Tuesday, July 31, 2012

"Will lowering my blood sugar more help me prevent a heart attack ? "

                      Diabetes management is more than just glucose control 


Back ground
The risk of developing cardiovascular disease is two 2 to 3 times  higher in people with Type 2 diabetes!
Cardiovascular disease is the #1 cause of death and disability in people with Diabetes !

Question
"Will lowering my blood sugar more help me prevent a heart attack "
                          Yes____      No____     Maybe____     I don't know____

This  question  was discussed in a recent CME ( Continuing Medical Education course ) in MedScape

An Update on Glycemic Control and Cardiovascular Disease in Diabetes CME
Robert S. Rosenson, MD, FACC Faculty and Disclosures
CME Released: 06/29/2012; Valid for credit through 06/29/2013


Classic studies 
Type 1 diabetes
   DCCT  demonstrated the benefits of achieving an A1c level of  7 in patients with type 1 diabetes with a significant reduction in the risk for developing eye , nerve and kidney damage but no significant reduction in the risk for heart disease. A followup study ,  EDIC , completed 17 years later on the same group of patients found a 42% relative risk reduction for any cardiovascular event in the intensive treatment group even though the A1c settled to an average of  about 8 shortly after the original study was completed in both groups.

Type 2 Diabetes
    UKPDS - This study also demonstrate  a significant reduction in the risk for developing eye , nerve and kidney damage in the intensive treatment group , with a A1c of 7 , compared to the control group. There was also a non- significant  14% reduction in the risk of developing cardiovascular disease in the intensive treatment group treated with sulfonylyureas and /or insulin. A sub-group , treated with metformin , did show a significant reduction of 39% in the risk of developing heart disease. Another sub-group of older  by 5 years , more overweight with higher sugars did not show the benefit from taking metformin.

comment- I recall one curve on a slide from the UKPDS study that suggested that achieving an A1c
                 below 7 and closer to 6 would demonstrate a reduction in the risk for developing
                 cardiovascular disease . A study done years later called the ACCORD study failed to answer
                 the question.

ACCORD study
      This study evaluated the vascular outcome comparing patients treated to achieve an A1c of <6 to a control group.  The study was discontinued early due excess mortality in the intensive treatment group.
There was also a significant increase in the risk of severe hypoglycemia in the intensive treatment group. Subsequent analysis of the data uncovered some interesting findings .
*The excess mortality seemed to occur in the patients struggling to achieve an A1c of less than 6 and
   not in the patients easily achieving an A1c of <6 .
* The A1c was the strongest  predictor of mortality with most of the increased risk occurring in patients
   with a A1c > 7 in both groups

ADVANCE  study ( type 2 diabetes )
 This study compared intensive treatment , A1c goal of 6.5 ,  to standard treatment over 5 years.
                                                    Mean A1c in the                                      Hypoglycemia
     intensive treatment group -              6.5                                                           2.7%
     control group                    -             7.3                                                           1.5%
   
   Results 
      Glucose control did not  significantly reduce the risk of heart disease
      Intensive treatment did increase the risk of hypoglycemia
      intensive treatment did reduce the risk of developing kidney disease

VADT study   
      Compared A1c levels of 6.9 in the intensive treatment group vs 8.4 in the control group  and found no difference in the the risk for developing heart disease. However a subsequent analysis of the data revealed that patient with Diabetes of less than 15 years duration seemed to have a significant benefit  from intensive treatment.

What does this mean to you and I in our every day dealing with diabetes ?
Any comments ?
My thoughts tomorrow.

 Have fun , Be smart , just doing your best may be a good thing
David Calder,MD
       

1 comment:

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Your comments and questions are appreciated. David Calder,MD