Abstract
The relationship between glucose control and cardiovascular outcomes in type 2 diabetes has been a matter of controversy over the years. Although epidemiological evidence exists in favor of an adverse role of poor glucose control on cardiovascular events, intervention trials have been less conclusive. The Action to Control Cardiovascular Risk in Diabetes (ACCORD) study, the Action in Diabetes and Vascular Disease (ADVANCE) study, and the Veterans Affairs Diabetes Trial (VADT) have shown no beneficial effect of intensive glucose control on primary cardiovascular endpoints in type 2 diabetes. However, subgroup analysis has provided evidence suggesting that the potential beneficial effect largely depends on patients’ characteristics, including age, diabetes duration, previous glucose control, presence of cardiovascular disease, and risk of hypoglycemia. The benefit of strict glucose control on cardiovascular outcomes and mortality may be indeed hampered by the extent and frequency of hypoglycemic events and could be enhanced if glucose-lowering medications, capable of exerting favorable effects on the cardiovascular system, were used. This review examines the relationship between intensive glucose control and cardiovascular outcomes in type 2 diabetes, addressing the need for individualization of glucose targets and careful consideration of the benefit/risk profile of antidiabetes medications.
Highlights
Cardiovascular disease (CVD) is the major cause of death in patients with type 2 diabetes (T2D), as more than 60% of T2D patients die of myocardial infarction (MI) or stroke, and an even greater proportion of patients have serious burdensome complications.[1]
The excess deaths from any cause, observed in the intensive arm at the end of the intervention for 3.7 years, persisted after a follow-up period of 1.3 years, in spite of similar HbA1c levels, use of glucose-lowering medications, and rates of severe hypoglycemia in the intensive and standard intervention groups.[62]. These analyses have suggested that hypoglycemia may not account for the excess mortality associated with intensive glucose lowering in the Action to Control Cardiovascular Risk in Diabetes (ACCORD) study and may instead be a marker of vulnerability that increases the risk for death in patients with diabetes, even when glycemia is controlled less intensively.[61]
The recent publication of the findings from the ACCORD trial, the ADVANCE trial, and the Veterans Affairs Diabetes Trial (VADT) has provided important insights into the balance of risks and benefits associated with the use of more intensive glucose control in patients with T2D
Summary
Cardiovascular disease (CVD) is the major cause of death in patients with type 2 diabetes (T2D), as more than 60% of T2D patients die of myocardial infarction (MI) or stroke, and an even greater proportion of patients have serious burdensome complications.[1].
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