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Is tighter glucose control better for the heart in diabetes?

Ami Banerjee
Last edited 7th June 2009
The global burden of diabetes mellitus (DM) is the theme of this week’s Lancet. Four-fifths of the 225 million diabetic patients live in developing countries and type 2 DM is the most common form. The major cause of morbidity and mortality is coronary heart disease (CHD). Tight control of glucose in diabetic patients has a proven benefit for microvascular disease (retinopathy, nephropathy and neuropathy) [1]. However, the existing trials have not consistently shown a benefit for macrovascular disease (coronary heart disease, or CHD, and stroke) [2]. Ray et al combined data from 5 randomised controlled trials with over 33 000 patients to show that tight control of glucose (measured by haemoglobin A1c or HbA1c) has cardiovascular benefit compared with standard treatment for type 2 DM [3]. 5 years of intensive glucose control with a 0·9% reduction of HbA1c concentration resulted in a 17% reduction in non-fatal myocardial infarction and a 15% reduction in CHD. There was also a non-significant 7% reduction in stroke. Importantly, intensive treatment did not affect all-cause mortality, which is in contrast to blood-pressure-lowering and cholesterol-lowering treatments in DM [4-5]. If 200 individuals with type 2 DM are treated for 5 years with tight glucose control (0.9% reduction of HbA1c concentration) three events of CHD will be prevented. This is a small benefit compared to a 1 mmol/L reduction in LDL cholesterol (8.2 events prevented) or a 4 mm Hg lower blood pressure (12·5 events prevented) [3-5]. The authors conclude, “In view of the burden of cardiovascular risk in individuals with type 2 diabetes, a general approach to cardiovascular risk that uses several interventions, including stricter glycaemic control, is warranted.” The accompanying editorial warns that “on the basis of current information, and the urgent need to address residual risk of coronary heart disease in a rapidly expanding population with type 2 diabetes, it is premature to conclude that glucose control has no part to play [6].”
  1. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet 352 (1998) 837–853. UK Prospective Diabetes Study (UKPDS) Group
  2. Intensive blood glucose control and vascular outcomes in patients with type 2 diabetes. N Engl J Med 358 (2008) 2560–2572. Patel, S MacMahon and J Chalmers et al.,
  3. Effect of intensive control of glucose on cardiovascular outcomes and death in patients with diabetes mellitus: a meta-analysis of randomised controlled trials. Lancet 373 (2009). 1765–1772. KK Ray, SR Kondapally Seshasai and S Wijesuriya et al.,
  4. Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38. BMJ 317 (1998), pp. 703–713. UK Prospective Diabetes Study Group
  5. Efficacy of cholesterol-lowering therapy in 18 686 people with diabetes in 14 randomised trials of statins: a meta-analysis. Lancet 371 (2008), pp. 117–125. Cholesterol Treatment Trialists' Collaborators
  6. Hyperglycaemia and coronary heart disease: the meta picture. Lancet 373 (2009).1737-1738. Mazzone T.

Dates on blog post

Dear Anne Marie

Thanks for this point. I see what you mean and we will address it. BTW this post was on 25th May 2009.

Best wishes

Ami

date on blog posts?

I can't see that this site has dates on posts. Could you introduce that?
Thanks
Anne Marie
strangely I can see the date of posting after I enter a comment!

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