Q&A: Should heart patients consider taking weight loss medications?

Over the last year, prescriptions for medications that can accelerate weight loss in people with diabetes or without it have skyrocketed. Known by brand names like Ozempic and Wegovy, the drugs have gotten a lot of attention for their cost, their potential impact on weight, and their short supply.

For over a decade, this type of medicine—called GLP-1 receptor agonists—has been used to treat diabetes. Recently, two drugs, semaglutide and terzepatide, were approved by the FDA for weight management in people without diabetes.

But how can these weight loss medications affect the heart? While information is still emerging, Eric J. Brandt, M.D., M.H.S., FACC, director of preventive cardiology at the University of Michigan Health Frankel Cardiovascular Center, shares how this shifting landscape might affect cardiovascular care and how he advises his patients.

How do diet and obesity affect the heart? What treatments are available?

Cardiovascular disease remains the top cause of death in the United States, and diet has now eclipsed tobacco as the top contributor to premature death. Independent of dietary risk, obesity is also a top contributor to risk for cardiovascular disease. Poor diet combined with obesity is common and has become a major focus for public health efforts.

The first line for treatment of many medical conditions, including obesity but also high cholesterol, and high blood pressure, is healthy lifestyle habits. This includes such things as getting appropriate exercise and eating healthier, including a whole food, mostly plant-based diet with the appropriate number of calories. It should be emphasized here that this doesn't mean fad, crash, or yo-yo dieting; this means sticking to a healthy lifestyle over a long period of time.

However, sometimes lifestyle changes are not enough, and this is the case for many people. Fortunately, there are now more treatments for obesity that are effective at helping with weight loss. This includes not only bariatric surgery but also these newer GLP-1 agonist medications, such as Wegovy. These are more effective than older weight management medications that tend to have more side effects, including some not currently on the market (i.e., fen-phen) that may negatively impact the heart.

How do these weight loss drugs work? Do they affect the heart, and can I get them for cardiovascular disease?

The GLP-1 agonists mimic a hormone in the body that helps to decrease appetite and, along with other mechanisms, leads to weight loss.

In a 2023 study published in the New England Journal of Medicine, semaglutide was found to decrease the risk for cardiac events by 20% among those over 45 years old who had preexisting cardiovascular disease and were overweight or had obesity.

While more research is needed to understand this better and to look for any impacts in more typical groups of cardiovascular disease patients, the randomized, placebo-controlled clinical trial is promising for the medication's downstream cardiovascular effects.

However, it's important to note that not everyone who has an unhealthy body weight will develop cardiovascular disease—genetics and other factors, like smoking history, also play a role.

GLP agonists also may also impact other risk factors, including blood pressure and cholesterol. The medications are not yet approved as part of treatment for cardiovascular disease.

How common is it to experience a combination of obesity and/or diabetes alongside cardiovascular disease?

This is a very common problem. The two are closely linked together because they share some mechanisms and are made more likely by unhealthy food intake and low exercise.

In fact, 2021 research from the Journal of the American Heart Association found that obesity is linked to between 30 and 53% of new diabetes cases annually in the U.S.

What do we know about the impact of sustained weight loss on cardiovascular disease/risk?

Gradual, healthy, and sustained weight loss is good for the heart. For example, lowering body weight in someone with elevated blood pressure and cholesterol can help reduce these risk factors, as well as help prevent abnormal heart rhythms, heart failure, and heart attacks.

Is there a worry about yo-yo dieting with these medications?

Yes, when someone stops the medication, they tend to gain the weight back. Research is still being done to understand the best ways to come off of these medications.

I recommend to my patients that while they are taking them, they set better lifestyle habits. This includes eating more whole plant-based foods, reducing calories from sugary beverages, stopping smoking, using stress-reducing techniques such as meditation, and committing to an exercise regimen. Later, we can consider coming off them. However, I also emphasize that obesity is a chronic disease and that sometimes we need to stay on long-term treatments.

What is the future for these types of medications and cardiovascular disease? What needs to be done?

These medications have been found to be helpful for several conditions, such as diabetes, weight loss, heart failure, and heart attack. I expect that additional research will help us understand all those that might stand to benefit. As things currently stand, they are rewriting obesity management.