Weight-Loss Medications Should Be Part of Cardiology’s Arsenal: ACC

Cardiologists should “embrace” managing care for patients with obesity and become more comfortable with prescribing the new weight-loss therapies, particularly given the prevalence of obesity and its impact on cardiovascular disease.

That’s the message from a new expert consensus statement issued by the American College of Cardiology, which was chaired by Olivia Gilbert, MD (Wake Forest University School of Medicine, Winston-Salem, NC), and published recently in JACC.

“These emerging therapies are becoming highly relevant to our patient population,” Martha Gulati, MD (Cedars-Sinai Medical Center, Los Angeles, CA), vice chair of the writing committee, told TCTMD. “The reason we wrote this paper was really to provide a simple tool and to summarize the evidence in a short, concise way to help our colleagues in the cardiovascular field feel more comfortable [with the weight-loss medications].”

While lifestyle changes remain the foundation of obesity management, patients shouldn’t be obligated to fail in their weight loss effort with diet and exercise before these therapies are initiated, say the experts.

“There is still a lot of stigma around excess weight,” said Gulati, noting that “move more, eat less” is often pushed as the solution. “We have to recognize [obesity] as a risk factor for cardiovascular disease and recognize it as its own chronic disease. It’s not that lifestyle doesn’t work. It does work in some patients, but the problem is adhering to it. Long-term has always been a challenge. Even the amount of weight loss that you get with lifestyle, particularly for people with severe obesity, is not enough to lower cardiovascular risk.”

The consensus statement, which is not a guideline recommendation, is intended to help inform cardiologists about an area of medicine that is relatively new for them, and to help them become involved in the management of obesity. In settings where they might not feel completely at ease, it’s also intended to help them refer patients to appropriate physicians who can manage their weight loss, said Gulati.

CVD Outcome Trials

The new document outlines the complex causes of obesity and the risks associated with it, including atherosclerotic cardiovascular disease, heart failure, atrial fibrillation, sudden cardiac death, venous thromboembolism, and valvular heart disease. “Obesity-related mechanisms result in hemodynamic, functional, and structural changes to the cardiovascular system, which contribute to the development of these disparate forms of CVD,” the experts write.

It also outlines the rationale and eligibility for medical therapy, such as the more recent drugs approved by the US Food and Drug Administration: the glucagon-like peptide-1 (GLP-1) receptor agonists semaglutide (Wegovy; Novo Nordisk) and liraglutide (Saxenda; Novo Nordisk), and the GLP-1/glucose-dependent insulinotropic polypeptide (GIP-1) receptor agonist tirzepatide (Zepbound; Eli Lilly).

The statement also recaps the evidence supporting the use of the new medications, such as LEADER and SUSTAIN-6 in patients with obesity, type 2 diabetes, and cardiovascular disease (or high risk for CVD), as well as SELECT and STEP-HFpEF for patients with obesity but without type 2 diabetes. For patients without diabetes, only semaglutide has been shown to reduce the risk of major adverse cardiovascular events, although the ongoing SURMOUNT-MMO trial is currently testing tirzepatide for CVD event reduction in overweight people with established disease.

These emerging therapies are becoming highly relevant to our patient population. Martha Gulati

To TCTMD, Gulati noted just how rapidly the treatment of obesity is changing. At the American Diabetes Association’s 85^th Scientific Sessions this past weekend, there were numerous studies showing that newer agents, some of them combination therapies, were effective at reducing body weight in patients with and without diabetes. For example, the REDEFINE 1 and 2 trials highlighted the effectiveness of combination therapy with a long-acting amylin analogue and GLP-1 receptor agonist, as did early data from a phase II study testing a once-monthly GLP-1/GIP receptor agonist.  

Right now, however, none of these newer agents are FDA approved. “The amount of evidence is still small, but we all know that’s changing overnight,” said Gulati.

Goals of Treatment

When it comes to weight loss, changes in lifestyle typically result in a 5% reduction in body weight and improvements in triglycerides, blood pressure, and fasting glucose levels. The newer GLP-1 and GLP-1/GIP agents have been shown to reduce body weight by 15% and 20%, respectively, while metabolic surgery remains the most effective weight-loss tool, capable of reducing body weight by 20% to 25%.

Management of obesity should remain a multidisciplinary approach, with coordinated care to address modifiable risk factors, potential comorbidities that may impact treatment, and to tailor therapy, according to the ACC statement. The goals of weight-loss treatment should be to achieve at least a 5% reduction in body weight, improve CVD risk factors, and prevent incident disease. While weight-loss medications can be deescalated as needed, “long-term treatment should be the default plan,” according to the writing committee.

“I think we've given [cardiologists] tools that they can use or refer to experts if they're not comfortable,” said Gulati. “There may be some subspecialists in cardiology who may still feel like they're not comfortable enough yet with these drugs, but knowing that they're indicated and who they're indicated for will help them in their practice, whether it's referring [patients] to a preventive cardiologist or an obesity specialist.”

For patients, having a cardiologist involved in weight management can be important as it shows them the concern is not simply about weight, but about reducing the risk of future cardiac events.