Obesity Management Following NSTEMI : Pre-test

2.

A 59-year-old woman is in your office for a 1-year follow-up after hospitalization for non-ST segment elevation myocardial infarction (NSTEMI). She is receiving optimal antiplatelet, antihypertensive, and cholesterol control therapy for secondary prevention. She does not have diabetes, but she has obesity (BMI 35 kg/m², waist circumference 42 in). She has a weight loss goal of at least 10% but has achieved only 3% weight loss in a lifestyle management program during the past year. She would also like to do whatever she can to minimize the risk of CV events and wants to discuss antiobesity medication (AOM). In addition to recommending that she maintains her lifestyle management program, which would you recommend as the optimal AOM for this patient?

A. Liraglutide 3.0 mg
B. Phentermine/topiramate
C. Semaglutide 2.4 mg
D. Tirzepatide

Among the agents listed, the optimal choice is semaglutide 2.4 mg, which is the semaglutide formulation indicated in combination with reduced-calorie diet and increased physical activity for reduction of excess body weight and long-term maintenance of weight reduction in patients aged 12 years or older with obesity and adults with overweight and ≥1 weight-related condition. The same formulation of semaglutide is also approved to reduce the risk of MACE in adults with established CVD and obesity or overweight and for the treatment of noncirrhotic metabolic dysfunction–associated steatohepatitis (MASH) in adults with moderate to advanced liver fibrosis. Semaglutide 2.4 mg is the optimal choice because it is associated with weight loss of ~15% and is also indicated to reduce the risk of MACE in patients with obesity and established CVD, so it would help the patient reach her obesity and CV management goals.

Liraglutide 3.0 mg is the liraglutide formulation approved in combination with reduced-calorie diet and increased physical activity for reduction of excess body weight and long-term maintenance of weight reduction in patients aged 12 years or older with obesity and body weight >60 kg and in adults with overweight and ≥1 weight-related condition. Liraglutide 3.0 mg is associated with closer to 5% weight loss, and it does not have an indication to reduce CV risk in patients with obesity and established CVD, so it is not the best choice for helping the patient reach her obesity and CV management goals.

Phentermine/topiramate, as phentermine and topiramate in extended-release capsules, is approved in combination with reduced-calorie diet and increased physical activity for the reduction of excess body weight and long-term maintenance of weight reduction in patients aged 12 years or older with obesity and in adults with overweight and ≥1 weight-related condition. It is associated with ~10% weight loss, but no trial has been completed to assess its effects on CV morbidity and mortality, so it does not have an indication to reduce CV event risk. In addition, phentermine should be avoided in patients with CVD, including prior MI, because it has been associated with CV risks, including blood pressure elevation and ischemic events.

One formulation of tirzepatide is approved in combination with reduced-calorie diet and increased physical activity for the reduction of excess body weight and long-term maintenance of weight loss in adults with obesity and overweight with ≥1 weight-related condition and for the treatment of moderate to severe sleep apnea in adults with obesity. Comparing formulations approved for weight reduction, tirzepatide is associated with greater weight loss than semaglutide for obesity (~20% vs ~15%). However, it is not currently indicated to reduce the risk of CV events in patients with obesity and established CVD. A CV outcomes trial is in progress to assess tirzepatide effects on CV morbidity and mortality in patients with overweight or obesity and established CVD but without type 2 diabetes (T2D).

3.

How would you counsel a patient starting an incretin-based AOM, also known as a nutrient-stimulated hormone (NuSH) AOM, regarding gastrointestinal (GI) adverse effects (AEs)?

A. GI AEs can be minimized by including carbonated beverages with meals
B. GI AEs can be reduced by slowing titration
C. GI AEs cannot be mitigated by specific approaches, but they typically subside over time
D. GI AEs happen in <10% of patients and are an indication to discontinue the NuSH AOM

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Obesity Management in Follow-up After Hospitalization for NSTEMI

Robert Kushner, MD, MS

Erin D. Michos, MD, MHS, FACC, FAHA, FASE, FASPC

Pretest

Please answer the questions below.

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