Characteristics of patients with diabetes and a history of myocardial infarction initiating PCSK9 and SGLT2 inhibitors

Demetria Hubbard, Emily C. McKinley, Lisandro D. Colantonio, Bharat Poudel, Robert S. Rosenson, Todd M. Brown, Elizabeth A. Jackson, Lei Huang, Kate K. Orroth, Katherine E. Mues, Paul J. Dluzniewski, Vera Bittner, Paul Muntner

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Study objective: Proprotein convertase subtilisin/kexin type 9 inhibitors (PCSK9i) and sodium-glucose cotransporter-2 inhibitors (SGLT2i) reduce the risk for atherosclerotic cardiovascular disease (ASCVD) events in patients with diabetes and ASCVD. We assessed factors associated with initiating either medication among patients with diabetes and a prior myocardial infarction (MI). Setting/participants: US adults ≥19 years old with private health insurance (MarketScan) or government health insurance (Medicare) who had diabetes and a prior MI and initiated a PCSK9i or an SGLT2i in 2017 or 2018. Main outcome measures: PCSK9i or SGLT2i initiation was identified using pharmacy claims. Results: Overall, 8102 patients initiated a PCSK9i (n = 1501; 18.5%) or an SGLT2i (n = 6601; 81.5%). Patients with 2 and ≥3 versus 1 prior MI (risk ratio [RR]: 1.32 [95%CI: 1.17–1.48] and 1.68 [1.41–2.01], respectively), prior coronary revascularization (1.47 [1.31–1.64]), prior stroke (1.28 [1.06–1.56]), history of peripheral artery disease (1.27 [1.14–1.41]), receiving cardiologist care (1.51 [1.36–1.67]) or taking ezetimibe (2.57 [2.35–2.82]) were more likely to initiate a PCSK9i versus an SGLT2i. Patients with a history of short-term (RR 1.07 [95%CI 1.05–1.09]) or long-term (1.07 [1.04–1.09]) diabetes complications, and taking a low/moderate- and high-intensity statin dosage (1.61 [1.51–1.70] and 1.68 [1.58–1.77], respectively) were more likely to initiate an SGLT2i versus a PCSK9i. Among patients who initiated a PCSK9i, 2.9% subsequently initiated an SGLT2i; 0.8% who initiated an SGLT2i subsequently initiated a PCSK9i. Conclusion: The decision to initiate PCSK9i or SGLT2i is explained by having very high cardiovascular disease risk for those initiating PCSK9i and diabetes complications for those initiating SGLT2i.

Original languageEnglish
Article number100121
JournalAmerican Heart Journal Plus: Cardiology Research and Practice
StatePublished - Jan 2022


  • Atherosclerotic cardiovascular disease
  • Diabetes
  • Secondary prevention


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