 RA may be considered.
For patients with concomitant chronic kidney disease (defined as structural or functional abnormalities of the kidneys lasting more than 3 months), priority should be given to those with SGLT2i or GLP-1 RA for whom there is evidence of cardiac and renal protection.
For patients with overweight or obesity, treatment should be prioritized for GLP-1 RAs with a proven weight-loss effect.
Different GLP-1 RAs differ in their weight-loss effects. For example, treatment with semaglutide 1.0 mg once a week for 40 weeks resulted in significant weight reduction, with an average reduction of up to 6.5 kg; In contrast, treatment with 1.8 mg liraglutide (once daily) for 26 weeks resulted in an average weight loss of 3.5 kg from baseline.
Recommendation 5: Perioperative blood glucose management with coronary intervention
In the case of elective PCI, it is usually not necessary to switch to insulin therapy in patients who have good glycemic control with oral glucose-lowering drugs. However, if preoperative glycemic control is poor, such as a fasting blood glucose level of more than 7.8 mmol/L, switching to insulin therapy is a viable option. Subcutaneous insulin is the preferred regimen for preoperative glycemic control.
During surgery, a continuous intravenous infusion regimen may be an option, while blood glucose levels need to be closely monitored and the rate of insulin infusion dynamically adjusted based on blood glucose results to ensure that blood glucose is kept within a safe range.
Glucose-lowering drugs, such as DPP-4i and GLP-1 RA, can be continued perioperatively due to their glycemic dependence and low risk of hypoglycemia due to their hypoglycemic effects.
On the other hand, SGLT-2i may cause hypovolemia and urinary tract infection, so it needs to be discontinued for 48 hours before PCI.
In addition, drugs that promote insulin secretion, including sulfonylureas and meglitinides, may increase the risk of hypoglycemia in a fasted state and should be discontinued before surgery.
Reference Sources:
Cardiovascular Disease Branch of China Association for the Promotion of International Exchange in Health Care. Expert consensus on blood glucose management in patients with coronary heart disease and type 2 diabetes mellitus[J]. Chinese Journal of Circulation, 2024, 39: 342-352.
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