Clinical practice and implications of recent diabetes trials

Abstract

Diabetes is an increasingly prevalent risk factor for coronary and other vascular disease. Recent trials in patients with diabetes have examined the effects of intensive glycemic control on cardiovascular outcomes, and treatment of common concomitant risk factors, in particular hypertension and dyslipidemia. Optimal revascularization strategies have also been examined. Intensive glycemic control has a beneficial effect on microvascular but not macrovascular endpoints, with one major trial reporting increased mortality out to 5 years with intensive treatment. Similarly, aggressive lowering of SBP to below 120 mmHg produced no advantage over treatment to 130-140 mmHg. Statins are the best treatment for diabetic dyslipidemia, with little benefit from adding a fibrate. Medical treatment may be appropriate for many with diabetes and stable coronary disease. When revascularization is needed, coronary bypass graft surgery has an advantage over percutaneous coronary intervention in those at the severe end of the coronary disease spectrum. Patients with type 2 diabetes often have multiple cardiovascular risk factors and require multiple cardiac and diabetes medications. Caution over aggressive glucose and blood pressure lowering is needed, at least with currently available drugs.