It matched an older GLP-1 and was not shown to beat it. The trial randomized 13,299 people with type 2 diabetes and established heart disease. Cardiovascular death, heart attack or stroke occurred in 12.2% on tirzepatide against 13.1% on dulaglutide [1]. The hazard ratio was 0.92, 95.3% CI 0.83 to 1.01. Everything else on this page is structure and risk factors, not events, and what a cardiovascular result costs is a separate calculation.
What the outcomes trial asked
It was an active-comparator, double-blind noninferiority trial. Participants were randomized 1:1 to weekly tirzepatide, titrated to as much as 15 mg, or to dulaglutide 1.5 mg. The paper identifies that dulaglutide dose as the one already shown to reduce cardiovascular events. Mean age was 64.1, mean HbA1c 8.4%, and mean diabetes duration 14.7 years.
The design decides what the result can say. A noninferiority trial asks whether the new drug is not meaningfully worse. The margin was 1.05 for the upper confidence limit. Superiority required that limit to fall below 1.00. Noninferiority was met at P=0.003. Superiority was not, at P=0.09.
What happened to the heart itself
An imaging substudy scanned patients with obesity-related heart failure with preserved ejection fraction, before and after a year [2]. Left ventricular mass fell 11 g against placebo, 95% CI −19 to −4, P=0.004. Paracardiac fat fell 45 mL, 95% CI −69 to −22, P<0.001.
Two limits travel with those figures. Of 175 patients scanned, 106 completed a usable second scan, leaving arms of 50 and 56. And the change in left ventricular mass correlated with the change in body weight, P<0.02. The heart may have remodeled because of the drug, or because of the weight the drug removed, and one active arm cannot separate them.
These are structural measurements rather than events. Nobody in the substudy was shown to be hospitalized less often, because it did not measure that. The authors say the changes may contribute to the parent trial’s event reduction, and that verb is theirs.
The risk factors, counted as a package
A post hoc analysis of SURMOUNT-1 through SURMOUNT-4 asked how often three targets arrive together [3]. The targets were a weight-loss threshold, a systolic pressure fall of at least 5 mmHg, and non-HDL cholesterol below 130 mg/dL.
At the 15% weight threshold, 22% to 34% of treated participants hit all three, against 1% to 3% on placebo. At 5% it was 32% to 38% against 2% to 8%. Every comparison reached p<0.001. The ranges span four trials in different populations.
Missing the package is not the same as not benefiting. Non-HDL cholesterol under 130 mg/dL is an absolute threshold, so somebody starting at 220 can improve a great deal and still miss it. What the drug moves across the rest of the body is counted in what it does to blood pressure.
What this means for the price gap
Dulaglutide is not stocked by anybody on this roster. So the outcomes trial does not say which of two purchasable things to buy. It puts a limit on how much cardiovascular confidence the more expensive molecule has earned.
All three studies were funded by the manufacturer, which is ordinary and worth knowing. The population in the outcomes trial averaged nearly fifteen years of diabetes with established heart disease, and it is not the person buying for weight. Who does start these drugs is counted in why people start.
367 sellers here publish a price for both molecules by injection, read September 2026. Across those, tirzepatide runs a median of $66 more a month, with 326 charging more for it and 8 charging less. Whether that gap is worth paying is answered on its own evidence, and this trial is one input rather than the answer.