Advances in the management of CV risk factors have reduced the rate of cardiovascular events. However, residual CV risk remains a significant concern for cardiologists and endocrinologists.
Recommended treatment approach
The ADA-recommended multifactorial approach has shown clear benefits associated with modifying CV risk factors in patients. Their approach includes1,2:
- Lifestyle modification
- Platelet inhibition
- Blood pressure control
- Glycemic control
- Management of dyslipidemia
Diabetes-related complications have declined with better management, but considerable residual CV risk remains
With better management of glucose levels and CV risk factors over the past 20+ years, overall morbidity has declined, but death and complication rates are still much higher in patients with diabetes.3
Adults with diabetes experience more CV events than adults without diabetes
Top graph represents rates between 0 and 150 events per 10,000 patients with diagnosed diabetes.
Bottom graph represents rates between 0 and 10 events per 10,000 of the overall patient population, with or without diabetes.
Intensive therapy also falls short when it comes to reducing CV risk
Two large studies indicate that aggressive A1C reductions do not always correlate with reduced CV risk.10,11
Study showing CV risk with conventional vs intensive therapy
Even intensive therapyc for CVD leaves residual CV risk in patients with diabetes (STENO-2 study)d,12,13
- In the STENO-2 study, death from CVD was reduced by 62% but not eliminated12
CVD=cardiovascular disease; T2D=type 2 diabetes; CV=cardiovascular
aThe Collaborative Atorvastatin Diabetes Study (CARDS) included 2838 patients aged 40 to 75 years in 132 centers in the UK and Ireland. Patients had no previous history of cardiovascular disease and at least one of the following: retinopathy, albuminuria, current smoking, or hypertension. Patients were randomized to placebo (n=1410) or atorvastatin 10 mg daily (n=1428). The primary endpoint was time to first occurrence of acute coronary heart events, coronary revascularization, or stroke.6
bThe Treating to New Targets (TNT) study included 1501 patients with diabetes and CHD, with LDL cholesterol levels <130 mg/dL. Patients were randomized to receive either atorvastin 10 mg/day (n=753) or 80 mg/day (n=748) and were followed for a median of 4.9 years. The primary endpoint was the time to first major cardiovascular event.7
cIntensive therapy was target-driven approach with both behavioral and pharmacological treatment following a structured approach.12
dThe original intervention of the Steno-2 trial included 160 patients with T2D and microalbuminuria who were randomized to receive either conventional therapy (n=80) or intensified, multifactorial treatment including both behavioral and pharmacological approaches (n=80). After 7.8 years the study continued as an observational follow-up, lasting a total of 21.2 years, with all patients receiving intensified, multifactorial treatment. Patients were still analyzed based on their original groupings, with the first follow-up assessment including 40 patients from the original conventional therapy group and 56 patients from the original intensive therapy group. The primary endpoint of the follow-up was difference in median survival time between the original treatment groups with and without incident cardiovascular disease.12
- American Diabetes Association. Standards of medical care in diabetes—2017. Diabetes Care. 2017;40(Suppl1):S1-S135.
- Rydén L, Grant PJ, Anker SD, et al. ESC Guidelines on diabetes, pre-diabetes, and cardiovascular diseases developed in collaboration with the EASD. Eur Heart J. 2013;34:3035-3087.
- Gregg EW, Li Y, Wang J, et al. Changes in diabetes-related complications in the United States, 1990-2010. N Engl J Med. 2014;370(16):1514-1523.
- Rees A. Excess cardiovascular risk in patients with type 2 diabetes: do we need to look beyond LDL cholesterol? Br J Diabetes Vasc Dis. 2014;14:10-20.
- Nesto RW, Singh PP. Diabetes and residual risk of coronary heart disease. Nat Clin Pract Endocrinol Metab. 2007;3(2):71.
- Colhoun HM, Betteridge DJ, Durrington PN, et al; CARDS Investigators. Primary prevention of cardiovascular disease with atorvastatin in type 2 diabetes in the Collaborative Atorvastatin Diabetes Study (CARDS): multicenter randomized placebo-controlled trial. Lancet. 2004;364:685-696.
- Shepherd J, Barter P, Carmena R, et al. Effect of lowering LDL cholesterol substantially below currently recommended levels in patients with coronary heart disease and diabetes. Diabetes Care. 2006;29:1220-1226.
- Kotecha D, Manzano L, Altman DG; Beta-Blockers in Heart Failure Collaborative Group. Individual patient data meta-analysis of beta-blockers in heart failure: rationale and design. Syst Rev. 2013;2:1-9.
- Heart Outcomes Prevention Evaluation (HOPE) Study Investigators. Effects of ramipril on cardiovascular and microvascular outcomes in people with diabetes mellitus. Lancet. 2000;355:253-259.
- Gerstein HC, Miller ME, Genuth S, et al; ACCORD Study Group. Long-term effects on intensive glucose lowering on cardiovascular outcomes. N Eng J Med. 2011;364:818-828.
- Stolar M. Glycemic control and complications in type 2 diabetes mellitus. Am J Med. 2010;123:S3-S11.
- Gæde P, Oellgaard J, Carstensen B, et al. Years of life gained by multifactorial intervention in patients with type 2 diabetes mellitus and microalbuminuria: 21 years follow-up on the Steno-2 randomised trial. Diabetologia. 2016;59(11):2298-2307.
- Gæde P, Vedel P, Larsen N, et al. Multifactorial intervention and cardiovascular disease in patients with type 2 diabetes. N Engl J Med. 2003;348(5):383-393.