ADA:
Good Glycemic Control Is Not Enough in Managing Diabetes
Priorities
are misplaced because coronary artery disease is the major cause of
death in patients with type 2 diabetes mellitus
When
it comes to managing diabetes, doctors may achieve good glycemic
control but have a lower priority for controlling or treating other
cardiovascular risk factors, according to two presentations at the
annual American Diabetic Association meeting.
"An
opportunity exists to improve treatment rates and goal attainment for
glycemic, lipid, and blood pressure control among patients with
diabetes," write Richard Bergenstal, from the International
Diabetes Center in Minneapolis, Minnesota, and colleagues. "Only
by understanding how physicians prioritize and address these risk
factors will we be able to develop more effective strategies to reach
goals and reduce the burden of cardiovascular disease in
diabetes."
This
12-month, multicenter, observational study was one of the first and
largest prospective studies to investigate how clinicians approach
major cardiovascular risk factors and how this approach ultimately
affects HbA1c, blood pressure, and low-density lipoprotein
(LDL) cholesterol.
About
2,300 newly referred or newly diagnosed diabetes patients, aged 40
years and older, were enrolled from 144 sites. Mean age was 61 years,
and 87% of patients had type 2 diabetes. Baseline medications included
glycemic therapy in 70%, antihypertensives in 67%, and lipid-lowering
therapy in 44%. The percentage of patients meeting goal at baseline
was 33.5% for HbA1c, 30.4% for LDL cholesterol, and 17.6%
for blood pressure.
"Physicians
indicated a primary focus on glycemic control," the authors
write. "Controlling blood pressure or lipid levels were lower
priorities and commonly listed as secondary or tertiary goals."
In
a separate presentation, Silvio E. Inzucchi, from Yale University
School of Medicine in New Haven, Connecticut, and colleagues noted
that these priorities are misplaced because coronary artery disease is
the major cause of death in patients with type 2 diabetes mellitus.
Although glycemic control is not definitely known to reduce the
incidence of coronary artery disease, other features of the metabolic
syndrome, including hypertension, dyslipidemia, body weight, and
hypercoagulability, appear to be more important.
The
Detection of Ischemia in Asymptomatic Diabetics (DIAD) Study is a
multicenter study of the prevalence of silent myocardial ischemia in
patients with type 2 diabetes, using Adenosine-Sestamibi perfusion
imaging.
Of
402 subjects screened since September 2000, 55% are achieving the ADA
HbA1c target of less than 7.0%. Even in these
well-controlled subjects, control of other cardiovascular risk factors
was quite variable.
"In
our study population, large proportions of patients under seemingly
excellent diabetic control are not achieving an optimal overall
coronary artery disease risk profile," the authors write.
"To impact substantively upon the risk of coronary artery disease
in type 2 diabetes, emphasis on managing these other cardiovascular
risk factors, in addition to glucose control, is necessary."
ADA Annual Meeting: Abstracts 624-P, 32-OR. June 15, 2002.
FACT
On
average, each 1% reduction in HbA1c
is associated with a
37% decrease in the risk of microvascular endpoints and a 21% decrease
in the risk of any diabetes-related endpoint or death.
REFERENCE1.
Stratton IM, Adler AI, Neil HAW, et al. Association of glycaemia with
macrovascular and microvascular complications of type 2 diabetes (UKPDS
35): prospective observational study. BMJ. 2000;321:405-412.
