The Cardiovascular Department, Chang Gung Memorial Hospital at Linkou, Taoyuan City 333, Taiwan.
College of Medicine, Chang Gung University, Taoyuan City 333, Taiwan.
J Clin Endocrinol Metab. 2024 Sep 16;109(10):2617-2629. doi: 10.1210/clinem/dgae157.
The coexistence of diabetes mellitus and atrial fibrillation (AF) is associated with substantial risks of adverse cardiovascular events.
The relevant outcomes associated with the use of a sodium-glucose cotransporter-2 inhibitor (SGLT2i) vs glucagon-like peptide-1 receptor agonists (GLP-1RAs) among patients with type 2 diabetes (T2D) with/without concomitant AF remain unknown.
In this nationwide retrospective cohort study from the Taiwan National Health Insurance Research Database, there were 344 392 and 31 351 patients with T2D without AF, and 11 462 and 816 T2D patients with AF treated with SGLT2is and GLP-1RAs, respectively, from May 1, 2016, to December 31, 2019. Patients were followed from the drug index date until the occurrence of study events, discontinuation of the index drug, or the end of the study period (December 31, 2020), whichever occurred first. We used propensity score-stabilized weight to balance covariates across the 2 medication groups.
The incidence rate of all study outcomes in patients with concomitant AF was much higher than in those without concomitant AF. For the AF cohort, SGLT2i vs GLP-1RA was associated with a lower risk of hospitalization for heart failure (HF) (2.32 vs 4.74 events per 100 person-years; hazard ratio [HR] 0.48, 95% CI 0.36-0.66), with no benefit seen for the non-AF cohort (P for homogeneity < .01). SGLT2i vs GLP-1RA was associated with a lower risk of composite kidney outcomes both in the AF (0.38 vs 0.79 events per 100 person-years; HR 0.47; 95% CI 0.23-0.96) and the non-AF cohorts (0.09 vs 0.18 events per 100 person-years; HR 0.53; 95% CI 0.43-0.64). There were no significant differences in the risk of major adverse cardiovascular events and all-cause mortality in those who received SGLT2i compared with GLP-1RA for the AF or non-AF cohorts.
Considering the high risk of developing HF and/or high prevalence of concomitant HF in patients with concomitant diabetes and AF, whether SGLT2is should be the preferred treatment to GLP-1RAs for such a high-risk population requires further investigation.
糖尿病和心房颤动（AF）共存与不良心血管事件的发生风险显著增加有关。
在伴有或不伴有 AF 的 2 型糖尿病（T2D）患者中，使用钠-葡萄糖共转运蛋白 2 抑制剂（SGLT2i）与胰高血糖素样肽-1 受体激动剂（GLP-1RAs）相关的相关结局尚不清楚。
本研究是一项来自台湾全民健康保险研究数据库的全国性回顾性队列研究，纳入了 2016 年 5 月 1 日至 2019 年 12 月 31 日期间分别接受 SGLT2i 和 GLP-1RAs 治疗的 344392 例无 AF 的 T2D 患者和 11462 例伴有 AF 的 T2D 患者。从药物索引日期开始随访，直至研究事件发生、索引药物停药或研究期结束（2020 年 12 月 31 日），以先发生者为准。我们使用倾向评分稳定权重来平衡两组药物之间的协变量。
在伴有 AF 的患者中，所有研究结局的发生率均明显高于不伴有 AF 的患者。对于 AF 队列，与 GLP-1RA 相比，SGLT2i 与心力衰竭（HF）住院风险降低相关（每 100 人年 2.32 与 4.74 次事件；风险比[HR]0.48，95%CI0.36-0.66），但在非 AF 队列中未观察到获益（P ＜0.01，组间同质检验）。SGLT2i 与 AF（每 100 人年 0.38 与 0.79 次事件；HR0.47；95%CI0.23-0.96）和非 AF 队列（每 100 人年 0.09 与 0.18 次事件；HR0.53；95%CI0.43-0.64）的复合肾脏结局风险降低相关。在 AF 或非 AF 队列中，与 GLP-1RA 相比，SGLT2i 并未降低主要不良心血管事件和全因死亡率的风险。
鉴于伴有糖尿病和 AF 的患者发生 HF 的风险较高和/或同时伴有 HF 的患病率较高，对于此类高危人群，SGLT2i 是否应作为 GLP-1RA 的首选治疗方法，还需要进一步研究。
