Major adverse cardiovascular events among patients with type-2 diabetes, a nationwide cohort study comparing primary metabolic and bariatric surgery to GLP-1 receptor agonist treatment

[Bariatric surgery versus GLP-1 and dual GIP/GLP-1 receptor agonists : Effects on weight, risk factors and prognosis]

To overcome the increasing prevalence of obesity and associated secondary diseases, effective treatment strategies are required. While bariatric surgery (BS) is an established method for significant and sustainable weight reduction, drug treatment with glucagon-like peptide 1 (GLP-1), GLP‑1 receptor agonists (GLP‑1 RA) and dual glucose-dependent insulinotropic peptide (GIP)/GLP‑1 RA has gained increasing importance in recent years. This article highlights the effects of these both treatment approaches on body weight, cardiometabolic risk factors and long-term prognosis, particularly with respect to cardiovascular events and remission of type 2 diabetes. While BS shows more robust weight loss and greater improvement in metabolic parameters, GLP‑1 RA and dual GIP/GLP‑1 RA offer a conservative treatment alternative with a good safety profile. The choice of treatment should be individualized based on the patient risk profile and preferences.

Imaging Pearls and Pitfalls Following Common and Rare Bariatric Procedures

Bariatric surgery is an effective approach to management of morbid obesity. Given its increasing popularity worldwide, post-operative imaging of patients following bariatric surgery is frequently encountered in clinical practice. In this article we review the physiological principles, normal post-operative anatomy, and imaging appearance of common bariatric procedures (Roux-en-Y gastric bypass, vertical sleeve gastrectomy, and laparoscopic adjustable gastric banding) as well as less common bariatric procedures (including intragastric balloon and biliopancreatic diversion with duodenal switch). Technical considerations and imaging pearls for identifying perioperative and late complications following bariatric procedures will be illustrated through fluoroscopic upper GI studies and computed tomography case examples. Familiarity with expected anatomy and imaging appearances following bariatric procedures allows the radiologist to play a key role in early identification and management of postoperative complications.

Metabolic and bariatric surgery versus glucagon-like peptide-1 receptor agonist therapy: A comparison of cardiovascular outcomes in patients with obesity

BACKGROUND

This study compared cardiovascular outcomes associated with metabolic and bariatric surgery (MBS) and glucagon-like peptide-1 receptor agonist (GLP-1 RA) therapy in individuals with obesity.

METHODS

The TriNetX network was used to compare cardiovascular risk in adult patients with BMI ≥35 who underwent MBS with those who received GLP-1 RA therapy for ≥2 years. Primary outcome was cardiovascular disease (CVD), a composite of incident heart failure (HF), coronary artery disease (CAD), and cerebrovascular disease. Patient follow-up lasted up to 10 years.

RESULTS

MBS was associated with lower hazard of the primary composite outcome of CVD (HR, 0.54, 95 ​% CI, 0.49-0.60), and the secondary outcomes of incident HF (HR, 0.45, 95 ​% CI, 0.39-0.52), CAD (HR, 0.54, 95 ​% CI, 0.45-0.66), and cerebrovascular disease (HR, 0.64, 95 ​% CI, 0.53-0.77).

CONCLUSIONS

A lower risk of adverse cardiovascular outcomes was noted after MBS compared with GLP-1 RA therapy in patients with obesity.

The Influence of Metabolic and Bariatric Surgery on Cardiovascular Health in Women: A Comprehensive Study

BACKGROUND

Cardiovascular disease (CVD) is the main cause of death in patients with obesity. Bariatric surgery has been shown to promote substantial reduction in carotid intima-media thickness (C-IMT).

AIM

To comprehensively determine the influence of metabolic and bariatric surgery (MBS) on cardiovascular health in women.

METHODS

A total of 24 female patients with a body mass index (BMI) > 35 kg/m2 underwent sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), or one anastomosis gastric bypass (OAGB), a prospective cohort study in women. C-IMT were evaluated at baseline and 24 months post-MBS.

RESULTS

The results showed a significant reduction in BMI, weight, and C-IMT on the right side 24 months post-MBS (p < 0.001 for BMI and weight and p = 0.004 for C-IMT). There were also significant differences in fasting blood sugar (FBS), triglycerides (TG), total cholesterol, and low-density lipoprotein (LDL) levels. However, high-density lipoprotein (HDL) levels did not show a significant change.

CONCLUSION

The study underscores the potential of MBS in mitigating cardiovascular risk among women with obesity. However, further research is needed to fully understand the impact of MBS on various parameters. The findings highlight the importance of personalized and gender-specific approaches in the management of obesity and related disease.

Glycaemic and weight effects of metabolic surgery or semaglutide in diabetes dosage for patients with type 2 diabetes

AIM

To compare weight and glucometabolic outcomes of semaglutide and metabolic and bariatric surgery (MBS) for patients with type 2 diabetes and obesity.

MATERIALS AND METHODS

Patients treated with either semaglutide for a duration of ≥2 years or MBS in Sweden were identified within the Scandinavian Obesity Surgery Registry and the National Diabetes Registry and matched in a 1:1-2 ratio using a propensity score matching with a generalized linear model, including age, sex, glycated haemoglobin before treatment, duration of type 2 diabetes, use of insulin, presence of comorbidities and history of cancer, with good matching results but with a remaining imbalance for glomerular filtration rate and body mass index, which were then adjusted for in the following analyses. Main outcomes were weight loss and glycaemic control.

RESULTS

The study included 606 patients in the surgical group matched to 997 controls who started their treatment from 2018 until 2020. Both groups improved in weight and glucometabolic control. At 2 years after the intervention, mean glycated haemoglobin was 42.3 ± 11.18 after MBS compared with 50.7 ± 12.48 after semaglutide treatment (p < 0.001) with 382 patients (63.0%) and 139 (13.9%), respectively, reaching complete remission without other treatment than the intervention (p < 0.001). Mean total weight loss reached 26.4% ± 8.83% after MBS compared with 5.2% ± 7.87% after semaglutide (p < 0.001).

CONCLUSION

Semaglutide and MBS were both associated with improvements in weight and improved glycaemic control at 2 years after the start of the intervention, but MBS was associated with better weight loss and glucometabolic control.

Glucagon-like Peptide 1 Receptor Agonists in Cardio-Oncology: Pathophysiology of Cardiometabolic Outcomes in Cancer Patients

Cancer patients, especially long cancer survivors, are exposed to several cardio-metabolic diseases, including diabetes, heart failure, and atherosclerosis, which increase their risk of cardiovascular mortality. Therapy with glucagon-like peptide 1 (GLP1) receptor agonists demonstrated several beneficial cardiovascular effects, including atherosclerosis and heart failure prevention. Cardiovascular outcome trials (CVOTs) suggest that GLP-1 RA could exert cardiorenal benefits and systemic anti-inflammatory effects in patients with type-2 diabetes through the activation of cAMP and PI3K/AkT pathways and the inhibition of NLRP-3 and MyD88. In this narrative review, we highlight the biochemical properties of GLP-1 RA through a deep analysis of the clinical and preclinical evidence of the primary prevention of cardiomyopathies. The overall picture of this review encourages the study of GLP-1 RA in cancer patients with type-2 diabetes, as a potential primary prevention strategy against heart failure and atherosclerosis.

Comparative Effectiveness of Bariatric Metabolic Surgery Versus Glucagon-Like Peptide-1 Receptor Agonists on Cardiovascular Outcomes and Mortality: A Meta-Analysis

Cardiovascular disease (CVD) remains a leading cause of morbidity and mortality worldwide, particularly in individuals with obesity and type 2 diabetes mellitus (T2DM). This meta-analysis aimed to compare the effectiveness of bariatric metabolic surgery (BMS) and glucagon-like peptide-1 receptor agonists (GLP-1RAs) on cardiovascular outcomes and mortality in patients with obesity. A comprehensive literature search was conducted in Medline, Embase, and Cochrane CENTRAL from inception to September 15, 2024. Four observational studies meeting the inclusion criteria were analyzed, comprising a total of 247,000 patients. The primary outcomes were major adverse cardiovascular events (MACE) and all-cause mortality. Random effects models were used to calculate pooled risk ratios (RR) with 95% confidence intervals (CI). The results showed that BMS was associated with a significantly lower risk of MACE compared to GLP-1RAs (RR: 0.71, 95% CI: 0.56-0.90, p = 0.004), indicating a 29% reduction in MACE risk. Additionally, BMS demonstrated a 25% reduction in all-cause mortality risk (RR: 0.75, 95% CI: 0.65-0.87, p < 0.0001). These findings suggest that BMS offers superior cardiovascular protection and improved survival outcomes compared to GLP-1RAs in obese patients. The observed benefits may be attributed to more significant reductions in body mass index (BMI) and improvements in metabolic parameters achieved through surgical intervention. However, the limitations of this study, including its observational nature and the limited number of included studies, underscore the need for further research, particularly randomized controlled trials (RCTs), to confirm these findings and guide clinical decision-making in obesity management.

Impact of metabolic bariatric surgery on outcomes and the 10-year risk of major adverse cardiovascular events during a 7-year period: a retrospective cohort study

BACKGROUND

Metabolic bariatric surgery offers enduring weight reduction and alleviation of obesity-related comorbidities, including dyslipidemia, diabetes, hypertension, and major adverse cardiovascular events (MACE). Long-term data on one-anastomosis gastric bypass (OAGB) and single-anastomosis duodenal-jejunal bypass with sleeve gastrectomy (SADJB-SG) is lacking, necessitating this investigation.

MATERIALS AND METHODS

In this multicenter prospectively-collected retrospective observational study, 830 adult Taiwanese patients (682 OAGB, 148 SADJB-SG) who underwent surgery from 1 January 2011 to 31 December 2017, were initially identified. Following protocol, 224 patients (177 OAGB, 47 SADJB-SG) with complete follow-up data at various intervals up to 3 years after surgery were included in the final analysis. The study's primary focus is to evaluate the long-term safety, efficacy, and durability of OAGB and SADJB-SG in promoting weight loss and diabetes remission. Additionally, changes in 10-year and lifetime risks of MACE before and 3-year after surgery are assessed using Taiwan MACE risk prediction model and the China-PAR project model.

RESULTS

SADJB-SG patients exhibit higher diabetes prevalence, lower BMI, and more severe diabetes compared to OAGB. Both groups demonstrate significant improvements in BMI, diabetes, hypertension, and dyslipidemia three years after surgery, with the most substantial improvements occurring in the second year. The Taiwan MACE risk model reveals a significant reduction in 10-year MACE and stroke risks for both groups. The China-PAR project model indicates a synchronized reduction in atherosclerotic cardiovascular disease 10-year and lifetime risk in both OAGB and SADJB-SG groups.

CONCLUSIONS

OAGB and SADJB-SG exhibit sustained improvements in weight reduction and obesity-related comorbidities over 3 years after surgery. Notably, both procedures contribute to a substantial reduction in 10-year MACE, stroke, and atherosclerotic cardiovascular disease risks. These findings underscore the efficacy of OAGB and SADJB-SG in the context of metabolic bariatric surgery.

Cardiovascular and diabetes outcomes among patients with obesity and type 2 diabetes after metabolic bariatric surgery or glucagon-like peptide 1 receptor agonist treatment

BACKGROUND

With the increasing prevalence of obesity and type 2 diabetes, the availability of different treatment options remains essential. Studies comparing the outcomes of glucagon-like peptide 1 receptor agonists with those of metabolic bariatric surgery in patients with type 2 diabetes and obesity are lacking.

METHODS

Using propensity score matching, based on data from several nationwide clinical registries, patients who underwent primary metabolic bariatric surgery (Roux-en-Y gastric bypass or sleeve gastrectomy) were matched with patients who received glucagon-like peptide 1 receptor agonists. Outcome measures included the occurrence of major cardiovascular events, microvascular complications, and potential side effects (alcohol/substance abuse, self-harm, and fractures).

RESULTS

Over a mean follow-up of 7 years, major cardiovascular events occurred in 191 of 2039 patients (cumulative incidence 14.5%) in the surgery group compared with 247 of 2039 patients (19.6%) in the glucagon-like peptide 1 receptor agonist group (HR 0.75 (95% c.i. 0.62 to 0.91), P = 0.003). Patients in the surgery group had lower haemoglobin A1c values 5 years after treatment (mean difference 9.82 (95% c.i. 8.51 to 11.14) mmol/mol, P < 0.001) and fewer microvascular complications (retinopathy HR 0.88 (95% c.i. 0.79 to 0.99), P = 0.039; nephropathy HR 0.72 (95% c.i. 0.66 to 0.80), P < 0.001; and neuropathy or leg ulcers HR 0.82 (95% c.i. 0.74 to 0.92), P < 0.001), but a higher risk of alcohol/substance abuse (HR 2.56 (95% c.i. 1.87 to 3.50), P < 0.001), self-harm (HR 1.41 (95% c.i. 1.17 to 1.71), P < 0.001), and fractures (HR 1.86 (95% c.i. 1.11 to 3.12), P = 0.019).

CONCLUSION

Compared with glucagon-like peptide 1 receptor agonist treatment, metabolic bariatric surgery is associated with superior metabolic outcomes and a lower risk of major cardiovascular events in patients with type 2 diabetes and obesity, but a higher risk of alcohol/substance abuse, self-harm, and fractures.

Cardiovascular Protective Properties of GLP-1 Receptor Agonists: More than Just Diabetic and Weight Loss Drugs

Owing to their potent glucose-lowering efficacy and substantial weight loss effects, glucagon-like peptide-1 receptor agonists (GLP-1 RAs) are now considered part of the frontline therapeutic options to treat both type 2 diabetes mellitus and nondiabetic overweight/obesity. Stemming from successful demonstration of their cardiometabolic modulation and reduction of major adverse cardiovascular events in clinical outcome trials, GLP-1 RAs have since been validated as agents with compelling cardiovascular protective properties. Studies spanning from the bench to preclinical and large-scale randomised controlled trials have consistently corroborated the cardiovascular benefits of this pharmacological class. Most notably, there is converging evidence that they exert favourable effects on atherosclerotic ischaemic endpoints, with preclinical data indicating that they may do so by directly modifying the burden and composition of atherosclerotic plaques. This narrative review examines the underlying pharmacology and clinical evidence behind the cardiovascular benefits of GLP-1 RAs, with particular focus on atherosclerotic cardiovascular disease. It also delves into the mechanisms that underpin their putative plaque-modifying actions, addresses existing knowledge gaps and therapeutic challenges and looks to future developments in the field, including the use of combination incretin agents for diabetes and weight loss management.

From diabetes to diverse domains: the multifaceted roles of GLP-1 receptor agonists

Glucagon-like Peptide-1 (GLP-1) receptor agonists (GLP-1RAs) emerged as a primary treatment for type-2 diabetes mellitus (T2DM), however, their multifaceted effects on various target organs beyond glycemic control opened a new era of treatment. We conducted a comprehensive literature search using databases including Scopus, Google Scholar, PubMed, and the Cochrane Library to identify clinical, in-vivo, and in-vitro studies focusing on the diverse effects of GLP-1 receptor agonists. Eligible studies were selected based on their relevance to the varied roles of GLP-1RAs in T2DM management and their impact on other physiological functions. Numerous studies have reported the efficacy of GLP-1RAs in improving outcomes in T2DM, with demonstrated benefits including glucose-dependent insulinotropic actions, modulation of insulin signaling pathways, and reductions in glycemic excursions. Additionally, GLP-1 receptors are expressed in various tissues and organs, suggesting their widespread physiological functions beyond glycemic control potentially include neuroprotective, anti-inflammatory, cardioprotective, and metabolic benefits. However, further scientific studies are still underway to maximize the benefits of GLP-1RAs and to discover additional roles in improving health benefits. This article sought to review not only the actions of GLP1RAs in the treatment of T2DM but also explore its effects on potential targets in other disorders.

Bariatric Metabolic Surgery vs Glucagon-Like Peptide-1 Receptor Agonists and Mortality

Importance

Evidence regarding the relative effectiveness of bariatric metabolic surgery (BMS) and glucagon-like peptide-1 receptor agonists (GLP-1RAs) in reducing mortality and major adverse cardiovascular events (MACEs) is limited.

Objective

To compare all-cause mortality and nonfatal MACEs associated with BMS vs GLP-1RAs for adults with obesity and diabetes and without known cardiovascular disease.

Design, Setting, and Participants

This observational, retrospective cohort study was based on data obtained from the electronic medical records of Clalit Health Services (Clalit), the largest health care organization in Israel. The study included 6070 members aged 24 years or older, who had diabetes and obesity and no prior history of ischemic heart disease, ischemic stroke, or congestive heart failure. Patients who underwent BMS and patients who received GLP-1RAs from January 1, 2008, through December 31, 2021, were matched 1:1 by age, sex, and clinical characteristics. Follow-up ended December 31, 2022.

Exposures

Initiation of BMS or GLP-1RAs.

Main Outcomes and Measures

The primary outcome was all-cause mortality, assessed by multivariate Cox proportional hazards regression models. The secondary outcome was nonfatal MACEs, assessed by multivariate competing risk models.

Results

The study included 3035 matched pairs of patients (total, 6070; mean [SD] age, 51.0 [9.5] years; 3938 women [64.9%]), who were followed up for a median of 6.8 years (IQR, 4.1-9.4 years). Among those with a diabetes duration of 10 years or less (2371 pairs), mortality was lower for those who underwent BMS than for those treated with GLP-1RAs (hazard ratio [HR], 0.38; 95% CI, 0.25-0.58). This association became nonsignificant when weight loss during the follow-up period was also included in the model (HR, 0.79; 95% CI, 0.43-1.48). Among patients with a duration of diabetes longer than 10 years (664 pairs), no survival advantage was demonstrated for BMS over GLP-1RA (HR, 0.65; 95% CI, 0.39-1.08). The risk for nonfatal MACEs did not differ between the treatment groups (HR, 0.74; 95% CI, 0.49-1.10 among patients with a diabetes duration of ≤10 years; HR, 1.21; 95% CI, 0.80-1.85 among patients with a diabetes duration of >10 years).

Conclusions and Relevance

In this cohort study, BMS was associated with greater reduced mortality compared with first-generation GLP-1RAs among individuals with a diabetes duration of 10 years or less, mediated via greater weight loss. No differences in the risk for mortality were observed between the treatment modalities among individuals with a longer duration of diabetes, nor in the occurrence of nonfatal MACEs among all patients.

Surgery is associated with better long-term outcomes than pharmacological treatment for obesity: a systematic review and meta-analysis

Obesity is a highly prevalent disease with numerous complications. Both intensive medical treatment with the use of pharmacological drugs and bariatric surgery are current options. The objective of this meta-analysis was to compare, in the long-term, intensive medical treatment and surgery based on twelve parameters related to weight loss, cardiovascular and endocrine changes. A review of the literature was conducted in accordance with the PRISMA guidelines (PROSPERO: CRD42021265637). The literature screening was done from inception to October 2023 through PubMed, EMBASE and Web of Science databases. We included randomized clinical trials that had separate groups for medical treatment and bariatric surgery as an intervention for obesity. The risk of bias was assessed through RoB2. A meta-analysis was performed with measures of heterogeneity and publication bias. Subgroup analysis for each surgery type was performed. Data is presented as forest-plots. Reviewers independently identified 6719 articles and 6 papers with a total 427 patients were included. All studies were randomized controlled trials, three had a follow up of 5 years and two had a follow up of 10 years. Both groups demonstrated statistical significance for most parameters studied. Surgery was superior for weight loss (- 22.05 kg [- 28.86; - 15.23), total cholesterol (- 0.88 [- 1.59; - 0.17]), triglycerides (- 0.70 [- 0.82; - 0.59]), HDL (0.12 [0.02; 0.23]), systolic pressure (- 4.49 [- 7.65; - 1.33]), diastolic pressure (- 2.28 [- 4.25; - 0.31]), Hb glycated (- 0.97 [- 1.31; - 0.62]), HOMA IR (- 2.94; [- 3.52; - 2.35]) and cardiovascular risk (- 0.08; [- 0.10; - 0.05]). Patient in the surgical treatment group had better long term outcomes when compared to the non-surgical group for most clinical parameters.

Major Adverse Cardiovascular Events Among Obese Patients with Diabetes After Metabolic and Bariatric Surgery: a Meta-analysis of Matched Cohort and Prospective Controlled Studies with 122,361 Participates

PURPOSE

Metabolic and bariatric surgery (MBS) can exert effective function on glycemic control. The present study aimed to estimate the risk of MACE among obese patients with diabetes after MBS.

MATERIALS AND METHODS

Systematic search of PubMed, Embase, Medline, and Web of Science was performed for studies published before 20th February 2023. The odds ratio (OR) corresponding to the 95% confidence interval (95% CI) was used to assess the outcome. The statistical heterogeneity among studies was assessed with the Q-test and I2 statistics.

RESULTS

Fifteen cohort studies with 122,361 obese patients with diabetes were available for analysis. Our meta-analysis found significantly decreased morbidity and mortality of MACE (OR = 0.65, 95% CI = 0.59-0.72, I2 = 62.8% for morbidity, OR = 0.49, 95% CI = 0.36-0.67, I2 = 68.7% for mortality). Subgroup analysis revealed MBS decreased cerebrovascular disease, coronary artery disease, atrial fibrillation, heart failure, myocardial infarction, and stroke risk.

CONCLUSION

Our meta-analysis indicated that MBS for obese patients with diabetes is beneficial to decreasing MACE risk. Moreover, further studies estimating the functional effect may eventually provide a better and comprehensive understanding of the effect on different populations.