The American College of Cardiology has issued a Concise Clinical Guidance (CCG) document to aid clinicians in the use of medication for weight management in patients where treatment may provide cardiovascular benefit.
Obesity is a chronic, progressive disease that affects over 1 billion people worldwide. It can lead to devastating cardiovascular complications, including increased risk of heart failure, coronary artery disease and stroke. It is also associated with a significant reduction in life expectancy (9.1 years in men and 7.7 years in women.) Treatment is essential, but not all weight loss methods are effective.
Modern obesity medications, including semaglutide and tirzepatide, have been proven more effective than lifestyle interventions at not only weight loss, but at reducing overall cardiovascular disease (CVD) risk, with fewer risks than procedure-based interventions. Prior guidelines have recommended trying lifestyle interventions before beginning medication, but this new guidance recommends considering these medications as a first-line treatment option for eligible patients.
"Patients should not be required to 'try and fail' lifestyle changes prior to initiating pharmacotherapy; nonetheless, lifestyle interventions should always be offered in conjunction with obesity medications," said Olivia Gilbert, MD, MSc, FACC, Chair of the CCG and a cardiologist at Atrium Health Wake Forest Baptist Medical Center.
The new guidance outlines the clinical decision-making process for clinicians to incorporate pharmacologic weight management strategies into cardiovascular care, highlighting the following key areas:
- Rationale and eligibility - Pharmacotherapy strikes the balance between effectiveness and invasiveness. Eligibility may be determined by BMI thresholds or other risk indicators. These therapies can be adjusted to minimize adverse effects and personalize care.
- Pharmacological options – Among FDA approved medications, GLP-1 receptor agonist semaglutide and GLP-1/GIP receptor agonist tirzepatide have demonstrated the highest efficacy. Clinical trial and real-world observational data support slightly greater weight loss with tirzepatide. Insurance coverage, availability and affordability are likely to dictate agent selection.
- Impact on Cardiovascular Risk – Clinical evidence supports medications leading to a reduction in major adverse cardiovascular events—including cardiovascular death, myocardial infarction and stroke—particularly in individuals with Type 2 diabetes and elevated cardiovascular risk.
- Multidisciplinary care approaches - Team-based approaches are critical for effective weight management. Coordinated care can help to assess modifiable risk factors, identify comorbidities and tailor treatment strategies.
- Reducing Bias and Improving Experience – The guidance places emphasis on person-first language, creating welcoming clinical environments and addressing weight stigmas. Clinicians should make every effort to validate the lifelong journey that patients experience with this chronic disease.
- Access considerations – Lack of insurance coverage remains a major barrier for patients. Initial strategies to improve access to therapies include identifying individuals most likely to benefit, close monitoring of treatment outcomes, and price negotiations. There is ongoing need to improve access to these therapies in the United States.
"Weight management by the cardiovascular community needs to be embraced, given both the prevalence of obesity and the impact it has on many forms of CVD," Gilbert said.
