Second revolution in cardiovascular prevention

Type 2 diabetes has become a major disease burden in twenty-first century. Both incidence and prevalence of type 2 diabetes have quadrupled between 1980 and 2004 in the whole world. Atherosclerotic cardiovascular disease (ASCVD) is the major complication of type 2 diabetes. The introduction of statins in clinical settings is the first revolution in our battle against ASCVD. Most ASCVDs could be prevented or treated with statins. However, statin failed to reduce chronic kidney diseases (CKD) and heart failure (HF). Owing to a mandate from US Food and Drug Administration in 2008 that every new antidiabetic drug should be tested in clinical trials to demonstrate its safety, we now have a good opportunity to look for better antidiabetic drugs not only to decrease blood sugar but also to decrease CVD or renal disease. Among them, glucagon-like peptide-1 receptor agonists and sodium-glucose transport protein 2 inhibitors (SGLT-2 i) are two most extensively studied ones. SGLT-2 i, in particular, prevent CKD and end-stage renal disease, and prevent HF. In the recent CREDENCE trial, canagliflozin reduced renal endpoints by 34% and end-stage renal disease by 32%. Furthermore, in the recent DAPA-HF trial, dapagliflozin decreased hospitalization for HF/ cardiovascular death by 26%, and total death by 17%, in patients with HF with reduced ejection fraction, irrespective of diabetes or nondiabetes. The beneficial effects of SGLT-2 i in CKD and HF are complementary to the effects of statins. The introduction of SGLT-2 i in clinical practice is the second revolution in cardiovascular prevention.