Use of cardioprotective glucose lowering therapy before and after myocardial infarction among patients with type-2 diabetes: a nationwide registry study

Abstract Background According to guidelines the cardioprotective sodium-glucose co-transporter 2 inhibitors (SGLT2i) and glucagon-like peptide-1 receptor agonists (GLP1-RA) should be considered for patients with type-2 diabetes mellitus (T2DM) at high risk for atherosclerotic cardiovascular disease and are strongly recommended for T2DM patients after a myocardial infarction (MI). How well these recommendations are implemented in clinical practice is unclear. Purpose The aim of this study was to analyse time trends in prescription of cardioprotective glucose lowering treatment in an unselected national cohort of patients with MI and T2DM before and after their acute event. Methods All patients 80 years of age admitted with a MI between 2020-2023 and registered in the Swedish MI-registry SWEDEHEART were included (n=32,581). Time trends in prescription of cardioprotective glucose lowering medications at hospital admission, discharge, and at two follow-up visits (2-months and 1-year post-MI) were described. Further, associations between being prescribed SGLT2i and/or GLP1-RA and age, sex, history of heart failure, new-onset reduction in left ventricular ejection fraction (LVEF) post-MI and body mass index (BMI) were analysed in multiple logistic regression models. Results At MI admission, 6,768 (20.8%) patients had a diabetes diagnosis (any type) and an additional 219 (0.7%) were diagnosed during hospitalization (n total=6,987). Out of these 6,492 (92.9%) had T2DM (mean age 67.7±8.7 years, 75.4% male). During the study period, the proportion with ongoing SGLT2i and/or GLP1-RA treatment at admission increased from 20% in 2020 to 41% in 2023, most treated with SGLT2i (Figure 1). The same trend was seen at the one-year follow-up, with SGLT2i surpassing metformin in 2023 as the most commonly prescribed drug (Figure 1). While the proportion of patients prescribed SGLT2i markedly increased from admission to the one-year follow-up as well as over time, the same trend was not observed for GLP1-RA (Figure 2). Initiation of SGLT2i treatment during the first year post-MI was more common in men compared to women (odds ratio, 1.41, 95% confidence interval 1.21-1.66), in patients with a history of heart failure (1.45, 1.11-1.89) and in patients with new-onset LVEF reduction post-MI (2.88, 2.33-3.57). The likelihood of being prescribed a GLP1-RA was higher in overweight patients (2.52, 1.82-3.48). Still, only 22% of overweight patients with T2DM were prescribed a GLP1-RA at one-year in 2023. Older patients were less likely to receive any of the drugs (p0.0001). Conclusions Most patients with T2DM who suffer an MI are not treated with SGLT2i or GLP1-RA at the time of MI. Prescription of SGLT2i post-MI increased rapidly between 2020 and 2023 while the same trend was not observed for GLP-1RA, with obese patients and women being undertreated. The results indicate that the implementation of current guideline recommendations can be improved.Figure 1 Figure 2