Reduced coronary events in simvastatin-treated patients with coronary heart disease and diabetes or impaired fasting glucose levels: subgroup analyses in the Scandinavian Simvastatin Survival Study

Utilization patterns of cardiovascular medications in patients with diabetes mellitus; a retrospective cross-sectional study, 2013-17

BACKGROUND

Diabetes Mellitus (DM) is a prominent health care issue worldwide. One of the most prevalent comorbidities of DM is cardiovascular disease (CVD). The objective of this study was to assess the utilization patterns of cardiovascular medications in patients with DM in Iran from 2013 to 2017.

METHODS

This retrospective cross-sectional study was undertaken using prescription claims data from 2013 to 2017 in Iran. Epidemiological data elements used in this study were obtained from the Global Burden of Disease (GBD) 2019 study. In addition, data on total medication sales were obtained from the national regulatory authority database. The data on medication utilization were analyzed according to the Anatomical Therapeutic Chemical Classification (ATC) /Defined Daily Doses (DDD) international system.

RESULTS

Based on the findings, Acetylsalicylic acid was the mainstay of treatment with a utilization rate of 191.7 DDD/ patient/ year in 2017, followed by Atorvastatin with 170.0 and Losartan with 115.1. Although there was an increasing trend in the utilization rate of the medications, the rate of Atenolol and Enalapril was constantly declining during the 2013-17 period. On the other hand, Valsartan and Metoprolol were attracting attention. Almost all medication utilization rates increased from the 30-39 age group up to the 80 + age group. Females had a higher utilization rate in each age group during the whole study period.

CONCLUSION

The present study reflects that medication utilization patterns were rational, according to the standard treatment guidelines. Utilization patterns of medications that are recommended for both prevention and treatment of CVD in diabetes were observed to be the highest. Implementation of further policies is needed to minimize cardiovascular complications of diabetes.

HMG CoA reductase inhibitors (statins) for people with chronic kidney disease not requiring dialysis

BACKGROUND

Cardiovascular disease is the most frequent cause of death in people with early stages of chronic kidney disease (CKD), and the absolute risk of cardiovascular events is similar to people with coronary artery disease. This is an update of a review first published in 2009 and updated in 2014, which included 50 studies (45,285 participants).

OBJECTIVES

To evaluate the benefits and harms of statins compared with placebo, no treatment, standard care or another statin in adults with CKD not requiring dialysis.

SEARCH METHODS

We searched the Cochrane Kidney and Transplant Register of Studies up to 4 October 2023. Studies in the Register are identified through searches of CENTRAL, MEDLINE, EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal and ClinicalTrials.gov. An updated search will be undertaken every three months.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and quasi-RCTs that compared the effects of statins with placebo, no treatment, standard care, or other statins, on death, cardiovascular events, kidney function, toxicity, and lipid levels in adults with CKD (estimated glomerular filtration rate (eGFR) 90 to 15 mL/min/1.73 m2) were included.

DATA COLLECTION AND ANALYSIS

Two or more authors independently extracted data and assessed the study risk of bias. Treatment effects were expressed as mean difference (MD) for continuous outcomes and risk ratios (RR) for dichotomous benefits and harms with 95% confidence intervals (CI). The risk of bias was assessed using the Cochrane risk of bias tool, and the certainty of the evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

MAIN RESULTS

We included 63 studies (50,725 randomised participants); of these, 53 studies (42,752 participants) compared statins with placebo or no treatment. The median duration of follow-up was 12 months (range 2 to 64.8 months), the median dosage of statin was equivalent to 20 mg/day of simvastatin, and participants had a median eGFR of 55 mL/min/1.73 m2. Ten studies (7973 participants) compared two different statin regimens. We were able to meta-analyse 43 studies (41,273 participants). Most studies had limited reporting and hence exhibited unclear risk of bias in most domains. Compared with placebo or standard of care, statins prevent major cardiovascular events (14 studies, 36,156 participants: RR 0.72, 95% CI 0.66 to 0.79; I2 = 39%; high certainty evidence), death (13 studies, 34,978 participants: RR 0.83, 95% CI 0.73 to 0.96; I² = 53%; high certainty evidence), cardiovascular death (8 studies, 19,112 participants: RR 0.77, 95% CI 0.69 to 0.87; I² = 0%; high certainty evidence) and myocardial infarction (10 studies, 9475 participants: RR 0.55, 95% CI 0.42 to 0.73; I² = 0%; moderate certainty evidence). There were too few events to determine if statins made a difference in hospitalisation due to heart failure. Statins probably make little or no difference to stroke (7 studies, 9115 participants: RR 0.64, 95% CI 0.37 to 1.08; I² = 39%; moderate certainty evidence) and kidney failure (3 studies, 6704 participants: RR 0.98, 95% CI 0.91 to 1.05; I² = 0%; moderate certainty evidence) in people with CKD not requiring dialysis. Potential harms from statins were limited by a lack of systematic reporting. Statins compared to placebo may have little or no effect on elevated liver enzymes (7 studies, 7991 participants: RR 0.76, 95% CI 0.39 to 1.50; I² = 0%; low certainty evidence), withdrawal due to adverse events (13 studies, 4219 participants: RR 1.16, 95% CI 0.84 to 1.60; I² = 37%; low certainty evidence), and cancer (2 studies, 5581 participants: RR 1.03, 95% CI 0.82 to 1.30; I² = 0%; low certainty evidence). However, few studies reported rhabdomyolysis or elevated creatinine kinase; hence, we are unable to determine the effect due to very low certainty evidence. Statins reduce the risk of death, major cardiovascular events, and myocardial infarction in people with CKD who did not have cardiovascular disease at baseline (primary prevention). There was insufficient data to determine the benefits and harms of the type of statin therapy.

AUTHORS' CONCLUSIONS

Statins reduce death and major cardiovascular events by about 20% and probably make no difference to stroke or kidney failure in people with CKD not requiring dialysis. However, due to limited reporting, the effect of statins on elevated creatinine kinase or rhabdomyolysis is unclear. Statins have an important role in the primary prevention of cardiovascular events and death in people who have CKD and do not require dialysis. Editorial note: This is a living systematic review. We will search for new evidence every three months and update the review when we identify relevant new evidence. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review.

Management of diabetic dyslipidemia in Indians: Expert consensus statement from the Lipid Association of India

In 2021 an estimated 74 million individuals had diabetes in India, almost all type 2 diabetes. More than half of patients with diabetes are estimated to be undiagnosed and more 90% have dyslipidemia that is associated with accelerated development of atherosclerotic cardiovascular disease (ASCVD). Patients of Indian descent with diabetes have multiple features that distinguish them from patients with diabetes in Western populations. These include characteristics such as earlier age of onset, higher frequency of features of the metabolic syndrome, more prevalent risk factors for ASCVD, and more aggressive course of ASCVD complications. In light of the unique features of diabetes and diabetic dyslipidemia in individuals of Indian descent, the Lipid Association of India developed this expert consensus statement to provide guidance for management of diabetic dyslipidemia in this very high risk population. The recommendations contained herein are the outgrowth of a series of 165 webinars conducted by the Lipid Association of India across the country from May 2020 to July 2021, involving 155 experts in endocrinology and cardiology and an additional 2880 physicians.

Fasting C-peptide at type 2 diabetes diagnosis is an independent risk factor for total and cancer mortality

AIMS

We assessed the association between insulin resistance and blood glucose concentrations at type 2 diabetes diagnosis and future development of diabetes-related complications and mortality.

MATERIALS AND METHODS

This retrospective cohort study included 864 individuals with type 2 diabetes (median age 60 years) whose fasting C-peptide and HbA1c were measured at diabetes diagnosis. The median follow-up time until death or study end was 16.4 years (interquartile range 13.3-19.6). The association between C-peptide and mortality/complications was estimated by Cox regression adjusted for sex, age at diabetes diagnosis, smoking, hypertension, BMI, total cholesterol, and HbA1c. C-peptide and HbA1c were converted to Z scores before the Cox regression analysis.

RESULTS

An increase by one standard deviation in fasting C-peptide at diabetes diagnosis was associated with all-cause (hazard ratio [HR] 1.33; 95% confidence intervals [CI] 1.12-1.58; p = 0.001) and cancer mortality (HR 1.51; 95% CI 1.13-2.01; p = 0.005) in the fully adjusted model. An increase by one standard deviation in HbA1c at diabetes diagnosis was associated with all-cause mortality (HR 1.24; 95% CI 1.07-1.44; p = 0.005), major cardiovascular events (HR 1.20; 95% CI 1.04-1.39; p = 0.015), stroke (HR 1.36; 95% CI 1.09-1.70; p = 0.006), and retinopathy (HR 1.54; 95% CI 1.34-1.76; p < 0.0001) in the fully adjusted model.

CONCLUSIONS

Fasting C-peptide at type 2 diabetes diagnosis is an independent risk factor for total and cancer-related mortality. Thus, treatment of type 2 diabetes should focus not only on normalising blood glucose levels but also on mitigating insulin resistance.

Efficacy of Lipid-Lowering Therapy during Cardiac Rehabilitation in Patients with Diabetes Mellitus and Coronary Heart Disease

Background: Cardiac rehabilitation (CR) in patients with coronary heart disease (CHD) increases adherence to a healthy lifestyle and to secondary preventive medication. A notable example of such medication is lipid-lowering therapy (LLT). LLT during CR improves quality of life and prognosis, and thus is particularly relevant for patients with diabetes mellitus, which is a major risk factor for CHD. Design: A prospective, multicenter registry study with patients from six rehabilitation centers in Germany. Methods: During CR, 1100 patients with a minimum age of 18 years and CHD documented by coronary angiography were included in a LLT registry. Results: In 369 patients (33.9%), diabetes mellitus was diagnosed. Diabetic patients were older (65.5 ± 9.0 vs. 62.2 ± 10.9 years, p < 0.001) than nondiabetic patients and were more likely to be obese (BMI: 30.2 ± 5.2 kg/m² vs. 27.8 ± 4.2 kg/m², p < 0.001). Analysis indicated that diabetic patients were more likely to show LDL cholesterol levels below 55 mg/dL than patients without diabetes at the start of CR (Odds Ratio (OR) 1.9; 95% CI 1.3 to 2.9) until 3 months of follow-up (OR 1.9; 95% CI 1.2 to 2.9). During 12 months of follow-up, overall and LDL cholesterol levels decreased within the first 3 months and remained at the lower level thereafter (p < 0.001), irrespective of prevalent diabetes. At the end of the follow-up period, LDL cholesterol did not differ significantly between patients with or without diabetes mellitus (p = 0.413). Conclusion: Within 3 months after CR, total and LDL cholesterol were significantly reduced, irrespective of prevalent diabetes mellitus. In addition, CHD patients with diabetes responded faster to LTT than nondiabetic patients, suggesting that diabetic patients benefit more from LLT treatment during CR.

Usefulness of estimated average glucose (eAG) in glycemic control and cardiovascular risk reduction

OBJECTIVE

One of the 8 regional health authority (RHA) zones in New Brunswick, Canada has implemented eAG since 2010. We sought to evaluate the clinical outcomes of glycemic control and cardiovascular risk levels before and after the eAG implementation in this zone; and to compare the overall outcomes of this zone with other 7 zones of the province.

METHODS

Data (838,407 HbA1c values and 612,314 LDL-c values) was extracted from all adult diabetic patients in the provincial Diabetes Registry from 2008 to 2014. The Kruskal-Wallis statistic was conducted to compare the medians and inter quartile ranges of HbA1c and LDL-c from different zones. The proportion of patients achieving therapeutic targets, the distribution of HbA1c and LDL-c values pre/post the eAG implementation in RHA Zone 1.1 were assessed by Chi-square analysis.

RESULTS

The proportion of patients achieving targets in Zone 1.1 were at an intermediate level among all 8 zones and the trends of Zone 1.1 were no different than other zones. There were statistically significant differences for Zone 1.1 in the distribution of HbA1c (Z = -12.5190, P < 0.001) and LDL-c (Z = 16.4410, P < 0.001) before and after the eAG reported. The proportion of patients with HbA1c < 53 mmol/mol (7.0%) of the RHA Zone 1.1 was significantly lower after eAG reported (49.85% vs. 47.24%, P < 0.001); while the proportion of patients with LDL-c < 2.6 mmol/L showed statistically significant increase (68.56% vs. 71.90%, P < 0.001).

CONCLUSION

The utilization of eAG has demonstrated no significant impact on glycemic control and cardiovascular risk reduction.

The Usage of Lasso, Ridge, and Linear Regression to Explore the Most Influential Metabolic Variables that Affect Fasting Blood Sugar in Type 2 Diabetes Patients

Background and aims: To explore the most influential variables of fasting blood sugar (FBS) with three regression methods, to identify the existence chance of type 2 diabetes based on influential variables with logistic regression (LR), and to compare the three regression methods according to Mean Squared Error (MSE) value.

Material and Methods: In this cross-sectional study, 270 patients suffering from type 2 diabetes for at least 6 months and 380 healthy people were participated. The Linear regression, Ridge regression, and Least Absolute Shrinkage and Selection Operator (Lasso) regression were used to find influential variables for FBS.

Results: Among 15 variables (8 metabolic, 7 characteristic), Lasso regression selected HbA1c, Urea, age, BMI, heredity, and gender, Ridge regression selected HbA1c, heredity, gender, smoking status, and drug use, and Linear regression selected HbA1c as the most effective predictors for FBS.

Conclusion: HbA1c is the most influential predictor of FBS among 15 variables according to the result of three regression methods. Controlling the variation of HbA1c leads to a more stable FBS. Beside FBS that should be checked before breakfast, maybe HbA1c could be helpful in diagnosis of Type 2 diabetes.

Effect of lifestyle focused text messaging on risk factor modification in patients with diabetes and coronary heart disease: A sub-analysis of the TEXT ME study

AIMS

There is potential to provide public health interventions through text messaging for patients with Type 2 diabetes mellitus (T2DM). Our objective was to ascertain if lifestyle focused text messaging addressing cardiovascular risk factors in patients with coronary heart disease (CHD) and T2DM, was more effective than usual care.

METHODS

This is a secondary analysis of the TEXT ME study, a randomised clinical trial of a 6-month text messaging intervention in patients with coronary heart disease. The measured outcomes include cholesterol, blood pressure (BP), body mass index (BMI), HbA1c, waist/hip circumference and smoking status. Our objective was to ascertain if lifestyle focused text messaging in patients with T2DM was more effective than usual care, and to determine if the intervention was more effective in patients with T2DM compared to those without.

RESULTS

229 participants in the TEXT ME study had T2DM (32%), 111 participants in the intervention group and 118 in the control group. At 6 months, the mean difference in systolic BP was -7.6 mmHg (95%CI -11.8, -3.37, p = 0.0003) and diastolic BP -3.7 mmHg (95%CI -6.12, -1.24, p = 0.0032). The mean difference in low density lipoprotein in the intervention arm, compared to the control arm, was -0.05 mmol/L (95%CI -0.27, 0.18, p = 0.813), and in triglycerides was -0.29 mmol/L (95%CI -0.59, 0.01, p = 0.035) respectively. The mean difference in BMI was -0.89 kg/m² (95%CI -2.74, 0.95, p < 0.0001) in the intervention group, waist circumference -3.98 cm (95%CI -8.57, 0.61, p < 0.0001) and hip circumference -3.26 cm (95%CI -7.67, 1.16, p = 0.0006). Intervention subjects with diabetes were less likely to be smokers at 6 months. The mean difference in HbA1c between the control and intervention group was not significant (p = 0.126). The intervention was as effective in patients with diabetes, compared to those without.

CONCLUSION

Among patients with coronary heart disease with T2DM, lifestyle-focused text messaging resulted in significant risk factor reduction.

Regional evidence and international recommendations to guide lipid management in Asian patients with type 2 diabetes with special reference to renal dysfunction

The anticipated increase in the prevalence and incidence of type 2 diabetes in Asia, and its associated cardiovascular-renal complications, will place a significant burden on patients, caregivers, and society. Despite the proven effectiveness of lipid management in reducing these complications, there are major treatment gaps, especially in Asian patients with young-onset diabetes and chronic kidney disease (CKD). Recent international guidelines recommended the adoption of absolute risk estimation of atherosclerosis and cardiovascular disease to guide treatment intensity. These recommendations replaced the previous strategy of using low-density lipoprotein cholesterol targets to guide initiation and intensification of lipid lowering, albeit still widely practiced in Asia. The latest guidelines also highlight the high risk of atherosclerosis and cardiovascular disease (ASCVD) for people with diabetes, who should be protected with statins, except for young patients without other risk factors, who will need yearly monitoring of blood lipid levels. Given the propensity of Asian patients with diabetes to develop CKD and the amplifying effect of CKD on ASCVD, the use of statins in Asian patients is particularly important. Due to interethnic differences in drug metabolism, rosuvastatin, which is largely cleared by the kidney, should be prescribed in low dosages (5-10 mg daily) in Asian populations. Conversely, epidemiological and experimental data confirm pleotropic and organ-protective effects of atorvastatin, with proven safety in Asian populations within a daily dose range of 10-40 mg. Thus, there is a need for Asian countries to review and align their lipid-lowering treatment guidelines to reduce the substantial burden of diabetes in the Asian region.

Interplay between proteins and metabolic syndrome-A review

Metabolic syndrome is characterized by hypertension; hyperglycemia; hypertriglyceridemia; reduced high-density lipoprotein cholesterol levels and abdominal obesity. Abundant data suggest that, compared with other people, patients meeting these diagnostic criteria have a greater risk of having substantial clinical consequences, the two most prominent of which are the development of diabetes mellitus and coronary heart disease. The metabolic syndrome is a health issue of epidemic proportions. Its prevalence in the world continues to increase, hand in hand with that of obesity. Protein, on the other hand, is the foundation of cell-building, especially in muscle tissue. The body needs protein to build not only muscle cells, but the cells of major organs, skin and red blood cells. For people with metabolic syndrome, one of the other functions of protein is to slow down the absorption of carbohydrates. When proteins are consumed with carbohydrates, it takes longer for the digestive system to break down that meal. This means that the sugar created from those carbohydrates is released at a slower rate, preventing spikes in both blood sugar and insulin. As the understanding of the metabolic syndrome evolves, it is likely that more comprehensive therapeutic options will become available.

Can Cardiovascular Epidemiology and Clinical Trials Close the Risk Management Gap Between Diabetes and Prediabetes?

PURPOSE OF REVIEW

We reviewed published literature to determine the relationship between A1c and cardiovascular disease (CVD) and summarize the need and implications for CVD risk reduction with interventions, focusing in the prediabetic A1c range (<6.5%).

RECENT FINDINGS

Strong evidence supports a continuous relationship between A1c and CVD-even below the current levels of A1c-defined prediabetes and after adjustment for known risk factors for CVD. Clinical trials have demonstrated a reduction in CV morbidity and/or mortality when interventions are invoked in the prediabetic A1c range. Guidelines advocating CV risk factor management in prediabetes have not been widely adopted, subsequently leading to comparable coronary heart disease risk between people with prediabetes (HR = 1.9, 95% CI 1.7-2.1 vs normoglycemia) and diabetes itself (HR=2.0, 95% CI 1.8-2.2 vs no diabetes). This review highlights the missed opportunity to utilize multiple risk factor interventions to reduce CVD in high-risk people with prediabetes.

The American Heart Association Ideal Cardiovascular Health and Incident Type 2 Diabetes Mellitus Among Blacks: The Jackson Heart Study

Background

The concept of ideal cardiovascular health (CVH), defined by the American Heart Association primarily for coronary heart disease and stroke prevention, may apply to diabetes mellitus prevention among blacks.

Methods and Results

Our sample included 2668 adults in the Jackson Heart Study with complete baseline data on 6 of 7 American Heart Association CVH metrics (body mass index, healthy diet, smoking, total cholesterol, blood pressure, and physical activity). Incident diabetes mellitus was defined as fasting glucose ≥126 mg/dL, physician diagnosis, use of diabetes mellitus drugs, or glycosylated hemoglobin ≥6.5%. A summary CVH score from 0 to 6, based on presence/absence of ideal CVH metrics, was derived for each participant. Cox regression was used to estimate adjusted hazard ratios. Mean age was 55 years (65% women) with 492 incident diabetes mellitus events over 7.6 years (24.6 cases/1000 person‐years). Three quarters of participants had only 1 or 2 ideal CVH metrics; no participant had all 6. After adjustment for demographic factors (age, sex, education, and income) and high‐sensitivity C‐reactive protein, each additional ideal CVH metric was associated with a 17% diabetes mellitus risk reduction (hazard ratio, 0.83; 95% CI, 0.74–0.93). The association was attenuated with further adjustment for homeostasis model assessment for insulin resistance (hazard ratio, 0.89; 95% CI, 0.79–1.00). Compared with participants with 1 or no ideal CVH metric, diabetes mellitus risk was 15% and 37% lower in those with 2 and ≥3 ideal CVH metrics, respectively.

Conclusions

The AHA concept of ideal CVH is applicable to diabetes mellitus prevention among blacks. These associations were largely explained by insulin resistance.

Pharmacologic Treatment of Dyslipidemia in Diabetes: A Case for Therapies in Addition to Statins

PURPOSE OF REVIEW

The purpose of the study is to review the use of statins and the role of both non-statin lipid-lowering agents and diabetes-specific medications in the treatment of diabetic dyslipidemia.

RECENT FINDINGS

Statins have a primary role in the treatment of dyslipidemia in people with type 2 diabetes, defined as triglyceride levels >200 mg/dl and HDL cholesterol levels <40 mg/dL. A number of clinical trials suggest that treatment with a fibrate may reduce cardiovascular events. However, the results of these trials are inconsistent, probably because many of their participants did not have dyslipidemia. The choice of medications used to treat diabetes can have major implications regarding management of dyslipidemia; metformin, GLP-1 agonists, and pioglitazone all have favorable lipid effects. These agents, as well as the new SGLT2 inhibitors, may reduce cardiovascular events. Management of dyslipidemia in people with type 2 diabetes should start with statin therapy and optimal glycemic control with agents that have favorable lipid and cardiovascular effects. We believe that there is a role for adding fenofibrate to moderate-intensity statins in selected patients with true dyslipidemia. We propose an algorithm for selecting add-on medications for diabetes (after metformin) based on lipid status.

Consensus on the Statin of Choice in Patients with Impaired Glucose Metabolism: Results of the DIANA Study

Introduction and Objectives

Despite the recognized clinical benefit of statins on cardiovascular prevention, providing correct management of hypercholesterolaemia, possible adverse effects of their use cannot be disregarded. Previously published data shows that there is a risk of developing diabetes mellitus or experiencing changes in glucose metabolism in statin-treated patients. The possible determining factors are the drug characteristics (potency, dose), patient characteristics (kidney function, age, cardiovascular risk and polypharmacy because of multiple disorders) and the pre-diabetic state.

Methods

In order to ascertain the opinion of the experts (primary care physicians and other specialists with experience in the management of this type of patient) we conducted a Delphi study to evaluate the consensus rate on diverse aspects related to the diabetogenicity of different statins, and the factors that influence their choice.

Results

Consensus was highly significant concerning aspects such as the varying diabetogenicity profiles of different statins, as some of them do not significantly worsen glucose metabolism. There was an almost unanimous consensus that pitavastatin is the safest statin in this regard.

Conclusions

Factors to consider in the choice of a statin regarding its diabetogenicity are the dose and patient-related factors: age, cardiovascular risk, diabetes risk and baseline metabolic parameters (which must be monitored during the treatment), as well as kidney function.

Reducing cardiovascular risk in patients with type 2 diabetes: the potential contribution of nicotinic acid

Current treatment guidelines highlight the increased cardiovascular risk associated with type 2 diabetes and identify the need for intensive risk factor management. Dyslipidaemia characterised by elevated serum triglycerides, low levels of high-density lipoprotein cholesterol (HDL-C) and an increase in small, dense low-density lipoprotein cholesterol (LDL-C) particles (the lipid triad), is one of the most important modifiable cardiovascular risk factors in patients with type 2 diabetes. Statins, which are effective in reducing LDL-C, are currently considered the foundation of lipid-lowering treatment in type 2 diabetes, in addition to lifestyle modification. Increasingly, guidelines also identify low HDL-C as an important secondary priority for treatment. Of the available treatment options, both fibrates and nicotinic acid are effective in treating dyslipidaemia associated with type 2 diabetes, although the latter has greater potency in raising HDL-C. Based on its profile of activity, addition of nicotinic acid to primary statin therapy would be a logical strategy in the treatment of diabetic dyslipidaemia. Outcome data from large prospective studies are awaited to confirm the potential morbidity and mortality benefits of this approach.

Clinical trials of lipid-lowering medication in diabetes

Evidence that patients with type 2 diabetes can benefit from statin therapy is strong. Issues remain to be resolved about whether all patients with type 2 diabetes should receive statin treatment. For the present the National Institute for Clinical Excellence has recommended statin treatment in secondary prevention and in primary prevention when coronary heart disease (CHD) risk exceeds 15% over the next 10 years or lipid levels are high. Fibrates are a better first-line drug therapy when triglycerides exceed 10 mmol/L. Consideration should also be given to combining a fibrate with a statin in patients with CHD whose triglycerides exceed 2.3 mmol/L despite statin treatment, but this requires careful monitoring for myositis. Clinical guidelines are needed for the use of lipid-lowering medication in type 1 diabetes.

The treatment of type 2 diabetes mellitus in youth : which therapies?

Type 2 diabetes mellitus in children and adolescents is becoming an increasingly important public health concern throughout the world. This epidemic is closely associated with the increased prevalence of obesity among youth of all ethnic backgrounds, as increased visceral adipose tissue produces adipokines that increase insulin resistance. Type 2 diabetes represents one arm of the metabolic syndrome, which includes abdominal obesity, disturbed glucose regulation and insulin resistance, dyslipidemia, and hypertension. The treatment of type 2 diabetes and the metabolic syndrome poses a challenge for pediatric endocrinologists. This review provides information regarding diagnosis of type 2 diabetes in children, as well as prevention strategies, such as lifestyle modification and pharmacologic options for weight loss, including metformin, orlistat, and sibutramine. Pharmacologic treatment options, their modes of action, and clinical indications for use are also reviewed. Treatment regimens for youth-onset type 2 diabetes that are discussed include metformin, sulfonylureas, glucosidase inhibitors, thiazolidinediones, glucagon-like peptide-1, and insulin.

Persistent lipid abnormalities in statin-treated patients: Portuguese diabetic subpopulation of the Dyslipidaemia International Study (DYSIS)

AIMS

To assess the treatment patterns and prevalence of persistent lipid abnormalities in Portuguese statin-treated patients with diabetes.

METHODS

DYSIS was an epidemiological, cross-sectional and multicentre international study. Outpatients ≥ 45 years old seen at primary and secondary care centres and treated with statins for at least three months were enrolled. This study presents the results for the Portuguese subpopulation, focusing on lipid control of the diabetic patients.

RESULTS

Of the 916 patients recruited, 348 (38%) had diabetes mellitus (DM). The majority of the diabetic patients (58%) failed to attain an LDL-C < 2.5 mmol/L, and 77% did not reach the optional goal of LDL-C < 2.0 mmol/L set by the 2007 recommendations of the European Society of Cardiology. The most frequently used statin was simvastatin, both in patients with and without diabetes (55.7% vs. 57.1%, p = 0.68). The mean (SD) statin dose in simvastatin-equivalent units was 26.1 (9.2) mg in diabetics and 25.3 (8.8 mg) in non-diabetics (p = 0.19).

CONCLUSIONS

The majority of Portuguese diabetic patients treated with statins failed to attain the recommended LDL cholesterol goals. Relatively low doses of medium potency statins were the prevailing therapy. There seems to be considerable room for improvement through the use of more potent statins, dose up-titration and/or the addition of other lipid-modifying therapies.

WITHDRAWN: Targeting intensive glycaemic control versus targeting conventional glycaemic control for type 2 diabetes mellitus

The Cochrane Metabolic and Endocrine Disorders Group withdrew this review as of Issue 7, 2015 because the involvement of two authors (C Hemmingsen and SS Lund) being employed in pharmaceutical companies. The authors of the review and the Cochrane Metabolic and Endocrine Disorders Group did not find that this was a breach of the rules of the Cochrane Collaboration at the time when it was published. However, after the publication of the review, the Cochrane Collaboration requested withdrawal of the review due to the employment of the two authors. A new protocol for a review to cover this topic will be published. This will have a new title and a markedly improved protocol fulfilling new and important developments and standards within the Cochrane Collaboration as well as an improved inclusion and search strategy making it necessary to embark on a completely new review project.

The editorial group responsible for this previously published document have withdrawn it from publication.

Cholesterol lowering in diabetes

Recent guidelines for treating patients with diabetes categorize the disorder as a coronary heart disease (CHD) equivalent and urge aggressive treatment of modifiable risk factors, such as plasma levels of low-density lipoprotein cholesterol (LDL-C). In this article, Dr Rosenson discusses the rationale for cholesterol lowering in patients with diabetes, the lipoprotein abnormalities that accompany insulin resistance, and the prognostic significance of high LDL particle numbers. He also highlights major findings from recent clinical trials to explore statin therapy and other treatment strategies for lowering lipoprotein levels in this patient population.

Disparities in lipid control and statin drug use among diabetics with noncoronary atherosclerotic vascular disease vs those with coronary artery disease

BACKGROUND

Diabetes mellitus (DM), coronary artery disease (CAD), and noncoronary atherosclerotic vascular diseases (NCVDs) have similar risks of cardiovascular events and similar recommendations for lipid control. There are limited data regarding lipid control in diabetic patients with NCVD in current clinical practice.

OBJECTIVE

To assess current day practice of lipid control in patients with DM with NCVD vs those with CAD.

METHODS

We retrospectively identified 3336 patients with DM and known atherosclerotic vascular disease between January 2009 and March 2012. We compared demographic variables, lipid levels, and statin use in diabetics with CAD alone vs diabetics without CAD but with one or more NCVD.

RESULTS

There were 234 patients in DM with NCVD group and 3102 patients in DM with CAD group. The DM with NCVD group had a higher mean total cholesterol (152 ± 40 vs 146 ± 42 mg/dL; P = .019) and mean low-density lipoprotein (LDL; 86 ± 35 vs 80 ± 34 mg/dL; P = .04) with only 70% of patients achieving LDL of <100 mg/dL (compared with 80% in the DM with CAD group; P < .001). Statin use was 100% in CAD vs 75% in NCVD group (P < .001). In addition to limited use of more potent statins in the NCVD group, there was also a significantly lower dose of statins used overall.

CONCLUSION

Our study demonstrates lower use and less aggressive application of statins among diabetics with NCVD compared with diabetics with CAD, resulting in higher mean LDL and total cholesterol in the NCVD group.

The Effect of Rosuvastatin on Low-Density Lipoprotein Subfractions in Patients With Impaired Fasting Glucose

Background:

Prediabetes substantially increases cardiovascular risk. We examined the effect of rosuvastatin on the quantity and quality of low-density lipoprotein cholesterol (LDL-C) in patients with dyslipidemia having impaired fasting glucose (IFG) compared to normoglycemic patients with dyslipidemia.

Methods:

This was a prospective observational study including patients with dyslipidemia and IFG (IFG group, n = 49) matched with normoglycemic patients with dyslipidemia (control group, n = 64). Study participants, following dietary intervention, were prescribed rosuvastatin 10 or 20 mg/d to achieve LDL-C goals. Baseline as well as 24 weeks posttreatment changes in the serum lipid profile were evaluated. Moreover, analysis of the LDL subfraction profile was conducted using a polyacrylamide tube gel electrophoresis method.

Results:

Similar effects were observed in lipid profile in both treatment groups. Patients with IFG experienced a greater decrease in the cholesterol concentration of small dense LDL particles (−65.7%, P < .001 vs baseline) compared to controls (−38.5%, P < .001 vs baseline; P = .018 vs patients with IFG). There was no significant difference in the changes of cholesterol concentration of large and buoyant LDL particles in the IFG group when compared to the control group. A greater increase in the mean LDL particle size (+1.5%, P < .001 vs baseline) was noted in the IFG group compared to the control group at 24 weeks (+0.4%, P = .028 vs baseline; P = .008 vs IFG group).

Conclusion:

Targeting dyslipidemia with rosuvastatin was associated with more favorable changes in the LDL subfraction profile in patients with IFG compared to normoglycemic ones.

Novel determinants preventing achievement of major cardiovascular targets in type 2 diabetes

BACKGROUND

T2DM management requires tight control of 3 critical quality indicators to prevent vascular complications: LDL-C, SBP, and HbA1c. This study evaluated the rate of T2DM patients attaining these critical quality indicators, and the pathophysiological or cardiometabolic traits predicting goal achievement.

PATIENTS AND METHODS

Cross-sectional analysis evaluating combined goal achievement (LDL-C<100 mg/dL; SBP<130 mmHg and HbA1c<7.0%) in 1005 T2DM outpatients (654 men) followed in a university hospital multidisciplinary department. Triple-goal achievers were compared to non-achievers regarding sociodemographics; anthropometrics; homeostatic model assessment (HOMA; β-cell function (B); insulin sensitivity (S); hyperbolic product (B×S)); CV and glucose-lowering drugs; micro-/macro-vascular outcomes; and 10-year UKPDS risk.

RESULTS

Eighty-eight patients (9%; ((3 targets) group) reached all goals, whereas 917 patients (91%; ((0-2 target(s)) group) missed 1, 2 or all 3 goals. Compared to (0-2 target(s)), (3 targets) had shorter diabetes duration; less familial diabetes history; lower waist/visceral fat; higher β-cell function and hyperbolic product (B×S); lower (B×S) loss rate and less metabolic syndrome (all p<0.05). They had lower apoB and triglycerides; and a 28% prevalence of atherogenic dyslipidemia (vs. 40% in (0-2 target(s)); p 0.0398). Microangiopathy (36% vs. 53%) and 10-year CAD risk (13% vs. 18%) were also significantly lower in (3 targets).

CONCLUSIONS

The subset of T2DM patients achieving all critical quality indicators are characterized by a less severe cardiometabolic phenotype, while exhibiting a less pronounced alteration of their residual β-cell function. These differences are related to fewer microvascular outcomes and lower 10-year CV risk.

Cardiac autonomic testing and treating heart disease. "A clinical perspective"

Background

Coronary heart disease (CHD) is a major health concern, affecting nearly half the middle-age population and responsible for nearly one-third of all deaths. Clinicians have several major responsibilities beyond diagnosing CHD, such as risk stratification of patients for major adverse cardiac events (MACE) and treating risks, as well as the patient. This second of a two-part review series discusses treating risk factors, including autonomic dysfunction, and expected outcomes.

Methods

Therapies for treating cardiac mortality risks including cardiovascular autonomic neuropathy (CAN), are discussed.

Results

While risk factors effectively target high-risk patients, a large number of individuals who will develop complications from heart disease are not identified by current scoring systems. Many patients with heart conditions, who appear to be well-managed by traditional therapies, experience MACE. Parasympathetic and Sympathetic (P&S) function testing provides more information and has the potential to further aid doctors in individualizing and titrating therapy to minimize risk. Advanced autonomic dysfunction (AAD) and its more severe form cardiovascular autonomic neuropathy have been strongly associated with an elevated risk of cardiac mortality and are diagnosable through autonomic testing. This additional information includes patient-specific physiologic measures, such as sympathovagal balance (SB). Studies have shown that establishing and maintaining proper SB minimizes morbidity and mortality risk.

Conclusions

P&S testing promotes primary prevention, treating subclinical disease states, as well as secondary prevention, thereby improving patient outcomes through (1) maintaining wellness, (2) preventing symptoms and disorder and (3) treating subclinical manifestations (autonomic dysfunction), as well as (4) disease and symptoms (autonomic neuropathy).

HMG CoA reductase inhibitors (statins) for people with chronic kidney disease not requiring dialysis

BACKGROUND

Cardiovascular disease (CVD) is the most frequent cause of death in people with early stages of chronic kidney disease (CKD), for whom the absolute risk of cardiovascular events is similar to people who have existing coronary artery disease. This is an update of a review published in 2009, and includes evidence from 27 new studies (25,068 participants) in addition to the 26 studies (20,324 participants) assessed previously; and excludes three previously included studies (107 participants). This updated review includes 50 studies (45,285 participants); of these 38 (37,274 participants) were meta-analysed.

OBJECTIVES

To evaluate the benefits (such as reductions in all-cause and cardiovascular mortality, major cardiovascular events, MI and stroke; and slow progression of CKD to end-stage kidney disease (ESKD)) and harms (muscle and liver dysfunction, withdrawal, and cancer) of statins compared with placebo, no treatment, standard care or another statin in adults with CKD who were not on dialysis.

SEARCH METHODS

We searched the Cochrane Renal Group's Specialised Register to 5 June 2012 through contact with the Trials' Search Co-ordinator using search terms relevant to this review.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and quasi-RCTs that compared the effects of statins with placebo, no treatment, standard care, or other statins, on mortality, cardiovascular events, kidney function, toxicity, and lipid levels in adults with CKD not on dialysis were the focus of our literature searches.

DATA COLLECTION AND ANALYSIS

Two or more authors independently extracted data and assessed study risk of bias. Treatment effects were expressed as mean difference (MD) for continuous outcomes (lipids, creatinine clearance and proteinuria) and risk ratio (RR) for dichotomous outcomes (major cardiovascular events, all-cause mortality, cardiovascular mortality, fatal or non-fatal myocardial infarction (MI), fatal or non-fatal stroke, ESKD, elevated liver enzymes, rhabdomyolysis, cancer and withdrawal rates) with 95% confidence intervals (CI).

MAIN RESULTS

We included 50 studies (45,285 participants): 47 studies (39,820 participants) compared statins with placebo or no treatment and three studies (5547 participants) compared two different statin regimens in adults with CKD who were not yet on dialysis. We were able to meta-analyse 38 studies (37,274 participants).The risk of bias in the included studies was high. Seven studies comparing statins with placebo or no treatment had lower risk of bias overall; and were conducted according to published protocols, outcomes were adjudicated by a committee, specified outcomes were reported, and analyses were conducted using intention-to-treat methods. In placebo or no treatment controlled studies, adverse events were reported in 32 studies (68%) and systematically evaluated in 16 studies (34%).Compared with placebo, statin therapy consistently prevented major cardiovascular events (13 studies, 36,033 participants; RR 0.72, 95% CI 0.66 to 0.79), all-cause mortality (10 studies, 28,276 participants; RR 0.79, 95% CI 0.69 to 0.91), cardiovascular death (7 studies, 19,059 participants; RR 0.77, 95% CI 0.69 to 0.87) and MI (8 studies, 9018 participants; RR 0.55, 95% CI 0.42 to 0.72). Statins had uncertain effects on stroke (5 studies, 8658 participants; RR 0.62, 95% CI 0.35 to 1.12).Potential harms from statin therapy were limited by lack of systematic reporting and were uncertain in analyses that had few events: elevated creatine kinase (7 studies, 4514 participants; RR 0.84, 95% CI 0.20 to 3.48), liver function abnormalities (7 studies, RR 0.76, 95% CI 0.39 to 1.50), withdrawal due to adverse events (13 studies, 4219 participants; RR 1.16, 95% CI 0.84 to 1.60), and cancer (2 studies, 5581 participants; RR 1.03, 95% CI 0.82 to 130).Statins had uncertain effects on progression of CKD. Data for relative effects of intensive cholesterol lowering in people with early stages of kidney disease were sparse. Statins clearly reduced risks of death, major cardiovascular events, and MI in people with CKD who did not have CVD at baseline (primary prevention).

AUTHORS' CONCLUSIONS

Statins consistently lower death and major cardiovascular events by 20% in people with CKD not requiring dialysis. Statin-related effects on stroke and kidney function were found to be uncertain and adverse effects of treatment are incompletely understood. Statins have an important role in primary prevention of cardiovascular events and mortality in people who have CKD.

Torcetrapib/atorvastatin combination therapy

Elevated blood levels of low-density lipoprotein cholesterol (LDL-C) are associated with an increased risk for atherosclerotic coronary heart disease (CHD). Atorvastatin is a statin drug that inhibits 3-hydroxy-3-methyl-glutaryl coenzyme A reductase (the rate-limiting step of cholesterol production) and primarily lowers LDL-C levels. Atorvastatin has also been shown to significantly reduce CHD events. However, as with all statins (and all other monotherapy lipid-altering drugs), atorvastatin alone reduces the risk of CHD in only a minority of patients relative to placebo. Conversely, it is low levels of high-density lipoprotein cholesterol that are associated with increased CHD risk. Torcetrapib is a cholesteryl ester transfer protein inhibitor that primarily raises high-density lipoprotein cholesterol levels, and cholesteryl ester transfer protein inhibition has generally been shown to reduce atherosclerosis in rabbits. Taken together, atorvastatin and torcetrapib provide striking improvements in lipid levels, and complementary actions upon important lipid parameters. This review examines the chemistry, mechanism of action, pharmacokinetics, metabolism, safety/tolerability and efficacy of the combination torcetrapib/atorvastatin agent that is currently in development and that provides complementary lipid benefits towards the goal of reducing CHD risk beyond that of atorvastatin alone.

Greenselect phytosome for borderline metabolic syndrome

The beneficial effects of Greenselect Phytosome, a proprietary lecithin formulation of a caffeine-free green tea catechin extract, were evaluated in a controlled registry study on 50 asymptomatic subjects borderline for metabolic syndrome factors and with increased plasma oxidative stress. After 24 weeks of intervention, improvement in weight, blood lipid profile, and blood pressure positioned 68% of subjects in the treatment arm out of the metabolic syndrome profile, while 80% of the subjects in the control group still remained in their initial borderline disease signature. Compared to the control (lifestyle and dietary changes alone), Greenselect Phytosome was especially effective for weight/waist changes. These results highlight the relevance of addressing multiple factors involved in the development of metabolic syndrome with a pleiotropic agent capable of improving the beneficial effects of lifestyle and dietary changes and foster the attainment of a globally improved health profile.

Targeting intensive glycaemic control versus targeting conventional glycaemic control for type 2 diabetes mellitus

BACKGROUND

Patients with type 2 diabetes mellitus (T2D) have an increased risk of cardiovascular disease and mortality compared to the background population. Observational studies report an association between reduced blood glucose and reduced risk of both micro- and macrovascular complications in patients with T2D. Our previous systematic review of intensive glycaemic control versus conventional glycaemic control was based on 20 randomised clinical trials that randomised 29 ,986 participants with T2D. We now report our updated review.

OBJECTIVES

To assess the effects of targeted intensive glycaemic control compared with conventional glycaemic control in patients with T2D.

SEARCH METHODS

Trials were obtained from searches of The Cochrane Library, MEDLINE, EMBASE, Science Citation Index Expanded, LILACS, and CINAHL (all until December 2012).

SELECTION CRITERIA

We included randomised clinical trials that prespecified targets of intensive glycaemic control versus conventional glycaemic control targets in adults with T2D.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed the risk of bias and extracted data. Dichotomous outcomes were assessed by risk ratios (RR) and 95% confidence intervals (CI). Health-related quality of life and costs of intervention were assessed with standardized mean differences (SMD) and 95% Cl.

MAIN RESULTS

Twenty-eight trials with 34,912 T2D participants randomised 18,717 participants to intensive glycaemic control versus 16,195 participants to conventional glycaemic control. Only two trials had low risk of bias on all risk of bias domains assessed. The duration of the intervention ranged from three days to 12.5 years. The number of participants in the included trials ranged from 20 to 11,140. There were no statistically significant differences between targeting intensive versus conventional glycaemic control for all-cause mortality (RR 1.00, 95% CI 0.92 to 1.08; 34,325 participants, 24 trials) or cardiovascular mortality (RR 1.06, 95% CI 0.94 to 1.21; 34,177 participants, 22 trials). Trial sequential analysis showed that a 10% relative risk reduction could be refuted for all-cause mortality. Targeting intensive glycaemic control did not show a statistically significant effect on the risks of macrovascular complications as a composite outcome in the random-effects model, but decreased the risks in the fixed-effect model (random RR 0.91, 95% CI 0.82 to 1.02; and fixed RR 0.93, 95% CI 0.87 to 0.99; P = 0.02; 32,846 participants, 14 trials). Targeting intensive versus conventional glycaemic control seemed to reduce the risks of non-fatal myocardial infarction (RR 0.87, 95% CI 0.77 to 0.98; P = 0.02; 30,417 participants, 14 trials), amputation of a lower extremity (RR 0.65, 95% CI 0.45 to 0.94; P = 0.02; 11,200 participants, 11 trials), as well as the risk of developing a composite outcome of microvascular diseases (RR 0.88, 95% CI 0.82 to 0.95; P = 0.0008; 25,927 participants, 6 trials), nephropathy (RR 0.75, 95% CI 0.59 to 0.95; P = 0.02; 28,096 participants, 11 trials), retinopathy (RR 0.79, 95% CI 0.68 to 0.92; P = 0.002; 10,300 participants, 9 trials), and the risk of retinal photocoagulation (RR 0.77, 95% CI 0.61 to 0.97; P = 0.03; 11,212 participants, 8 trials). No statistically significant effect of targeting intensive glucose control could be shown on non-fatal stroke, cardiac revascularization, or peripheral revascularization. Trial sequential analyses did not confirm a reduction of the risk of non-fatal myocardial infarction but confirmed a 10% relative risk reduction in favour of intensive glycaemic control on the composite outcome of microvascular diseases. For the remaining microvascular outcomes, trial sequential analyses could not establish firm evidence for a 10% relative risk reduction. Targeting intensive glycaemic control significantly increased the risk of mild hypoglycaemia, but substantial heterogeneity was present; severe hypoglycaemia (RR 2.18, 95% CI 1.53 to 3.11; 28,794 participants, 12 trials); and serious adverse events (RR 1.06, 95% CI 1.02 to 1.10; P = 0.007; 24,280 participants, 11 trials). Trial sequential analysis for a 10% relative risk increase showed firm evidence for mild hypoglycaemia and serious adverse events and a 30% relative risk increase for severe hypoglycaemia when targeting intensive versus conventional glycaemic control. Overall health-related quality of life, as well as the mental and the physical components of health-related quality of life did not show any statistical significant differences.

AUTHORS' CONCLUSIONS

Although we have been able to expand the number of participants by 16% in this update, we still find paucity of data on outcomes and the bias risk of the trials was mostly considered high. Targeting intensive glycaemic control compared with conventional glycaemic control did not show significant differences for all-cause mortality and cardiovascular mortality. Targeting intensive glycaemic control seemed to reduce the risk of microvascular complications, if we disregard the risks of bias, but increases the risk of hypoglycaemia and serious adverse events.

Benchmarking is associated with improved quality of care in type 2 diabetes: the OPTIMISE randomized, controlled trial

OBJECTIVE

To assess prospectively the effect of benchmarking on quality of primary care for patients with type 2 diabetes by using three major modifiable cardiovascular risk factors as critical quality indicators.

RESEARCH DESIGN AND METHODS

Primary care physicians treating patients with type 2 diabetes in six European countries were randomized to give standard care (control group) or standard care with feedback benchmarked against other centers in each country (benchmarking group). In both groups, laboratory tests were performed every 4 months. The primary end point was the percentage of patients achieving preset targets of the critical quality indicators HbA1c, LDL cholesterol, and systolic blood pressure (SBP) after 12 months of follow-up.

RESULTS

Of 4,027 patients enrolled, 3,996 patients were evaluable and 3,487 completed 12 months of follow-up. Primary end point of HbA1c target was achieved in the benchmarking group by 58.9 vs. 62.1% in the control group (P = 0.398) after 12 months; 40.0 vs. 30.1% patients met the SBP target (P < 0.001); 54.3 vs. 49.7% met the LDL cholesterol target (P = 0.006). Percentages of patients meeting all three targets increased during the study in both groups, with a statistically significant increase observed in the benchmarking group. The percentage of patients achieving all three targets at month 12 was significantly larger in the benchmarking group than in the control group (12.5 vs. 8.1%; P < 0.001).

CONCLUSIONS

In this prospective, randomized, controlled study, benchmarking was shown to be an effective tool for increasing achievement of critical quality indicators and potentially reducing patient cardiovascular residual risk profile.

Reassessing the benefits of statins in the prevention of cardiovascular disease in diabetic patients--a systematic review and meta-analysis

OBJECTIVES

Despite the fact that statins have been prescribed widely, cardiovascular disease (CVD) remains the leading cause of death in diabetic patients. The aim of this study was to reassess the benefits of statins for CVD prevention in patients with diabetes mellitus.

METHODS

Two independent investigators searched for prospective, randomized statin trials that investigated the power of reducing CVD in statin-treated patients. The search was performed using Pubmed, Web of Science, and CENTRAL databases. Data was extracted from eligible studies.

RESULTS

A total of 7061 articles were surveyed and 22 articles were identified as eligible articles. The meta-analyses of the 22 trials showed that statin treatment was positively associated with a lowered risk of CVD in the following groups: (i) total population with pooled odds ratios (OR) of 0.791 (95 % CI: 0.74-0.846, p < 0.001), (ii) diabetic population with OR 0.792 (95% CI: 0.721-0.872, p < 0.001), and (iii) non-diabetic population with OR 0.791 (95% CI: 0.730-0.857, p < 0.001). In diabetic patients, statins were also helpful in the primary and secondary prevention of CVD, with pooled ORs of 0.757 (95% CI: 0.676 to 0.847, p < 0.001) and 0.800 (95% CI: 0.712 to 0.898, p < 0.001), respectively. However, when trials that investigated only diabetic patients (i.e., CARDS, 4D, and ASPEN) were included in the analysis, statin treatment was not found to reduce CVD significantly (OR: 0.817, 95% CI: 0.649 to 1.029, p = 0.086). Furthermore, after performing subgroup analysis, no benefit of statin treatment was found in primary prevention (OR: 0.774, 95% CI: 0.506 to 1.186, p = 0.240) or secondary prevention (OR: 0.893, 95% CI: 0.734 to 1.088, p = 0.262) of CVD in diabetic patients.

CONCLUSIONS

Although our study may be limited by unmeasured confounders and heterogeneity among the studies included, the results suggest that the effects of statins in the prevention of CVD in diabetic patients are not only beneficial. More informative data are needed to verify the benefits of statins in the protection against CVD in diabetic patients.

Statins and diabetes: the good, the bad, and the unknown

The ability for statins to reduce major cardiovascular events and mortality has lead to this drug class being the most commonly prescribed in the world. In particular, the benefit of these drugs in type 2 diabetes (T2D) is well established. In February 2012, the Food and Drug Administration released changes to statin safety label to include that statins have been associated with increases in hemoglobin A1C and fasting serum glucose levels. This has stirred much debate in the medical community. Estimate for new onset diabetes from statin treatment is approximately one in 255 patients over four years. The number needed to treat for statin benefit is estimated at one in 40 depending on the population. The mechanism of this link remains unknown. Statins may accelerate progression to diabetes via molecular mechanisms that impact insulin resistance and cellular metabolism of carbohydrates. It remains clear that the benefit of statin therapy outweighs the risk of developing diabetes.

Management of dyslipidemia and hyperglycemia with a fixed-dose combination of sitagliptin and simvastatin

The risk of death due to heart disease and stroke is up to four times higher in individuals with diabetes compared to individuals without diabetes. Most guidelines that address treatment of dyslipidemia in patients with diabetes consider diabetes a cardiovascular disease (CVD) "risk equivalent" and recommend intensive treatment of dyslipidemia for the purpose of CVD prevention. Statins (3-hydroxy 3-methylglutaryl coenzyme A reductase [HMG-CoA reductase] inhibitors) are first-line agents in achieving lipid goals as an adjunct to diet and exercise and should be used in most patients. In addition to lipid management and blood pressure control, glycemic control is a basic component in the management of diabetes. Glycemic control is achieved by combining diabetes self-management education, diet and exercise, and, where required, antihyperglycemic agents (OHAs). Persistence and adherence to therapy are critical in achieving recommended treatment goals. However, overall compliance with concomitantly prescribed OHAs and statins is low in patients with type 2 diabetes. Fixed-dose combination (FDC) therapies have been shown to improve adherence by reducing pill burden, the complexity of treatment regimen, and, potentially, cost. Based on the available evidence regarding the pharmacokinetics and the efficacy and safety profiles of each component drug, the sitagliptin/simvastatin FDC may provide a rational and well-tolerated approach to achieving better adherence to multiple-drug therapy and improved lipid lowering and glycemic control, with consequent reduction in cardiovascular risk, diabetic microvascular disease, and mortality in diabetic patients for whom treatment with both compounds is appropriate.

Clinical Trials and Lipid Guidelines for Type II Diabetes

The management of dyslipidemia in adults with diabetes is receiving more attention. However, there is a paucity of large, prospective, randomized outcome trials designed for diabetic patients. Diabetic dyslipidemia is characterized by an increase in triglyceride levels, low high-density lipoprotein (HDL) cholesterol concentrations, and small, dense low-density lipoprotein (LDL) particles. The treatment goals include an LDL cholesterol less than 100 mg/dL, triglyceride level less than 150 mg/dL, and an HDL greater than 40 mg/dL for men and more than 50 mg/dL for women. In the Diabetic Atherosclerosis Intervention Study, fenofibrate resulted in a 42% less increase in the percent stenosis, as assessed by quantitative coronary arteriography. The Heart Protection Study documented the unambiguous benefit of simvastatin in reducing all-cause mortality among 5963 diabetic patients. The Lescol Intervention Prevention Study observed a reduction in major adverse cardiac events in diabetics undergoing percutaneous intervention who received fluvastatin. The Veterans Affairs HDL Cholesterol Intervention Trial reported a reduction in major coronary events among 627 diabetic patients with low HDL cholesterol who sustained a myocardial infarction. The Fenofibrate Intervention and Event Lowering in Diabetics (FIELD) Trial (n = 9795), the Action to Control Cardiovascular Risk in Diabetes (ACCORD, n = 10,000), the Atorvastatin Study for Prevention of Coronary Heart Disease Endpoints in Non Insulin Dependent Diabetes Mellitus (ASPEN, n = 2421), and the Collaborative Atorvastatin Diabetes Study (CARDS, n = 2140) will provide the prospective outcome data that are needed for the management of patients. Combination drug therapy will be necessary to achieve treatment goals. Careful monitoring will be required to avoid myositis and hepatotoxicity.

Meta-analysis of comparison of effectiveness of lowering apolipoprotein B versus low-density lipoprotein cholesterol and nonhigh-density lipoprotein cholesterol for cardiovascular risk reduction in randomized trials

This study evaluated the relation between apolipoprotein B (apoB) decrease and coronary heart disease, stroke, and cardiovascular disease risk. Bayesian random-effects meta-analysis was used to evaluate the association of mean absolute apoB decrease (milligrams per deciliter) with relative risk of coronary heart disease (nonfatal myocardial infarction and coronary heart disease death), stroke (nonfatal stroke and fatal stroke), or cardiovascular disease (coronary heart disease, stroke, and coronary revascularization). Analysis included 25 trials (n = 131,134): 12 on statin, 4 on fibrate, 5 on niacin, 2 on simvastatin-ezetimibe, 1 on ileal bypass surgery, and 1 on aggressive versus standard low-density lipoprotein (LDL) cholesterol and blood pressure targets. Combining the 25 trials, each 10-mg/dl decrease in apoB was associated with a 9% decrease in coronary heart disease, no decrease in stroke, and a 6% decrease in major cardiovascular disease risk. Non-high-density lipoprotein (non-HDL) cholesterol decrease modestly outperformed apoB decrease for prediction of coronary heart disease (Bayes factor [BF] 1.45) and cardiovascular disease (BF 2.07) risk decrease; apoB decrease added to non-HDL cholesterol plus LDL cholesterol decrease slightly improved cardiovascular disease risk prediction (1.13) but did not improve coronary heart disease risk prediction (BF 1.03) and worsened stroke risk prediction (BF 0.83). In the 12 statin trials, apoB and non-HDL cholesterol decreases similarly predicted cardiovascular disease risk; apoB improved coronary heart disease prediction when added to non-HDL cholesterol/LDL cholesterol decrease (BF 3.33) but did not improve stroke risk prediction when added to non-HDL cholesterol/LDL cholesterol decrease (BF 1.06). In conclusion, across all drug classes, apoB decreases did not consistently improve risk prediction over LDL cholesterol and non-HDL cholesterol decreases. For statins, apoB decreases added information to LDL cholesterol and non-HDL cholesterol decreases for predicting coronary heart disease but not stroke or overall cardiovascular disease risk decrease.

New concepts in dyslipidemia in the metabolic syndrome and diabetes

Trials have revealed that cardiovascular risk is not uniform in the population, but is distributed in a "risk pyramid." Diabetic patients with prior cardiovascular disease (CVD) are at greatest risk. Nondiabetic patients with CVD, diabetic patients without CVD, and subjects with the metabolic syndrome form the next three risk categories. The presence of insulin resistance-related metabolic abnormalities is a common denominator in this risk pyramid. Insulin resistance is a core defect in type 2 diabetes and the metabolic syndrome. Because insulin resistance may cause the atherogenic dyslipidemia that is commonly associated with these conditions, therapeutic strategies that combat insulin resistance could substantially reduce cardiovascular risk. Evidence suggests that defects in mitochondrial oxidative phosphorylation (which may be inherited, age related, or lifestyle acquired) may play a critical role in the pathogenesis of insulin resistance. Reduced mitochondrial oxidative phosphorylation can be partially reversed by improved diet, increased exercise, and administration of peroxisome proliferator-activated receptor-alpha agonists (omega-3 fatty acids and fibrates). Statin therapy has demonstrated clinical benefits in insulin-resistant patients but residual cardiovascular risk remains elevated. Fibrates also improve the lipid profile and reduce cardiovascular risk in a variety of insulin-resistant populations. Affected individuals should be targeted for therapeutic lifestyle intervention. Patients with atherogenic dyslipidemia who have developed insulin resistance, the metabolic syndrome, or type 2 diabetes should receive more intensive interventions including, where appropriate, statin-fibrate combination therapy, to comprehensively modify the lipid profile together with aggressive control of blood pressure and glucose to minimize risk in this very high-risk population.

Statin utilization according to indication and age: a Danish cohort study on changing prescribing and purchasing behaviour

OBJECTIVE

Introduced to reduce mortality after myocardial infarction (MI), statins are now recommended for a range of other conditions, including asymptomatic individuals without cardiovascular disease or diabetes. The aim was to describe trends in Danish statin utilization according to indication and age during 1996-2009, and to analyse changing prescribing and purchasing behaviour during time intervals (driver periods) a priori defined by potential influential factors.

METHODS

A nationwide cohort (N=4,998,580) was followed in Danish individual-level registries. Based on a hierarchy of register markers of indications for statin prescribing, we analysed incidence and prevalence of use by age and indication (age ≥ 40). Applying Poisson regression, we calculated Incidence Rate Ratios (IRR) of statin treatment for the last year of each driver period, applying the first year as reference.

RESULTS

Treatment prevalence increased from 7/1000 to 187/1000, representing a shift towards lower-level indications and increased relatively more in individuals aged 75+. While treatment prevalence in MI-patients reached 780/1000, asymptomatic individuals represented 50% of incident statin-users in 2009. A marked increase in incidence of statin use occurred during 1999-2003 (IRR=3.05) across all indications, followed by a more moderate rise during 2003-2006 (IRR=1.29) and 2006-2008 (IRR=1.15) - most marked increases in asymptomatic individuals. A sudden decrease was observed in 2009 (IRR=0.82) for all indications and ages.

CONCLUSION

While patent expiry and lower prices most likely boosted the general increase in statin utilization, the gradually altered indication and age pattern seems to be driven by guidelines, influencing both reimbursement rules and general healthcare policies. A media debate on statin side effects may have modified the general attitudes.

Diagnosis of coronary artery disease in persons with diabetes mellitus

Coronary heart disease (CHD) is the leading cause of morbidity and mortality in patients with diabetes. Asymptomatic CHD in these patients is elusive and carries a poor prognosis given the fact that an unheralded acute myocardial infarction or sudden cardiac death frequently constitutes its first presentation. Because effective screening for asymptomatic patients with type 2 diabetes for both the presence and severity of CHD is intuitively appealing, we have summarized the utility and prognostic value of various diagnostic modalities (both functionally and anatomically) in enhancing risk stratification and leading to improved and more aggressive management of the risk factors. There exist some evidence and recommendations for screening of asymptomatic persons with diabetes using certain modalities. More research is needed to define potential subsets of patients with diabetes who may benefit from additional testing for asymptomatic CHD.

Optimal type 2 diabetes mellitus management: the randomised controlled OPTIMISE benchmarking study: baseline results from six European countries

BACKGROUND

Micro- and macrovascular complications of type 2 diabetes have an adverse impact on survival, quality of life and healthcare costs. The OPTIMISE (OPtimal Type 2 dIabetes Management Including benchmarking and Standard trEatment) trial comparing physicians' individual performances with a peer group evaluates the hypothesis that benchmarking, using assessments of change in three critical quality indicators of vascular risk: glycated haemoglobin (HbA1c), low-density lipoprotein-cholesterol (LDL-C) and systolic blood pressure (SBP), may improve quality of care in type 2 diabetes in the primary care setting.

DESIGN

This was a randomised, controlled study of 3980 patients with type 2 diabetes.

METHODS

Six European countries participated in the OPTIMISE study (NCT00681850). Quality of care was assessed by the percentage of patients achieving pre-set targets for the three critical quality indicators over 12 months. Physicians were randomly assigned to receive either benchmarked or non-benchmarked feedback. All physicians received feedback on six of their patients' modifiable outcome indicators (HbA1c, fasting glycaemia, total cholesterol, high-density lipoprotein-cholesterol (HDL-C), LDL-C and triglycerides). Physicians in the benchmarking group additionally received information on levels of control achieved for the three critical quality indicators compared with colleagues.

RESULTS

At baseline, the percentage of evaluable patients (N = 3980) achieving pre-set targets was 51.2% (HbA1c; n = 2028/3964); 34.9% (LDL-C; n = 1350/3865); 27.3% (systolic blood pressure; n = 911/3337).

CONCLUSIONS

OPTIMISE confirms that target achievement in the primary care setting is suboptimal for all three critical quality indicators. This represents an unmet but modifiable need to revisit the mechanisms and management of improving care in type 2 diabetes. OPTIMISE will help to assess whether benchmarking is a useful clinical tool for improving outcomes in type 2 diabetes.

Global cardiovascular disease risk assessment in United States adults with diabetes

BACKGROUND

Diabetes mellitus (DM) is often considered a risk equivalent for cardiovascular disease (CVD); however, the variation in CVD risk in adults with DM has not been described.

METHODS

We studied 1114 US adults aged ≥18 years with DM from national survey data and the proportion at low (<10%), intermediate (10-20%) and high (>20%) risk, or with CVD, by age, gender, ethnicity and diabetes type and treatment, and glycaemic and risk factor control by risk group.

RESULTS

Overall, 22.9% were low, 17.5% intermediate, 31.4% high risk and 28.2% had pre-existing CVD (total 59.6% high risk/CVD). More Hispanics (32.4%) and Blacks (30.6%) versus Whites (18.8%) were at lower risk (p<0.0001). Among type 1 versus 2 DM, 35% vs. 65% (p<0.0001) and among insulin users 68.1% were high risk or with CVD. However, among low-intermediate risk, >50% have metabolic syndrome and 7% chronic kidney disease, increasing the high risk/CVD group to 86.8%. Simultaneous achievement of HbA1c, blood pressure and low density lipoprotein-cholesterol goals was low (<15%) regardless of risk group.

CONCLUSIONS

Many DM patients are not at high 10-year CVD risk, but metabolic factors may place them at greater long-term risk. Risk assessment could help target the intensity of treatment.

Rosuvastatin improves endothelial function in db/db mice: role of angiotensin II type 1 receptors and oxidative stress

BACKGROUND AND PURPOSE

HMG-CoA reductase inhibitors, statins, with lipid-reducing properties combat against atherosclerosis and diabetes. The favourable modulation of endothelial function may play a significant role in this effect. The present study aimed to investigate the cellular mechanisms responsible for the therapeutic benefits of rosuvastatin in ameliorating diabetes-associated endothelial dysfunction.

EXPERIMENTAL APPROACH

Twelve-week-old db/db diabetic mice were treated with rosuvastatin at 20 mg·kg⁻¹ ·day⁻¹ p.o.for 6 weeks. Isometric force was measured in isolated aortae and renal arteries. Protein expressions including angiotensin II type 1 receptor (AT₁R), NOX4, p22(phox) , p67(phox) , Rac-1, nitrotyrosine, phospho-ERK1/2 and phospho-p38 were determined by Western blotting, while reactive oxygen species (ROS) accumulation in the vascular wall was evaluated by dihydroethidium fluorescence and lucigenin assay.

KEY RESULTS

Rosuvastatin treatment of db/db mice reversed the impaired ACh-induced endothelium-dependent dilatations in both renal arteries and aortae and prevented the exaggerated contractions to angiotensin II and phenylephrine in db/db mouse renal arteries and aortae. Rosuvastatin reduced the elevated expressions of AT₁R, p22(phox) and p67(phox) , NOX4, Rac1, nitrotyrosine and phosphorylation of ERK1/2 and p38 MAPK and inhibited ROS production in aortae from db/db mice.

CONCLUSIONS AND IMPLICATIONS

The vasoprotective effects of rosuvastatin are attributed to an increase in NO bioavailability, which is probably achieved by its inhibition of ROS production from the AT₁R-NAD(P)H oxidase cascade.

Mitochondrial therapeutics for cardioprotection

Mitochondria represent approximately one-third of the mass of the heart and play a critical role in maintaining cellular function-however, they are also a potent source of free radicals and pro-apoptotic factors. As such, maintaining mitochondrial homeostasis is essential to cell survival. As the dominant source of ATP, continuous quality control is mandatory to ensure their ongoing optimal function. Mitochondrial quality control is accomplished by the dynamic interplay of fusion, fission, autophagy, and mitochondrial biogenesis. This review examines these processes in the heart and considers their role in the context of ischemia-reperfusion injury. Interventions that modulate mitochondrial turnover, including pharmacologic agents, exercise, and caloric restriction are discussed as a means to improve mitochondrial quality control, ameliorate cardiovascular dysfunction, and enhance longevity.

Multiple risk factor intervention and progression of coronary atherosclerosis in patients with type 2 diabetes mellitus

BACKGROUND

Diabetic patients with coronary artery disease (CAD) demonstrate accelerated progression of coronary atherosclerosis. The impact of multiple risk factor intervention on disease progression has not been investigated.

DESIGN

We investigated 448 diabetic patients with angiographic CAD who underwent serial intravascular ultrasound imaging to monitor the change in atheroma burden in seven clinical trials.

METHODS

Disease progression was compared in patients stratified according to whether they achieved increasing numbers of treatment goals of individual risk factors (HbA1c <7.0%, LDL cholesterol <2.5 mmol/l, triglyceride <1.7 mmol/l, systolic blood pressure <130 mmHg, high sensitivity C-reactive protein <2.0 mg/l).

RESULTS

A high rate of established medical therapies was used in all patients (89% statins, 94% aspirin, 76% β-blockers, 66% ACE inhibitors, 66% metformin, 62% thiazolidinediones, 17% insulin). No differences were observed with regard to percentage atheroma volume (PAV) and total atheroma volume (TAV) at baseline. On serial evaluation, slowing of progression of PAV (p = 0.01) and TAV (p < 0.001) was observed with increasing numbers of risk factors achieving treatment goals. On multivariate analysis adjusting for baseline risk factors, increasing the number of factors meeting treatment goals continued to be associated with a beneficial impact on progression of PAV (p = 0.03) and TAV (p < 0.001).

CONCLUSION

The benefit of achieving optimal control of multiple risk factors underscores the need for modification of global risk in patients with diabetes.