1. This population-based cohort study demonstrated that among older adults with type 2 diabetes, sodium-glucose cotransporter-2 inhibitor (SGLT-2i) use was associated with reduced atrial fibrillation incidence compared to dipeptidyl peptidase-4 inhibitors (DPP-4i) or glucagonlike peptide-1 receptor agonists (GLP-1RA) users.

2. The risk of stroke was decreased among SGLT-2i users compared to DPP-4i users, but similar rates were found between SGLT-2i and GLP-1RA users.

Evidence Rating Level: 2 (Good)

Study Rundown: Type 2 diabetes (T2D) is very prevalent in North America and is associated with an increased risk of atrial fibrillation (AF), increasing morbidity and mortality risk. Sodium-glucose cotransporter-2 inhibitors (SGLT-2is) independently improve mortality in patients with T2D; however, the evidence supporting its efficacy in reducing the onset of AF is unclear. Given the important implications of atrial fibrillation on patient outcomes, this population-based cohort study evaluated the incidence of AF with SGLT-2i use compared to two other commonly prescribed oral antihyperglycemics (dipeptidyl peptidase-4 inhibitors [DPP-4is] and glucagonlike peptide-1 receptor agonists [GLP-1RAs]) between April 1, 2013, and December 31, 2018. Older adults were included if they had T2D without current or previous use of either SGLT-2i, DPP-4i, or GLP-1RA during the baseline period. The primary outcome was incident AF (i.e. AF hospitalization events). Patients prescribed SGLT-2is had significantly reduced risk of AF hospitalization events (DPP-4i: HR, 0.82 [95% CI: 0.76-0.89]; GLP-1RA: HR, 0.90 [95% CI: 0.83-0.98]) and new AF diagnoses (DPP-4i: HR, 0.85 [95% CI: 0.79-0.91]; GLP-1RA: HR, 0.87 [95% CI: 0.81-0.94]) compared to the two comparators. In addition, SGLT-2i use was associated with reduced risk of stroke/transient ischemic attack compared to DPP-4i (HR, 0.86 [95% CI: 0.77-0.96]), but not with those who used GLP-1RA (HR, 1.01 [95% CI: 0.90-1.14]). Overall, this population-based cohort study of patients with T2D demonstrated an 18% and 10% reduction in the risk of incident AF compared with DPP-4i and GLP-1RA use, respectively. One limitation of this study is that the choice of each of the three oral antihyperglycemics may depend on cost and socioeconomic status (SES), and those with lower SES are known to have a higher risk of developing AF. Additionally, the absolute risk of AF with SGLT-2i therapy was not measured, which may be more useful when making clinical decisions.

Click to read the study in JAMA

Relevant Reading: Impact of intensive glycemic control on the incidence of atrial fibrillation and associated cardiovascular outcomes in patients with type 2 diabetes mellitus

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