A new study concludes that patients with type 2 diabetes 30 years of age and older who are receiving glucose-reducing treatment should also receive prompt intensive prophylactic treatment for cardiovascular disease. Diabetic patients requiring glucose-reducing treatment, say investigators, have the same cardiovascular risk as patients who have had a myocardial infarction (MI) and should be treated with antiplatelet drugs, statins, and possibly an ACE inhibitor or angiotensin receptor blocker.
These are the conclusions of a large population-based study of more than three million Danish subjects presented this week at the American Diabetes Association 2007 Scientific Sessions in Chicago, IL. Lead investigator Dr Tina Schramm (University of Copenhagen, Denmark) stated that any patient in need of antidiabetic medication should be a candidate for primary cardiovascular disease prevention.
"Any patient that needs antidiabetic medication is not very well regulated and should be considered high risk, and they should get primary prevention," said Schramm. "It’s a very easy way to allocate patients to treatment. If I have a 30-year-old patient who comes to me in need of antidiabetic drugs, maybe, if I’m lucky, I can change this person’s lifestyle in the next ten years. So let me prevent the myocardial infarction that might disable them. I can postpone the risk and maybe buy them more time to change their lifestyle."
Schramm said the magnitude of cardiovascular risk in patients with diabetes is unclear, particularly in younger patients. Although diabetes is accepted as a risk factor for cardiovascular disease–especially since an analysis of the East-West Study showed that a person who has diabetes without a history of heart disease has the same risk of dying of MI as a person who has already had a heart attack–there are still disparities in the recommendations for primary prevention in diabetes in the major clinical guidelines worldwide, she said.
The purpose of this study, said Schramm, was to estimate the diabetes-related cardiovascular risk in patients receiving glucose-reducing therapy. All residents in Denmark aged 30 years and older were followed for five years through nationwide administrative registers, a cohort that included 3.3 million subjects. Investigators compared the risk of cardiovascular events–MI, stroke, or cardiovascular death, and a combined end point that included all three–in patients with diabetes receiving antidiabetic medications, with and without a prior MI, with nondiabetic patients with and without a prior MI.
In estimating the risk, investigators found that men and women with diabetes requiring glucose-reducing medication (n=71 801) had an equivalent risk of cardiovascular death, as well as the combined end point of MI, stroke, and cardiovascular death, as patients without diabetes but who had experienced an MI (n=79 575). Looking only at MI as an end point, patients with diabetes had a lower risk than those who had had an MI; in terms of stroke, patients with diabetes mellitus had a greater risk than those with prior disease. A propensity score matching patients who had had an MI with diabetic patients found no difference in the risk of cardiovascular events.
In clinical practice, Schramm said diabetologists are most likely to be aggressive with intensive prophylactic therapies in patients with diabetes, mainly because they are aware of the risk that diabetes confers. Cardiologists, although certainly aggressive with secondary prevention, are sometimes less likely to aggressively treat these patients, said Schramm. Risk-stratification algorithms, she added, can often be so complicated that those who would benefit from treatment are overlooked, especially younger patients.
"If they’re taking antidiabetic medication, however, we should consider them at high risk and write them prescriptions for these other drugs," said Schramm.
Schramm TK, Gislason G, Rasmussen S, et al. Cardiovascular morbidity and mortality in diabetes patients receiving glucose reducing treatment: a population-based study of 3.3 million. American Diabetes Association 2007 Scientific Sessions; June 23, 2007; Chicago, IL. Poster 692.
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