LETTERS FROM READERS
Addressing Residual Risk in Type 2 Diabetes

Abordaje del riesgo residual en Diabetes tipo 2

  • RODRIGO ESPARZA IRAOLA, 1  ORCID logo 
  • 1  Cardiologist, Metabolic Unit, Favaloro University Hospital, Buenos Aires.

Rev Argent Cardiol 2025;93:391-392. https://doi.org/10.7775/rac.v93.i5.20921

Correspondence: Rodrigo Esparza Iraola. E-mail: resparza@ffavaloro.org


2025©Revista Argentina de Cardiología

Licencia Creative Commons  Creative Commons Atribution-NonCommercial-Sharelike 4.0 Internacional
This is an open-access article distributed under the terms of the Creative Commons Attribution License
 
 
 

Type 2 diabetes mellitus (T2DM) represents a global public health challenge. In 2022, it affected 830 million people, with a higher prevalence in low-income countries (1). This disease is linked to an elevated risk of cardiovascular complications such as coronary heart disease, heart failure, stroke, atrial fibrillation, peripheral vascular disease, and chronic kidney disease. In 2021, it was directly responsible for 1.6 million deaths, almost half of which occurred before the age of 70. (1)

Intensive control of classic risk factors -blood glucose, blood pressure, and LDL-C- has been shown to reduce mortality and cardiovascular events. However, a residual risk remains, with hypertriglyceridemia as an independent risk marker. Elevated triglyceride levels are associated with increased mortality in patients with coronary artery disease, reinforcing the need for complementary strategies. (2)

In this context, the REDUCE-IT trial showed that icosapent ethyl (IPE) reduces cardiovascular events by 25% in patients with atherosclerotic disease or T2DM with risk factors, leading to its inclusion in international guidelines. (3,4)

The study published in the Argentine Journal of Cardiology, "Eligibility for icosapent ethyl in a realworld population of patients with type 2 diabetes in the Argentine Republic," provides relevant local evidence. (5) Analyzing data from the registry of the Cardiometabolic Council of the Argentine Society of Cardiology, the authors observed that one in five patients with T2DM would meet the criteria for receiving IPE, with a higher proportion in secondary prevention (22.8%) than in primary prevention (15.5%). This finding underscores the importance of identifying residual risk in clinical practice and considering specific interventions to reduce it.

A striking finding is that only 25.9% of patients were receiving hypoglycemic drugs with proven cardiovascular benefits, which shows marked therapeutic inertia. This widely documented phenomenon delays the implementation of effective treatments and contributes to a worse prognosis in patients. The causes are multiple and complex: from professional factors (lack of time, lack of knowledge, fear of adverse effects) and patient factors (low adherence, low perception of risk) to healthcare system barriers (access and coverage). There is need to investigate the causes of undertreatment in T2DM and other cardiovascular diseases, as therapeutic inertia compromises the effectiveness of preventive strategies and results in unfavorable clinical outcomes.

In conclusion, this study not only estimates how many patients with T2DM in an Argentine population would be candidates for IPE, but also alerts us to the need to actively address therapeutic inertia and optimize the use of therapies with proven benefits. Recognizing and treating residual risk is essential for advances in scientific evidence to translate into actual benefits for patients.

Ethical considerations

Not applicable.

Conflicts of interest

None declared. (See authors' conflict of interests forms on the web).

 
 
 

REFERENCES

1. World Health Organization. Diabetes [Internet]. Geneva: World Health Organization; 2024 Nov 14. https://www.who.int/news-room/fact-sheets/detail/diabetes.
2. Klempfner R, Erez A, Sagit BZ, Goldenberg I, Fisman EZ, Kopel E, et al. Elevated triglyceride level is independently associated with increased all-cause mortality in patients with established coronary heart disease: twenty-two-year follow-up of the Bezafibrate Infarction Prevention Study and Registry. Circ Cardiovasc Qual Outcomes 2016;9:100-8. https://doi.org/10.1161/CIRCOUTCOMES.115.002104.
3. Bhatt DL, Steg PG, Miller M, Brinton EA, Jacobson TA, Ketchum SB, et al. REDUCE-IT Investigators. Cardiovascular risk reduction with icosapent ethyl for hypertriglyceridemia. N Engl J Med 2019;380:11-22. https://doi.org/10.1056/NEJMoa1812792.
4. Marx N, Federici M, Schütt K, Ajjan RA, Antunes MJ, et al. ESC Scientific Document Group. 2023 ESC Guidelines for the management of cardiovascular disease in patients with diabetes. Eur Heart J 2023;44:4043-40. https://doi.org/10.1093/eurheartj/ehad192.
5. Lavalle Cobo AM, Destaville J, Salmeri E, Forte E, Harwicz P, Corral P. Elegibilidad para icosapento de etilo en una población de mundo real de pacientes con diabetes tipo 2 en la República Argentina. Rev Argent Cardiol 2025;93:213-6. https://doi.org/10.7775/rac.es.v93.i3.20898.

 
 

AUTHORS’ REPLY

 

      We would like to thank Dr. Rodrigo Esparza Iraola for his observations and comments regarding our recently published article.

      We agree with his reflection on the importance of identifying residual risk in daily practice in order to implement interventions aimed at reducing it, ethyl icosapentenoate being one possible strategy for this purpose.

      When discussing residual risk in diabetes, Lawler et al. propose the use of drugs with proven cardiovascular benefits (GLP-1 receptor agonists and sodiumglucose cotransporter 2 inhibitors) as a strategy to reduce it. (1) In this regard, we agree with Dr. Esparza Iraola that 3 out of 4 patients did not receive these groups of drugs and that inertia might be its cause. However, it is important to note that we used data from a cohort of patients evaluated between May and July 2019 to carry out this work.(2) We consider this factor to be important since this date coincides with the publication of cardiovascular safety studies of different molecules in populations with lower cardiovascular risk than those included in the first studies Moreover, it precedes the publication of international and national guidelines with the participation of scientific cardiology societies in which these drugs are included as part of the recommendations for reducing cardiovascular risk. On the other hand, as Dr. Esparza Iraola rightly points out, there are related issues that we must consider as barriers in the healthcare system. In this regard, Resolution 2820/2002 updated Annex I on the “Rules for the Provision of Medicines and Supplies for People with Diabetes,” included the first of the two groups of drugs with proven cardiovascular benefits (SGLT2 inhibitors) as medications covered by the healhtcasre system for certain patients with type 2 diabetes. (3)

      We would like to thank you once again for the contributions highlighted in your letter, as they enrich the debate on such an important issue as the underuse of strategies with evidence of reducing cardiovascular risk.

      Augusto Lavalle Cobo MTSAC
       
       

      REFERENCES

      1. Lawler PR, Bhatt DL, Godoy LC, Lüscher TF, Bonow RO, Verma S, et al. Targeting cardiovascular inflammation: next steps in clinical translation. Eur Heart J 2021;42:113-31. https://doi.org/10.1093/eurheartj/ehaa099
      2. Forte E, Buso C, Duczynski P, Lavalle Cobo A, Harwicz P, Giorgi M, y cols. Características clínicas y control cardiometabólico de personas con diabetes en el consultorio de cardiología en la República Argentina. Rev Argent Cardiol 2020;99:517-24. https://doi.org/10.7775/rac.es.v88.i6.18201
      3. https://www.argentina.gob.ar/normativa/nacional/resoluci%C3%B3n-2820-2022-375042/texto

       
       

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