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Item
#3
Study
Verifies 50% Reduction in CVD and Microvascular Events with
Intensive MGMT
Patients
given an ACE inhibitor or angiotensin II-receptor antagonist,
regardless of blood pressure, a aspirin 150 mg q.d. and a
vitamin-mineral supplement that included chrome picolinate.
Long-term
intensified interventions focused on multiple risk factors in
patients with type 2 diabetes and microalbuminuria can reduce
cardiovascular and microvascular events by about half over an
8-year period, Danish physicians report in The New England Journal
of Medicine for January 30.
Dr.
Oluf Pedersen of Aarhus University and associates point out that
recent guidelines from the American Diabetes Association and other
national guidelines recommend intensified multifactorial treatment
for type 2 diabetes. However, "the effect of this approach
has not been confirmed in long-term studies," they write.
In
the Steno-2 Study, the investigators enrolled 160 diabetic
patients with persistent microalbuminuria. Eighty patients were
randomly assigned to conventional treatment, 73 of whom completed
the study that ended in December 2001. The other 80 were assigned
to the intensive treatment arm of the study, and 67 of these
subjects completed the trial.
In
the intensive treatment arm, all patients were given an
angiotensin-converting-enzyme (ACE) inhibitor or angiotensin
II-receptor antagonist, regardless of blood pressure, as well as
aspirin 150 mg q.d. and a vitamin-mineral supplement that included
chrome picolinate. Patients were advised to consume less than 30%
of calories as fat, and less than 10% as saturated fat.
Light-to-moderate exercise for a minimum of 30 minutes per day,
three to five times as week, along with smoking cessation, were
also recommended.
In
the intensive treatment arm, pharmacologic treatment was added as
necessary to maintain blood pressure below 140/85 before 2000 and
130/80 thereafter. Target total cholesterol was <190 and
<175 mg/dL before and after 2000, respectively, and target
triglycerides levels were <150mg/dL. Pharmaceutical
interventions were initiated in the control subjects after higher
values were reached.
After
a mean follow-up of 7.8 years, the two groups did not differ
significantly in changes in body mass index, smoking cessation, or
total energy intake. Nor did serum HDL cholesterol levels, urinary
sodium excretion and glomerular filtration differ significantly.
However,
measures of hyperglycemia, hypertension, lipid profiles, and
urinary albumin excretion had all decreased significantly more in
the intensive treatment group than in the control arm. Fat intake
was also significantly decreased in the intensive treatment group.
There
were 85 cardiovascular events during follow-up in the conventional
treatment group versus 33 among the intensive-therapy group. The
hazard ratio among the intensive treatment group for
cardiovascular disease was 0.47; for nephropathy, 0.39;
retinopathy, 0.42; and autonomic neuropathy, 0.37, compared with
the conventional therapy group.
"The
continued divergence in the rates of the primary end point
suggests that therapy for even longer periods may result in an
even better prognosis," Dr. Pedersen's team writes.
In
a Journal editorial, Dr. Caren G. Solomon recommends treatment
with ACE inhibitors for diabetics who have at least one other
cardiovascular risk factor, even in the absence of hypertension
and microalbuminuria. "A reasonable conclusion is that
targeting associated risk factors is much more likely to be
cardioprotective than controlling the glucose level," she
maintains.
N
Engl J Med
2003;348:383-393,457-459
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