My Top Stories in Cardiology for 2023
Medscape published my year-end review. In a series of posts I will comment further on my choices.
Each year, I’ve done a Top-Ten recap of what I feel are the biggest stories of the year.
The entire piece is over at theHeart.org | Medscape Cardiology—which is a site for medical professionals.
Here at Stop and Think, I will show you what I wrote for each topic and then add a bit of general commentary. I will do one topic per newsletter and send out a post every other day or so. This is not really a rank order. Except for the first choice—which I feel is the biggest story.
My Choice for Top Cardiology Story of 2023
Obesity Treatments:
Here is what I wrote:
Hyperbole is almost impossible when describing the potential benefits of the glucagon-like peptide-1 (GLP-1) receptor agonists. Obesity is that big of a problem.
The biggest breakthrough of the year for this drug class came in the SELECT trial. Semaglutide reduced cardiovascular outcomes in patients with established cardiovascular disease and obesity but without diabetes. SELECT turned semaglutide into a cardiac drug.
Two meta-analyses suggested that the dual GLP-1a and glucose-dependent insulinotropic polypeptide (GIP) receptor agonist tirzepatide is the more potent weight-reducing agent, but the sure-to-come cardiovascular indication will probably make semaglutide more popular, at least initially. I'd bet on a class effect regarding cardiac protection.
The placebo-controlled STEP-HFpEF trial of semaglutide in patients with obesity and heart failure with preserved ejection fraction (HFpEF) was unblinded and too small to conclude much about outcomes but at least hinted at safety in HFpEF.
Downsides include gastrointestinal intolerance and costs. And the just-published results of the SURMOUNT-4 withdrawal trial underscores the challenge of weight regain when the drugs are stopped.
This drug class may be the biggest story in medicine of the past 10 years.
I get the sense from writing publicly about this topic that many of you have trouble with this new drug class.
The struggle, I think, is that obesity ought to be controllable with diet and exercise. Most striking to me was my visit to Oslo Norway this year. I saw almost no obesity. Norwegians—at least those wealthy enough to hang out in Oslo—were fit and trim.
But the US is not Norway. Obesity is one of our top public health problems. It is a leading cause of illness and early death, often via cardiovascular disease.
Telling people to eat less, eat better, and exercise more hasn’t worked. The removal of gym class in schools, the dependence on cars, and the absence of neighborhoods safe for walking and cycling have contributed to the problem.
Doctors, however, can’t change policy or societal norms. Our job is to treat people with illness who ask for our help.
The GLP-1a drug class has passed muster in multiple clinical trials. We know that it lowers the rate of adverse cardiac outcomes in patients with diabetes. Recent data shows that it induces serious wight loss in patients with obesity.
And the SELECT trial showed that it actually reduced adverse cardiac outcomes in patients without diabetes. That is a major advance.
Yes, there are adverse effects, such as slow transport through the gut. And the drug will be costly. Most problematic is the clear signal of weight gain after stopping the drug.
Yet I would estimate that at least 2/3rds of the patients I see every day in this medium-sized American city are either obese or overweight. Now I have a drug that can help people lose weight and avoid adverse cardiac outcomes. It isn’t perfect. It doesn’t transform them into skinny Norwegians. But it is a proven treatment, at least in the short term.
As an endurance exerciser, bike commuter, conscientious citizen and physician, I don’t advocate that we replace societal measures with a drug class. We should continue to advocate for policy change to make our neighborhoods and food sources healthy.
But as a doctor who treats people with illness I see the GLP1a drug class as a major advance in the reduction of heart disease.
Eat less and work more. The 2 sec platitude as patients walk out to be checked out while their obese inflamed body sets them up for the next MACE. I was on the medical board of one meal replacement company and involved with a similar company. These programs work BUT of every 10 patients that very engaged physicians pleaded with to consider trying only 1 started. Of every 10 who started 7 did lose weight and keep it off . But what happened to the 93% of the obese patients who did nothing ? They were the farm of patients funding the practice with never ending imaging and ultimately invasive procedures. The drugs stop the food noise and give patients their life back . The advent of processed sugar and the bait and switch of its " cholesterol " ignore the sugar in the soda - poisoned several generations who are now addicted. The GLPs will result in more people ultimately eating less and walking more if only they are available at a rational price and are prescribed.
If there are physician and cardiologist readers here who are not aware of “this week in cardiology” on Medscape, I suggest adding that to your weekly reading “diet” asap. If there is a way to learn more in 10-15 minutes of reading a week, I haven’t found it.
I think the issue of GLP-1 RA’s is now less of a medical question (the evidence is already solid in a number of cardiac conditions as mentioned, although not for HFpEF), and more of a societal dilemma wrt “access”….both in terms of drug supply, and affordability (both individually, and as a society). To answer the latter question, I hope there will be cost effectiveness analyses moving forward, to allow us to properly slot this drug class in the hierarchy of societal priorities (at least in the realm of drug access).
As for lingering medical questions, we need long term data and data on children (since it’s been noted by Dr. Prasad on Sensible Med that this class is being pushed on kids, absent evidence). And we also need to be mindful of indication creep….SELECT was a secondary prevention population with BMI over 27… but if you think people aren’t going to be clamouring for it in primary prevention, have I got a great deal on a bridge for you! That kind of usage creep occurs on the regular, but in the context of limited drug supply, there is a squishier question of whether people who want it (purely for “vanity” reasons) should be given it when someone else has higher medical need for same, regardless of the ability to pay.