Wednesday, August 15, 2012

Treating multiple risk factors is additive

Effect of a Multifactorial Intervention on Mortality in Type 2 Diabetes
Steno-2 -Study
N. England Journal of Med. 2008:358:580-591

The Conclusion is first today

The overall conclusion of this study is , this target driven multi-risk factor treatment reduced the risk of cardiovascular and microvascular events by about 50 %. You can stop here are read on for more details.  

I recommend that you "google" this  study and look at the actual charts on page 584 and especially the charts on page 587 that provides the actual results achieved in each group. These results may be comforting to you in your struggles with this disease.

Small improvements in known multiple risk factors maintained over a few years have a major  lasting impact on the risk of developing all of the complications of diabetes, especially heart disease.

  160 patients with type 2 diabetes with microalbuminuria received either intensive multifactoral  therapy or conventional treatment for 7.8 years. The intensive management portion of the study ended and both groups were observed for an additional 5.5 years for a total of 13.3 years. the primary end point was death from any cause. All patients were offered intensive treatment after the initial 7.8 years of the study

Patients were divided into 2 groups

Intensive - therapy group
Involved a combination  of medication and focused behavioral modification including specific goals 
These targets included :  
           A1c <6.5  ,
           Total cholesterol < 175mg/dl( 4.5 mm/l) ,
           Triglyceride level < 150 mg/dl ( 1.7mm/l) and 
           Blood pressure < 130/80

The conventional treatment group received treatment consistent with Danish medical association

                                        intensive treatment group                    conventional treatment group
Macrovascular disease           number  of patients                           number of patients
Total Number who died                  24                                                       40
      Cardio vascular deaths                9                                                       19                                                      
      cancer                                          2                                                        5
      other conditions                         13                                                      16
Strokes                                              7                                                       30
Heart attack                                       7                                                       35
Coronary artery bypass surgery         8                                                      14
amputation                                       10                                                       32

Microvascular disease progression was reduced
progressed to end stage
kidney disease                                 1                                                           6
Retinopathy                                    39                                                        52
neuropathy                                      42                                                        45


Previous studies of individual risk factor treatments of blood pressure and lipids reduced the relative risk of cardiovascular events by about 25 %. 

This study demonstrated that the benefits of treating multiple risk factors is additive.
This study demonstrated a 59 % relative risk reduction  and a 29%reduction in absolute risk  for developing cardiovascular disease. 

Most effective  and least effective treatments
The use of statins and blood pressure medications  followed by aspirin and glucose lowering drugs seem to have the most impact on the reduction of cardiovascular risk. More of the patients in the intensive treatment group received metformin which could have effected the overall risk. The number of people who stopped smoking was about the same in both groups. Exercise measured in minutes /week was better in the conventional treatment group. 
Weight and waist circumference increased in both groups

This data suggest that we are pretty good at taking our pills and not as good at controlling our  food intake.

Actual treatment goals achieved
    Group                                                  intensive                 conventional 

 A1c less that 6.5                                       18%                        10 %
 Cholesterol less than 175 mg/dl            80%                        75%
 Triglycerides less than 150 mg/dl          78%                       50 %
 systolic blood pressure less than 130    22%                       15%

Tomorrow I will review the actual treatment results achieved on each of these risk factors.

Have Fun , Be Smart  and remember , any improvement is better than no improvement
David Calder,MD

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Your comments and questions are appreciated. David Calder,MD