The positive results from the SELECT trial for the glucagon-like peptide-1 receptor agonists (GLP-1 RAs) were hailed as ushering in a “new era for patients with obesity.” In the trial of overweight and obese patients with cardiovascular disease (CVD), but no diabetes, semaglutide showed meaningful reductions in cardiovascular death, myocardial infarction, and stroke compared with placebo.
“I definitely see increasing adoption of GLP-1 RAs by cardiologists and expect the number to increase now that the data support its use in secondary prevention,” said Nicole L. Lohr, MD, PhD, chair of the American College of Cardiology (ACC) Board of Governors, and Mary G. Waters, chair of cardiovascular medicine at UAB, Birmingham.
But many cardiologists are more hesitant. said American Heart Association (AHA) volunteer Chiadi E. Ndumele, MD, PhD, an associate professor at Johns Hopkins Medicine in Baltimore and chair of the AHA’s recent presidential advisory on cardiovascular-kidney-metabolic health.
“Weight loss hasn’t been a central focus in our practice until recently, with the advent of these more powerful agents. There’s a need for more education around not only the use of these agents, but also around initiating weight loss discussions in a nonjudgmental way that reflects the complexity of obesity as a condition with multifactorial causes.”
The process will take time and may be similar to what happened with statins, he suggests. “Statins started in the endocrinology space, but as their cardiovascular benefits became more clear, they were increasingly adopted by cardiologists, primary care physicians, and others.”
Eugene Yang, MD, chair of the ACC Prevention of CVD Council and codirector of UW Medicine’s Cardiovascular Wellness and Prevention Program in Seattle, agrees that GLP-1 uptake by cardiologists will likely be slow. “It’s a bit premature to start prescribing right away,” he said. “Semaglutide hasn’t been approved for secondary prevention at this point, and until it’s approved specifically for that indication, I don’t think many cardiologists will prescribe it.”
Side Effects ‘Concerning’
Beyond the requisite approval, Dr. Yang is concerned about side effects such as gastroparesis, severe nausea, and vomiting. “I’m not sure cardiologists are going to feel comfortable helping patients deal with these effects.”
Because GLP-1 RAs are already being used widely in primary care, he says, “I personally would work in collaboration with either my primary care colleagues or with endocrinologists.”
Ambarish Pandey, MD, an associate professor of internal medicine (cardiology) and medical director of the heart failure with preserved ejection fraction (HFpEF) program at UT Southwestern Medical Center, Dallas, is already prescribing semaglutide to patients with HFpEF and obesity. “In terms of side effects, I just tell patients what to expect,” he says.
Dr. Pandey prepares patients for appetite reduction, early satiety and fullness, abdominal discomfort, nausea, and other gastrointestinal symptoms. “Then I start low and slowly titrate to achieve enough weight loss. If they’re having adverse effects on a higher dose, I use a lower dose.”
The approach is working well for most patients, he says. “Obviously there’s some initial getting used to the drug, but once that has happened, patients like it because they see improvements in their exercise capacity and quality of life.”
But GLP-1 RAs are also associated with increased heart rate, which “is never good news,” notes Howard Weintraub, MD, a professor of medicine at NYU Grossman School of Medicine in New York City and clinical director of the NYU Center for the Prevention of Cardiovascular Disease. At least some of the elevation may be masked by beta-blocker use, he suggests. “The mechanism is not well elucidated, but it is something we’re going to need to keep an eye on, because we don’t want to get ambushed.”