Prevention of Cardiovascular Risk in Diabetic Patients – An Update

Abstract

Patients with type 2 diabetes have a well-documented increased risk of cardiovascular disease (CVD) that is more than two to three times higher than the risk seen in non-diabetic subjects.1 In spite of modern methods to treat diabetes and its complications, the increased risk is still substantial even if data on risk factor controls in national surveys have shown improving trends for blood pressure and lipid control, for example from Sweden.2 The most important CVD risk factors to detect, treat and make follow-up visits for are elevated blood-pressure levels, dyslipidaemia and elevated low-density lipoprotein (LDL) cholesterol, as well as hyperglycaemia and smoking. In addition, chronic inflammation, defects in fibrinolytic function and adverse psychosocial conditions could all contribute to this risk, besides the impact of background factors that it is not possible to change such as age, gender and diabetes duration. For a number of years data have been accumulating on treatment benefits of risk-factor control based on reports from large-scale clinical trials involving patients with type 1 diabetes ‐ i.e. Diabetes Control and Complications Trial (DCCT) ‐ or type 2 diabetes ‐ i.e. UK Prospective Diabetes Study (UKPDS), Heart Protection Study (HPS), Reduction of Endpoints in NIDDM [non-insulin-dependent diabetes mellitus] with the Angiotensin II Antagonist Losartan (RENAAL), Irbesartan Diabetic Nephropathy Trial (IDNT), Collaborative Atorvastatin Diabetes Study (CARDS), Losartan Intervention For Endpoint Reduction in Hypertension (LIFE) and Anglo‐Scandinavian Cardiac Outcomes Trial (ASCOT). Therefore, we have so far had strong support for some, but not all, of the goals for risk factor control stated in contemporary guidelines for treatment of patients with diabetes, from both the joint American Diabetes Association (ADA) and American Heart Association (AHA) guidelines3 and the corresponding joint European Society of Cardiology (ESC) and European Association for the Study of Diabetes (EASD) guidelines.4 For example, the recommended goal of blood-pressure control in patients with diabetes and hypertension (<130/80mmHg)3,4 was not based on solid evidence from intervention studies, but from observational studies, most notably from the observational arm of UKPDS where a linear association between systolic blood pressure and risk of coronary artery disease (CAD) was noticed.5