Diabetes cardiovascular risk reduction — ABIM Board MCQ

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ModerateEndocrinology/MetabolismDiabetes cardiovascular risk reductionABIM Board

A 60-year-old woman with type 2 diabetes and a prior myocardial infarction has an A1c of 7.4% while taking metformin. Her eGFR is 74 mL/min/1.73 m², and her BMI is 34 kg/m². She has no history of heart failure and is willing to use injectable therapy. Which of the following is the most appropriate addition to reduce her risk of recurrent major adverse cardiovascular events?

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Correct answer: E — Add a GLP-1 receptor agonist with proven cardiovascular benefit

A GLP-1 receptor agonist with proven cardiovascular benefit is appropriate because this patient has type 2 diabetes and established ASCVD from her prior myocardial infarction. Cardioprotective therapy is indicated even though her A1c is near the usual individualized goal; her obesity also favors a GLP-1 receptor agonist because these agents promote weight loss. Glyburide can cause hypoglycemia and weight gain and does not reduce cardiovascular events. Basal insulin is unnecessary without marked hyperglycemia or catabolic symptoms and may cause weight gain and hypoglycemia. Continuing metformin alone neglects indicated cardiovascular risk reduction. DPP-4 inhibitors are generally cardiovascularly neutral rather than cardioprotective. An SGLT2 inhibitor would also be guideline-supported, particularly with heart failure or chronic kidney disease, but it is not offered.

Reference: American Heart Association/American College of Cardiology/American Diabetes Association/American Society of Nephrology. 2026 Guideline for the Prevention, Detection, Evaluation, and Management of Cardiovascular-Kidney-Metabolic Syndrome, section 7: Cardioprotective Antihyperglycemic Therapies in Diabetes. 2026. https://professional.heart.org/en/science-news/2026-guideline-for-the-prevention-detection-evaluation-and-management-of-ckm-syndrome/top-things-to-know