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ACCORD Analysis Suggests Intensive Glucose Lowering May Reduce Ischemic Cardiovascular Events

Higher A1C target recommended for patients over 65 with comorbidities…

A team of Canadian and American researchers have analyzed data from the ACCORD trial to investigate whether the intensive lowering of glucose concentrations affects the risk of ischemic heart disease in patients with type 2 diabetes.

The researchers assessed 10,251 adults aged 40–79 years with established type 2 diabetes, mean glycated hemoglobin A1c (HbA1c) concentration of 67 mmol/mol (8.3%), and risk factors for ischemic heart disease enrolled in the ACCORD trial. Participants were assigned to intensive or standard therapy (target HbA1c less than 42 or 53–63 mmol/mol [less than 6.0% or 7.0–7.9%], respectively). The team assessed fatal or non-fatal myocardial infarction, coronary revascularisation, unstable angina, and new angina during active treatment (mean 3.7 years) plus a further mean 1.2 years.

Myocardial infarction was less frequent in the intensive than in the standard therapy group during active treatment (hazard ratio [HR] 0.80, 95% CI 0.67–0.96; p=0.015) and overall (0.84, 0.72–0.97; p=0.02). Findings were similar for combined myocardial infarction, coronary revascularisation, and unstable angina (active treatment HR 0.89, 95% CI 0.79–0.99, overall 0.87 0.79–0.96) and for coronary revascularization alone (0.84, 0.75–0.94) and unstable angina alone (0.81, 0.67–0.97) during full follow-up. With lowest achieved HbA1C concentrations included as a time-dependent covariate, all hazards became non-significant.

The researchers concluded that raised glucose concentration is a modifiable risk factor for ischemic heart disease in middle-aged people with type 2 diabetes and other cardiovascular risk factors.

 

Practice Pearls:

  • The trial suggests that intensively lowering glucose concentrations in diabetic patients might reduce the risk of ischemic heart disease.
  • The reason for the reduction in ischemic heart disease can be explained, at least statistically, by the difference in HbA1C.
  • These potential benefits, however, do not totally negate the potential harmful effect of intensive glycemic treatment on cardiovascular mortality in selected patients under specific conditions.

Dr Hertzel Gerstein, Effects of intensive glycaemic control on ischaemic heart disease: analysis of data from the randomised, controlled ACCORD trial, November 29, 2014 issue of the Lancet. Abstract