Advances in the Management of Patients with Stable Angina and Type 2 Diabetes

Type 2 diabetes mellitus (T2DM) is a well-established risk factor for coronary artery disease (CAD). Patients with CAD and T2DM have more extensive CAD and a higher risk of cardiovascular complications, such as chronic stable angina (CSA). In treating patients with CSA and T2DM, it is important to ensure that pharmacological therapy not only improves symptoms but exerts no deleterious effects on glucose control and, if possible, improves clinical outcomes. However, the present ESC guidelines have no specific recommendations for these patients. Interestingly, some first-choice drugs recommended for the relief of angina symptoms, including β-blockers and calcium channel blockers, may worsen glycemic control by increasing glycosylated hemoglobin A1c (HbA1c) levels in diabetic patients. Ranolazine is a selective inhibitor of the late sodium current with anti-ischemic and metabolic properties. In several clinical trials, ranolazine improves glycemic control and decreases HbA1c (0.4-0.7%) compared with placebo among patients with CSA or non-ST-elevation acute coronary syndromes and T2DM. This reduction in HbA1c levels is similar to that produced by several antidiabetic drugs used in patients with T2DM without an increase in hypoglycemia. Trimetazidine is an anti-ischemic metabolic modulator that in small trials improves HbA1c and glycemia, but it has not been evaluated in large outcome studies in CSA patients. The introduction of new antidiabetics (i.e., glucagon-like peptide-1 agonists, dipeptidyl peptidase IV inhibitors, selective sodium-glucose transporter-2 inhibitors) opens new therapeutic perspectives for patients with CSA and T2DM. Unfortunately, available data from clinical trials on the efficacy of these agents is still limited. Therefore, new prospective studies in patients with CSA and T2D are needed to guide therapy decisions. The final goal is to develop tailored antianginal therapeutic strategies to obtain relief of symptoms with a neutral or positive effects on glucose control and to prevent CV events.