Cardiovascular disease and intensive glucose control in type 2 diabetes mellitus: moving practice toward evidence-based strategies.
Type 2 diabetes mellitus (T2DM) is associated with a high risk of complications, essentially macrovascular events. Surprisingly, the effect of improved glucose control on coronary and cerebrovascular complications and the target level of glycated hemoglobin (HbA(1c)) in this population remains questionable. We here report the results of 4 recently published randomized controlled trials (ACCORD, ADVANCE, VADT, UKPDS post-trial), which did not demonstrate a significant reduction of cardiovascular events in the intensive group compared to the standard group. On the contrary, in ACCORD, the study with the most ambitious goal (HbA(1c) < 6%), the overall and cardiovascular mortality was greater in the intensive group, although the risk of microangiopathic complications, especially nephropathy, was significantly decreased. VADT suggests that one possibility for the lack of observed effect of intensive therapy could be that the cardiovascular benefit is delayed. This contrasts strongly with the long-term postintervention outcomes of UKPDS, which show a persistent benefit of glycemic control during 10 years of post-trial follow-up ('legacy effect'). Therefore, the best way to protect patients with T2DM against coronary and cerebrovascular disease is to target all cardiovascular risk factors as early as possible by an individualized approach.
Meier
Matthias
M
Clinic for Hypertension and Nephrology, Hannover, Germany. kfnh_hannover@web.de
Hummel
Michael
M
D000368:Aged; D000959:Antihypertensive Agents / Q000627:therapeutic use; D001786:Blood Glucose / Q000187:drug effects*; D001794:Blood Pressure / Q000187:drug effects; D002318:Cardiovascular Diseases / Q000097:blood / Q000209:etiology / Q000401:mortality / Q000503:physiopathology / Q000517:prevention & control*; D003924:Diabetes Mellitus, Type 2 / Q000097:blood / Q000150:complications / Q000188:drug therapy* / Q000401:mortality / Q000503:physiopathology; D003925:Diabetic Angiopathies / Q000097:blood / Q000209:etiology / Q000401:mortality / Q000503:physiopathology / Q000517:prevention & control*; D004359:Drug Therapy, Combination; D019317:Evidence-Based Medicine; D006442:Glycated Hemoglobin / Q000378:metabolism*; D006801:Humans; D007004:Hypoglycemic Agents / Q000627:therapeutic use*; D008875:Middle Aged; D017410:Practice Guidelines as Topic; D016032:Randomized Controlled Trials as Topic; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome
D000959:Antihypertensive Agents; D001786:Blood Glucose; D006442:Glycated Hemoglobin; D007004:Hypoglycemic Agents; C517652:hemoglobin A1c protein, human