Obesity, a chronic and progressive disease affecting over one billion people globally, significantly elevates the risk of cardiovascular complications, including heart failure, coronary artery disease, and stroke. Recent advancements in obesity medications, such as semaglutide and tirzepatide, have demonstrated superior efficacy compared to lifestyle interventions, not only in achieving weight loss but also in reducing overall cardiovascular disease (CVD) risk, with potentially fewer risks than invasive procedures.
The Intersection of Obesity and Cardiovascular Health
Cardiovascular disease remains the leading cause of death in the United States, with diet now surpassing tobacco as the primary contributor to premature mortality. Independent of dietary risks, obesity also stands as a major risk factor for cardiovascular disease. The co-occurrence of obesity, diabetes, and cardiovascular disease is a prevalent issue, highlighting the need for comprehensive treatment strategies.
Rationale and Eligibility for Pharmacotherapy
Pharmacotherapy offers a balanced approach between effectiveness and invasiveness in managing obesity and its associated cardiovascular risks. Eligibility for weight loss medications may be determined by Body Mass Index (BMI) thresholds or other risk indicators, allowing for personalized care and dosage adjustments to minimize adverse effects.
Pharmacological Options for Weight Management
Among the FDA-approved medications, glucagon-like peptide-1 (GLP-1) receptor agonists like semaglutide (Wegovy, Ozempic) and GLP-1/GIP receptor agonists like tirzepatide have shown the greatest efficacy. Clinical trials and real-world observational data suggest slightly greater weight loss with tirzepatide. These medications mimic a hormone in the body that helps decrease appetite and, along with other mechanisms, leads to weight loss. GLP-1 agonists may also positively impact other risk factors, including blood pressure and cholesterol.
The Role of Semaglutide in Reducing Cardiovascular Events
In March 2024, the Food and Drug Administration (FDA) approved semaglutide (Wegovy) to reduce the risk of cardiovascular death, heart attack, and stroke in adults with cardiovascular disease and either obesity or overweight. This approval was based on the SELECT trial, which demonstrated that semaglutide could lower the risk of major heart events by as much as 20% in certain individuals.
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The SELECT Trial: A Breakthrough in Cardiovascular Prevention
The Semaglutide Effects on Cardiovascular Outcomes in People With Overweight or Obesity (SELECT) trial was a major breakthrough. It showed that Wegovy, containing a higher dose of semaglutide, lowers the risk of heart events even in people without diabetes. The trial tracked 17,604 adults aged 45 and older with overweight or obesity and a cardiovascular condition but no history of diabetes. Participants received either 2.4mg of semaglutide (Wegovy) weekly or a placebo for an average of three years.
The results indicated that Wegovy not only reduced the overall risk of major cardiac events by 20% but also led to a 28% reduction in heart attacks (for those already taking heart medications like statins), a 7% decrease in non-fatal strokes, and a 15% drop in cardiovascular-related deaths. Additionally, there was a 19% lower death rate from any cause among those who took Wegovy.
Target Population and Potential Impact
A follow-up study estimated that 6.6 million Americans with obesity and cardiovascular conditions, but not diabetes, could benefit from Wegovy. Making this medication more accessible could significantly change how cardiovascular disease is treated.
Cardiologists and the Prescription of Weight Loss Medications
Given the strong link between obesity and cardiovascular disease, cardiologists are increasingly recognizing the importance of addressing weight management in their patients. The American College of Cardiology (ACC) emphasizes that obesity should be viewed and treated as a chronic disease, urging doctors to prescribe weight-loss medications when appropriate, especially for those at high risk for heart disease.
ACC Expert Consensus Statement
The ACC's "2025 Concise Clinical Guidance: An ACC Expert Consensus Statement on Medical Weight Management for Optimization of Cardiovascular Health" provides guidance on medical weight management for optimizing cardiovascular health. The ACC also issued a Scientific Statement addressing the management of obesity specifically in adults with heart failure (HF), with a specific focus on those with stage 2 HF with preserved ejection fraction (HFpEF).
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Multidisciplinary Care Approaches
Team-based approaches are critical for effective weight management. Coordinated care can help assess modifiable risk factors, identify comorbidities, and tailor treatment strategies. Comprehensive treatment includes blood pressure management, lipid-lowering therapies, and glucose-lowering medications. A multidisciplinary clinic can address various aspects of a patient's health, including sleep, exercise, diet, and stress.
Practical Considerations for Prescribing Weight Loss Medications
While medications like semaglutide and tirzepatide offer promising benefits, it's essential to consider potential side effects and individual patient factors.
Potential Side Effects and Monitoring
The FDA cautions that Wegovy carries the risk of side effects such as nausea, diarrhea, constipation, vomiting, low blood sugar, pancreas or gallbladder problems, eye problems in people with diabetes, and suicidal behavior or thinking. Patients must be carefully monitored, and the drug should be administered gradually, increasing the dose a little every week.
Access and Affordability
Lack of insurance coverage remains a major barrier for patients. The list price for Wegovy is $1,349 for a 28-day supply. Strategies to improve access include identifying individuals most likely to benefit, close monitoring of treatment outcomes, and price negotiations. Recent guidance from the Centers for Medicare and Medicaid Services indicates that Medicare Part D plans can start covering anti-obesity drugs if they are also approved for an added health benefit, such as heart health.
Lifestyle Modifications
While weight loss medications can be highly effective, they should be used in conjunction with lifestyle modifications. Gradual, healthy, and sustained weight loss is beneficial for the heart. Patients should focus on setting better lifestyle habits, including eating more whole plant-based foods, reducing calories from sugary beverages, stopping smoking, using stress-reducing techniques, and committing to an exercise regimen.
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The Future of Weight Management in Cardiology
The emergence of effective weight loss medications represents a significant advancement in cardiology. These medications have been found helpful for several conditions, such as diabetes, weight loss, heart failure, and heart attack. Additional research will help us understand all those who might stand to benefit.
Addressing Weight Stigma and Bias
It is crucial to reduce bias and improve the patient experience by using person-first language, creating welcoming clinical environments, and addressing weight stigmas. The statement emphasizes that obesity should be viewed and treated as a chronic disease, not a personal failing.
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