title: Outcomes of combined cardiovascular risk factor management strategies in type 2 diabetes: the ACCORD randomized trial.
abstract: OBJECTIVE
  To compare effects of combinations of standard and intensive treatment of glycemia and either blood pressure (BP) or lipids in the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial.
  
  
  METHODS
  ACCORD enrolled 10,251 type 2 diabetes patients aged 40-79 years at high risk for cardiovascular disease (CVD) events. Participants were randomly assigned to hemoglobin A1c goals of <6.0% (<42 mmol/mol; intensive glycemia) or 7.0-7.9% (53-63 mmol/mol; standard glycemia) and then randomized a second time to either 1) systolic BP goals of <120 mmHg (intensive BP) or <140 mmHg (standard BP) or 2) simvastatin plus fenofibrate (intensive lipid) or simvastatin plus placebo (standard lipid). Proportional hazards models were used to assess combinations of treatment assignments on the composite primary (deaths due to CVD, nonfatal myocardial infarction [MI], and nonfatal stroke) and secondary outcomes.
  
  
  RESULTS
  In the BP trial, risk of the primary outcome was lower in the groups intensively treated for glycemia (hazard ratio [HR] 0.67; 95% CI 0.50-0.91), BP (HR 0.74; 95% CI 0.55-1.00), or both (HR 0.71; 95% CI 0.52-0.96) compared with combined standard BP and glycemia treatment. For secondary outcomes, MI was significantly reduced by intensive glycemia treatment and stroke by intensive BP treatment; most other HRs were neutral or favored intensive treatment groups. In the lipid trial, the general pattern of results showed no evidence of benefit of intensive regimens (whether single or combined) compared with combined standard lipid and glycemia treatment. The mortality HR was 1.33 (95% CI 1.02-1.74) in the standard lipid/intensive glycemia group compared with the standard lipid/standard glycemia group.
  
  
  CONCLUSIONS
  In the ACCORD BP trial, compared with combined standard treatment, intensive BP or intensive glycemia treatment alone improved major CVD outcomes, without additional benefit from combining the two. In the ACCORD lipid trial, neither intensive lipid nor glycemia treatment produced an overall benefit, but intensive glycemia treatment increased mortality.
authors.affiliation: HealthPartners Institute for Education and Research, Minneapolis, MN karen.l.margolis@healthpartners.com.
authors.forename: Karen L
authors.initials: KL
authors.lastname: Margolis
authors.affiliation: HealthPartners Institute for Education and Research, Minneapolis, MN.
authors.forename: Patrick J
authors.initials: PJ
authors.lastname: O'Connor
authors.affiliation: Wake Forest University School of Medicine, Winston-Salem, NC.
authors.forename: Timothy M
authors.initials: TM
authors.lastname: Morgan
authors.affiliation: University of North Carolina School of Medicine, Chapel Hill, NC.
authors.forename: John B
authors.initials: JB
authors.lastname: Buse
authors.affiliation: Cincinnati Veterans Affairs Medical Center and University of Cincinnati, Cincinnati, OH.
authors.forename: Robert M
authors.initials: RM
authors.lastname: Cohen
authors.affiliation: Memphis Veterans Affairs Medical Center, Memphis, TN.
authors.forename: William C
authors.initials: WC
authors.lastname: Cushman
authors.affiliation: National Heart, Lung, and Blood Institute, Bethesda, MD.
authors.forename: Jeffrey A
authors.initials: JA
authors.lastname: Cutler
authors.affiliation: Wake Forest University School of Medicine, Winston-Salem, NC.
authors.forename: Gregory W
authors.initials: GW
authors.lastname: Evans
authors.affiliation: McMaster University, Hamilton, Ontario, Canada.
authors.forename: Hertzel C
authors.initials: HC
authors.lastname: Gerstein
authors.affiliation: Berman Center for Outcomes and Clinical Research, Minneapolis, MN.
authors.forename: Richard H
authors.initials: RH
authors.lastname: Grimm
authors.affiliation: University of Washington, Seattle, WA.
authors.forename: Edward W
authors.initials: EW
authors.lastname: Lipkin
authors.affiliation: Emory University, Atlanta, GA.
authors.forename: K M Venkat
authors.initials: KM
authors.lastname: Narayan
authors.affiliation: Oregon Health and Science University, Portland, OR.
authors.forename: Matthew C
authors.initials: MC
authors.lastname: Riddle
authors.affiliation: Louis Stokes Veterans Affairs Medical Center and Case Western Reserve University, Cleveland, OH.
authors.forename: Ajay
authors.initials: A
authors.lastname: Sood
authors.affiliation: Colorado School of Public Health, Aurora, CO.
authors.forename: David C
authors.initials: DC
authors.lastname: Goff
mesh_terms: D000328:Adult; D000368:Aged; D001786:Blood Glucose / Q000378:metabolism*; D001794:Blood Pressure / Q000187:drug effects*; D002318:Cardiovascular Diseases / Q000209:etiology / Q000517:prevention & control*; D003924:Diabetes Mellitus, Type 2 / Q000150:complications* / Q000503:physiopathology; D019468:Disease Management; D050171:Dyslipidemias / Q000188:drug therapy / Q000209:etiology; D005260:Female; D011345:Fenofibrate / Q000627:therapeutic use; D006442:Glycated Hemoglobin / Q000032:analysis; D006801:Humans; D000960:Hypolipidemic Agents / Q000627:therapeutic use; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000209:etiology / Q000517:prevention & control*; D010043:Outcome and Process Assessment, Health Care; D012307:Risk Factors; D040242:Risk Reduction Behavior; D019821:Simvastatin / Q000627:therapeutic use; D020521:Stroke / Q000209:etiology / Q000517:prevention & control*
chemical_list: D001786:Blood Glucose; D011345:Fenofibrate; D006442:Glycated Hemoglobin; D000960:Hypolipidemic Agents; D019821:Simvastatin