The clinical reality of guidelines for primary prevention of cardiovascular disease in type 2 diabetes in Italy

National treatment guidelines poorly achieved among older subjects with type 2 diabetes - call to action!

OBJECTIVE

To assess risk factors and factors associated with nonachievement of the treatment target levels among 75-year-old Finns with type 2 diabetes (T2D).

DESIGN

Cross-sectional study.

SETTING

Outpatient.

SUBJECTS

Seventy-five-year-old participants of the Turku Senior Health Clinic Study (N = 1296) with T2D (n = 247).

MAIN OUTCOME MEASURES

Nonachievement of fasting blood glucose (FBG), low-density lipoprotein (LDL-C), and blood pressure (BP) levels set by the national treatment guidelines.

RESULTS

Nonachievement rates of FBG, BP and LDL-C were 47%, 85%, and 47%, respectively. Non-usage of T2D medication was negatively (adjusted OR 0.38, 95% CI 0.16-0.88) and central obesity positively (1.88, 1.09-3.24) related to nonachievement of FBG target level; alcohol use was positively (3.71, 1.04-13.16) and decreased self-rated health negatively (0.34, 0.12-0.97) related to the nonachievement of BP target level. Nonachievement of LDL-C target level was positively related to poor financial status (3.50, 1.19-10.28) and non-use of lipid-lowering medication (7.70, 4.07-14.56).

CONCLUSIONS

Nonachievement rates of the national treatment goals were high among older T2D patients, and nonachievement was related to use of medication, obesity, alcohol use, poor health, and poor financial status. We emphasize the importance of customized target setting by risk factor levels and active treatment.

Factors Associated with Controlled Glycemic Levels in Type 2 Diabetes Patients: Study from a Large Medical Center and Its Satellite Clinics in Southeast Region in the USA

Diabetes, including type 1, type 2, and gestational, is a significant public health issue responsible for various clinical, economic, and societal issues. Most of the consequences, if uncontrolled, can result in serious health problems, such as heart disease, vision loss, and kidney disease. Approximately 37.3 million Americans have diabetes, including 37.1 million adults 18 years or older, with 90-95% type 2 diabetes (T2D). The purpose of this study is (1) to explore the profile of patients with T2D and (2) to identify the associated factors of diabetic status. Examined factors included sociodemographic characteristics, social factors, and comorbidities. The study analyzed a primary dataset from a retrospective chart review of adult patients with T2D who were seen at a large medical center and its satellite clinics in the southeast region of the United States in 2019. Sex, dyslipidemia, and the number of concordant comorbidities were found to be significant associated factors of diabetic status. In the era of intertwined patient-centered approach and public health, the study's findings can guide treatment plans and interventions targeting individuals and communities.

MG53 does not mark cardiovascular risk and all-cause mortality in subjects with type 2 diabetes: A prospective, observational study

AIMS

Subjects with type 2 diabetes (T2D) are characterized by a high cardiovascular morbidity and mortality. MG53, a marker of peripheral insulin resistance, has been linked with impaired β-cell function and decreased β-cell survival, and its circulating levels are increased in T2D. Its relationship with the cardiovascular risk profile and mortality in T2D is currently unknown.

METHODS

In this longitudinal study, MG53 was measured in serum samples collected at baseline for 296 Caucasian participants in the MIND.IT study, relating its circulating levels with the cardiovascular risk profile and all-cause mortality over a 17-years follow up.

RESULTS

As compared to a reference cohort of 234 healthy subjects, MG53 levels were higher in T2D individuals (p < 0.001), and higher in T2D women than in men (p = 0.001). In the whole study cohort, MG53 levels were directly related to HbA1c (r2 0.029; p = 0.006) and systolic blood pressure (r2 0.032; p = 0.004). There was no difference in baseline MG53 levels between deceased and alive participants, neither predict all-cause mortality.

CONCLUSIONS

MG53 does not mark the cardiovascular risk profile neither predict long-term mortality in Caucasian T2D individuals.

Potentially inappropriate prescribing for adults living with diabetes mellitus: a scoping review

BACKGROUND

People living with diabetes often experience multiple morbidity and polypharmacy, increasing their risk of potentially inappropriate prescribing. Inappropriate prescribing is associated with poorer health outcomes.

AIM

The aim of this scoping review was to explore and map studies conducted on potentially inappropriate prescribing among adults living with diabetes and to identify gaps regarding identification and assessment of potentially inappropriate prescribing in this group.

METHOD

Studies that reported any type of potentially inappropriate prescribing were included. Studies conducted on people aged < 18 years or with a diagnosis of gestational diabetes or prediabetes were excluded. No restrictions to language, study design, publication status, geographic area, or clinical setting were applied in selecting the studies. Articles were systematically searched from 11 databases.

RESULTS

Of the 190 included studies, the majority (63.7%) were conducted in high-income countries. None of the studies used an explicit tool specifically designed to identify potentially inappropriate prescribing among people with diabetes. The most frequently studied potentially inappropriate prescribing in high-income countries was contraindication while in low- and middle-income countries prescribing omission was the most common. Software and websites were mostly used for identifying drug-drug interactions. The specific events and conditions that were considered as inappropriate were inconsistent across studies.

CONCLUSION

Contraindications, prescribing omissions and dosing problems were the most commonly studied types of potentially inappropriate prescribing. Prescribers should carefully consider the individual prescribing recommendations of medications. Future studies focusing on the development of explicit tools to identify potentially inappropriate prescribing for adults living with diabetes are needed.

Cardiovascular risk factors control according to diabetes status and prior cardiovascular events in patients managed in different settings

AIMS

To document in recent cohorts the degree of control of major cardiovascular (CV) risk factors according to diabetes status and prior CV disease in different settings.

METHODS

We studied men and women aged 50-75 years of whom 3028 with type 2 diabetes mellitus (T2DM) managed at diabetes clinics participants of the TOSCA.IT (NCT00700856) study recruited in 2008-2014; 742 with T2DM managed mainly in primary care and 6753 without diabetes participating in the Moli-sani (NCT03242109) study and recruited in 2005-2010 from an adult general population.

RESULTS

Among people without a prior CV event people with diabetes managed at diabetes clinics have lower LDL-cholesterol and blood pressure and a more frequent use of lipid-lowering and antihypertensive medications as compared to people with diabetes managed mainly in primary care and to people without diabetes. The proportions achieving the recommended treatment targets are respectively 47.4% vs 33.4% vs 29.5% for LDL-cholesterol and 42.6% vs 9.5% vs 47.4% for blood pressure. Figures for the participants with prior CV events were 26.8% vs 15.1% vs 42.5% for LDL-cholesterol and 43.8% vs 8.5% vs 43.6% for blood pressure.

CONCLUSIONS

The study documents that in modern cohorts a large proportion of people with or without diabetes does not achieve the treatment targets for LDL-cholesterol and blood pressure, both in primary and secondary CV prevention. People with diabetes attending diabetes clinics achieve a better control of major CV risk factors than those managed mainly in primary care, thus highlighting the relevant role of a structured model of care.

Diabetes as a risk factor for heart failure in women and men: a systematic review and meta-analysis of 47 cohorts including 12 million individuals

AIMS/HYPOTHESIS

The prevalence of diabetes and heart failure is increasing, and diabetes has been associated with an increased risk of heart failure. However, whether diabetes confers the same excess risk of heart failure in women and men is unknown. The aim of this study was to conduct a comprehensive systematic review with meta-analysis of possible sex differences in the excess risk of heart failure consequent to diabetes. Our null hypothesis was that there is no such sex difference.

METHODS

A systematic search was conducted in PubMed for population-based cohort studies published between January 1966 and November 2018. Studies were selected if they reported sex-specific estimates of RRs for heart failure associated with diabetes, and its associated variability, which were adjusted at least for age. Random-effects meta-analyses with inverse variance weighting were used to obtain pooled sex-specific RRs and women-to-men ratio of RRs (RRRs) for heart failure associated with diabetes.

RESULTS

Data from 47 cohorts, involving 12,142,998 individuals and 253,260 heart failure events, were included. The pooled multiple-adjusted RR for heart failure associated with type 1 diabetes was 5.15 (95% CI 3.43, 7.74) in women and 3.47 (2.57, 4.69) in men, leading to an RRR of 1.47 (1.44, 1.90). Corresponding pooled RRs for heart failure associated with type 2 diabetes were 1.95 (1.70, 2.22) in women and 1.74 (1.55, 1.95) in men, with a pooled RRR of 1.09 (1.05, 1.13).

CONCLUSIONS/INTERPRETATION

The excess risk of heart failure associated with diabetes is significantly greater in women with diabetes than in men with diabetes. PROSPERO registration: CRD42019135246.

Type 2 diabetes: Prescription patterns and treatment outcomes of IDMPS survey in Argentina

AIM

To assess prescription patterns for treatment of type 2 diabetes (T2D) and their outcomes in the IDMPS survey in Argentina.

METHODS

Data from 2551 people with T2D recruited from 210 physicians participating in IDMPS surveys in Argentina (2006 to 2012 waves) were recorded, including medical history, medications, glycemic control, blood pressure, and lipid status.

RESULTS

Most people were treated with oral glucose-lowering drugs (OGLDs) (65%), followed by combinations of these drugs plus insulin (22%) and only insulin (13%). These percentages varied according to T2D duration, the frequency of OGLDs decreasing while contrastingly and only insulin increasing (under 5 years versus over 10 years of disease duration, respectively). Average systolic blood pressure (SBP), HbA1c and LDL-c were significantly higher in patients treated with insulin either alone or associated with OGLDs. The percentage of people at target values for these parameters was also lower in these two groups. The percentage of people that reached simultaneous goal treatment values for BP, HbA1c and LDL-c levels was markedly low.

CONCLUSION

Prescription patterns for treatment of T2D follows a chronological trend and the percentage of people at goal values (HbA1c, BP and LDL-c values) was significantly lower in people receiving insulin. These data must be carefully considered by health and academic authorities in order to implement effective strategies to modify this situation.

Current status of treatment of type 2 diabetes mellitus in Ningbo, China

BACKGROUND

The treatment status of type 2 diabetes mellitus (T2DM) in Ningbo has not been reported in the past. To evaluate the current status of T2DM in Ningbo and provide evidence to formulate more policies, a multicenter investigation was needed.

METHODS

The Ningbo Clinical Research Group of Diabetes constituted nine hospitals. Participants included 3015 patients who visited the nine hospitals from June to December 2016. General characteristics, the medication situation, the laboratory indexes in nearly 3 months consisting of glycosylated hemoglobin level (HbA1c), low-density lipoprotein cholesterol (LDL-C), and fasting blood glucose (FBG), and the results of ophthalmologic examination were investigated. The evaluation criteria were defined based on 2013 China guideline for T2DM.

RESULTS

The 3015 subjects included 1685 men and 1330 women. The average age was 63.3 ± 13.0 years. The prevalence of hypertension and dyslipidemia was 58.7% and 56.7%, respectively. In the examinees, nephropathy appeared in 11.6% and retinopathy in 14.5%. More than half (50.9%) of the subjects were overweight. The achievement rate of blood pressure (BP) was 39.6% (<140/80 mm Hg), FBG was 46.0% (4.4-7.0 mmol/L), HbA1c was 41.7% (<7.0%), and LDL-C was 51.7% (<1.8 mmol/L; and if accompanied by CHD, <2.6).

CONCLUSION

Ningbo City T2DM status is not optimistic, and there is a big gap with the indicators.

Achievement of guideline targets for blood pressure, lipid, and glycaemic control in type 2 diabetes: A meta-analysis

We assessed global achievement of targets recommended by the American Diabetes Association (ADA), European Association for the Study of Diabetes (EASD), and National Institute of Health and Care Excellence (NICE) for type 2 diabetes. We searched Medline, Embase, and The Cochrane Library for observational studies reporting target attainment (2006 to 2017 inclusive) for HbA1c, blood pressure, or lipids (low density lipoprotein cholesterol [LDL-C], high density lipoprotein cholesterol [HDL-C], or triglycerides). Rates were pooled using a random-effects meta-analysis. Study quality and risk of small study of bias was assessed. From 2491 screened records, 24 studies were included reporting on 369,251 people from 20 countries. The pooled target achievement rates were; 42.8% (95% CI 38.1-47.5%) for glycaemic control, 29.0% (22.9-35.9%) for blood pressure, 49.2% (39.0-59.4%) for LDL-C, 58.2% (51.7-64.4%) for HDL-C, and 61.9% (55.2-68.2%) for triglyceride control. A higher proportion of people achieved HbA1c targets within Europe and North America than the rest of the world. A higher proportion of people achieved blood pressure targets in North America than Europe or the rest of the world. Meta regression showed no significant improvement in rates by year for any target. The achievement of evidence-based targets is markedly suboptimal globally and not improving.

Cardiovascular safety of abiraterone acetate in metastatic castration-resistant prostate cancer patients: a prospective evaluation

AIM

The aim of this study is to evaluate cardiotoxicity of abiraterone acetate (AA) in metastatic castration-resistant prostate cancer patients (pts) with cardiovascular comorbidities or coronary artery disease (CAD) risk factors.

PATIENTS & METHODS

We prospectively analyzed pts receiving AA in order to evaluate correlations between cardiotoxicity onset and CAD risk factors or cardiovascular comorbidities.

RESULTS

Eighty-seven pts were enrolled, with median treatment duration of 9 months (1-44). At baseline, 84 pts (96%) had CAD risk factors. During treatment four pts (4; 6%) developed hypertension and 26 pts (30%) worsened the preexisting hypertension. Median left ventricular ejection fraction were 64 and 63% at baseline and after treatment, respectively.

CONCLUSION

AA appears to be safe in pts with cardiovascular comorbidities or CAD risk factors.

Diabetes as a risk factor for acute coronary syndrome in women compared with men: a meta-analysis, including 10 856 279 individuals and 106 703 acute coronary syndrome events

BACKGROUND

Diabetes mellitus is a significant cause of death and disability worldwide and is a strong risk factor for acute coronary syndrome (ACS). Whether diabetes confers the same excess risk of ACS in both sexes is unknown. Therefore, we undertook a meta-analysis to estimate the relative risk (RR) for ACS associated with diabetes in men and women.

METHODS

We systematically searched PubMed, Embase, and Cochrane Library databases for both case-control and cohort studies published between January 1, 1966, and January 1, 2015. Studies were included if they reported sex-specific estimates of the RR, hazard ratio, or odds ratio for the association between diabetes and ACS. We pooled the sex-specific RR and the ratio between women and men using a random-effect model with inverse-variance weighting.

RESULTS

We included 9 case-control and 10 cohort studies with data for 10 856 279 individuals and at least 106 703 fatal and nonfatal ACS events. The pooled maximum-adjusted RR of ACS associated with diabetes was 2.46 (95% CI, 1.92-3.17) in women and 1.68 (95% CI, 1.39-2.04) in men. In patients with diabetes compared with those without diabetes, women had a significantly greater risk of ACS-the pooled women-to-men RR and the ratio of relative risks was 1.38 (95% CI, 1.25-1.52; P < .001), with no evidence of publication bias.

CONCLUSIONS

The excess risk of ACS associated with diabetes is significantly higher in women than in men. This finding may be explained by more adverse cardiovascular risk profiles and suggests that further work is needed to clarify the relevant biological, behavioural, and social mechanisms.

Transcultural Endocrinology: Adapting Type-2 Diabetes Guidelines on a Global Scale

Type-2 diabetes (T2D) needs to be prevented and treated effectively to reduce its burden and consequences. White papers, such as evidence-based clinical practice guidelines (CPG) and their more portable versions, clinical practice algorithms and clinical checklists, may improve clinical decision-making and diabetes outcomes. However, CPG are underused and poorly validated. Protocols that translate and implement these CPG are needed. This review presents the global dimension of T2D, details the importance of white papers in the transculturalization process, compares relevant international CPG, analyzes cultural variables, and summarizes translation strategies that can improve care. Specific protocols and algorithmic tools are provided.

Estrogen Therapy and Ischemic Stroke in Women with Diabetes Aged Over 55 Years: A Nation-Wide Prospective Population-Based Study in Taiwan

This study explores the possible association between the risk of ischemic stroke and conjugated equine estrogen (CEE) use in women who are over 55 years old and have diabetes. Data from the National Health Insurance system of Taiwan were used to identify 428 women over 55 years old with diabetes who used CEE (0.625 mg daily) from 2003 to 2009. For comparison, 21026 women with diabetes who were from the same cohort and did not use estrogen were used as a control group, excluding patients with previous ischemic stroke at the baseline. The propensity score method was used to identify a 1:3 ratio for the matched cohort (n = 1284). Covariates used for propensity score-matching included age and comorbidities. Cox’s proportional hazard model was applied to estimate the relationship between CEE use and ischemic stroke. The overall incidence of ischemic stroke was significantly lower in patients using CEE than in the control group (0.9% compared with 3.0%, p = 0.016). Further analyses using Cox’s proportional hazard model revealed that after adjusting for age, comorbidities, socioeconomic status, urbanization, and other medications associated with ischemic stroke, a lower risk was present in patients with CEE use (hazard ratio: 0.34; 95% confidence interval: 0.12–0.97). Time of menopause could not be identified because of the nature of the database. CEE might decrease the risk of ischemic stroke in women with diabetes aged over 55 years, according to this population-based study.

Current status of glucose, blood pressure and lipid management in type 2 diabetes clinic attendees in Isfahan, Iran

AIMS/INTRODUCTION

To estimate the prevalence of meeting American Diabetes Association clinical practice recommendations for hemoglobin A1c (HbA1c), blood pressure (BP) and low-density lipoprotein cholesterol (LDLC) among Iranian type 2 diabetes clinic attendees, and to identify the factors associated with therapeutic target achievement.

MATERIALS AND METHODS

A total of 2,640 patients with type 2 diabetes (944 men and 1,696 women) from Isfahan Endocrine and Metabolism Research Center outpatient clinics, Iran, were examined. The main outcome measures were HbA1c, BP and LDLC, in accordance with the American Diabetes Association recommendations. The mean (standard deviation) age of participants was 49.6 years (9.3 years) with a mean (standard deviation) duration of diabetes of 5.0 years (4.9 years) at initial registration.

RESULTS

The percentages of patients who had HbA1c <7%, BP <140/90 mmHg and LDLC <100 mg/dL was 37.4% (95% confidence interval [CI] 35.6-39.3), 35.3% (95% CI 33.5-37.3) and 48.9% (95% CI 47.0-50.8), respectively. The proportion of patients meeting all three goals was 7.7% (95% CI 6.7-8.8). Lower BP, cholesterol level and higher education at registration, and higher follow up but lower number of follow-up visits affected achievement of all three goals.

CONCLUSIONS

The present study highlights that a substantial proportion of Iranian type 2 diabetes clinic attendees did not meet the American Diabetes Association clinical practice recommendations, and shows the difficult challenges physicians face when treating patients with type 2 diabetes.

Health care delivery in type 2 diabetes. A survey in an Italian primary care practice

AIMS

Evidence-based guidelines provide targets and performance measures for the treatment of type 2 diabetic patients but a wide gap separates guidelines-driven recommendations from their clinical application, a phenomenon hindering the transfer of proven benefits to affected populations.

METHODS

We analyzed the quality of diabetic care delivered by 8 general practitioners joint in a group practice attending 571 diabetic patients (5.6% of the total enlisted subjects) by assessing process (% of HbA1c, SBP and LDL-C determinations) and intermediate outcome (% of patients with HbA1c <7% vs >8%, systolic BP <130 mmHg vs >140 mmHg, LDL-cholesterol <100 mg/dL vs >130 mg/dL) indicators.

RESULTS

HbA1c was at target in 49% of patients and >8% in 22%; SBP and LDL-C determination was available in about two-thirds of patients, only a minority at target for SBP and LDL-C. Antihyperglycemic and antihypertensive treatment was prescribed in most patients but only a third was on statins. During the post-evaluation phase, percentages of patients with HbA1c >8%, SBP < 130 mmHg and LDL-C < 100 mg/dL and the drug prescription pattern did not change.

CONCLUSIONS

Several weaknesses affect primary care delivery to type 2 diabetic patients and efforts are needed to improve the management of this high-risk group.

Diabetes as a risk factor for stroke in women compared with men: a systematic review and meta-analysis of 64 cohorts, including 775,385 individuals and 12,539 strokes

BACKGROUND

Diabetes mellitus is a major cause of death and disability worldwide and is a strong risk factor for stroke. Whether and to what extent the excess risk of stroke conferred by diabetes differs between the sexes is unknown. We did a systematic review and meta-analysis to estimate the relative effect of diabetes on stroke risk in women compared with men.

METHODS

We systematically searched PubMed for reports of prospective, population-based cohort studies published between Jan 1, 1966, and Dec 16, 2013. Studies were selected if they reported sex-specific estimates of the relative risk (RR) for stroke associated with diabetes, and its associated variability. We pooled the sex-specific RRs and their ratio comparing women with men using random-effects meta-analysis with inverse-variance weighting.

FINDINGS

Data from 64 cohort studies, representing 775,385 individuals and 12,539 fatal and non-fatal strokes, were included in the analysis. The pooled maximum-adjusted RR of stroke associated with diabetes was 2·28 (95% CI 1·93-2·69) in women and 1·83 (1·60-2·08) in men. Compared with men with diabetes, women with diabetes therefore had a greater risk of stroke--the pooled ratio of RRs was 1·27 (1·10-1·46; I(2)=0%), with no evidence of publication bias. This sex differential was seen consistently across major predefined stroke, participant, and study subtypes.

INTERPRETATION

The excess risk of stroke associated with diabetes is significantly higher in women than men, independent of sex differences in other major cardiovascular risk factors. These data add to the existing evidence that men and women experience diabetes-related diseases differently and suggest the need for further work to clarify the biological, behavioural, or social mechanisms involved.

FUNDING

None.

Feasibility and effectiveness in clinical practice of a multifactorial intervention for the reduction of cardiovascular risk in patients with type 2 diabetes: the 2-year interim analysis of the MIND.IT study: a cluster randomized trial

OBJECTIVE

To evaluate the feasibility and effectiveness of an intensive, multifactorial cardiovascular risk reduction intervention in a clinic-based setting.

RESEARCH DESIGN AND METHODS

The study was a pragmatic, cluster randomized trial, with the diabetes clinic as the unit of randomization. Clinics were randomly assigned to either continue their usual care (n = 5) or to apply an intensive intervention aimed at the optimal control of cardiovascular disease (CVD) risk factors and hyperglycemia (n = 4). To account for clustering, mixed model regression techniques were used to compare differences in CVD risk factors and HbA1c. Analyses were performed both by intent to treat and as treated per protocol.

RESULTS

Nine clinics completed the study; 1,461 patients with type 2 diabetes and no previous cardiovascular events were enrolled. After 2 years, participants in the interventional group had significantly lower BMI, HbA1c, LDL cholesterol, and triglyceride levels and significantly higher HDL cholesterol level than did the usual care group. The proportion of patients reaching the treatment goals was systematically higher in the interventional clinics (35% vs. 24% for LDL cholesterol, P = 0.1299; 93% vs. 82% for HDL cholesterol, P = 0.0005; 80% vs. 64% for triglycerides, P = 0.0002; 39% vs. 22% for HbA1c, P = 0.0259; 13% vs. 5% for blood pressure, P = 0.1638). The analysis as treated per protocol confirmed these findings, showing larger and always significant differences between the study arms for all targets.

CONCLUSIONS

A multifactorial intensive intervention in type 2 diabetes is feasible and effective in clinical practice and it is associated with significant and durable improvement in HbA1c and CVD risk profile.

Women show worse control of type 2 diabetes and cardiovascular disease risk factors than men: results from the MIND.IT Study Group of the Italian Society of Diabetology

BACKGROUND AND AIMS

The study explores the degree of control of hyperglycaemia and cardiovascular (CV) disease risk factors in men and women with type 2 diabetes and the impact thereon of obesity, central adiposity, age and use of medications.

METHODS AND RESULTS

A cross-sectional survey was conducted at 10 hospital-based outpatients diabetes clinics. 1297 men and 1168 women with no previous CV events were studied. Women were slightly (only one year) older and more obese than men: average BMI was respectively 30.7 ± 5.7 vs 28.6 ± 4.1 kg/m(2) (p < 0.001), and prevalence of abdominal obesity was 86% vs 44% (p < 0.001). Women smoked less, but had higher HbA1c, LDL cholesterol, non-HDL cholesterol, systolic blood pressure and serum fibrinogen than men. Accordingly optimal targets for HbA1c (<7%), LDL cholesterol (<100 mg/dL), HDL cholesterol (>40 for men, >50 for women, mg/dL), and systolic blood pressure (<130 mmHg) were less frequently achieved by women than men (respectively 33.8% vs 40.2%; 14.6% vs 19.2%; 34.1% vs 44.5%; 68.8% vs 72%; p < 0.05 for all). Findings were confirmed after stratification for waist circumference (< or ≥ 88 cm for women; < or ≥ 102 cm for men), BMI (< or ≥ 25 kg/m(2)) or age (< or ≥ 65 years). As for treatment, women were more likely than men to take insulin, alone or in combination with oral hypoglycaemic drugs, to be under anti-hypertensive treatment, whereas the use of lipid lowering drugs was similar in men and women.

CONCLUSIONS

Control of hyperglycaemia and major CVD risk factors is less satisfactory in women than men. The gender disparities are not fully explained by the higher prevalence of total and central obesity in women; or by a less intensive medical management in women.

Sex-specific differences in Type 2 Diabetes Mellitus and dyslipidemia therapy: PPAR agonists

The influence of sex on the development of obesity, Type 2 Diabetes Mellitus (T2DM), and dyslipidemia is well documented, although the molecular mechanism underlying those differences reminds elusive. Ligands of peroxisome proliferator-activated receptors (PPARs) are used as oral antidiabetics (PPARgamma agonists: thiazolidinediones, TZDs), or for the treatment of dyslipidemia and cardiovascular diseases, due to their lipid-lowering properties (PPARalpha agonists: fibrates), as PPARs control transcription of a set of genes involved in the regulation of lipid and carbohydrate metabolism. Given a high prevalence of those metabolic disorders, and thus a broad use of PPAR agonists, the present review will discuss distinct aspects of sex-specific differences in antiobesity treatment using those groups of PPAR ligands.

Effectiveness of treat-to-target strategy for LDL-cholesterol control in type 2 diabetes: post-hoc analysis of data from the MIND.IT study

BACKGROUND

The paper presents a post-hoc analysis of the intensity of dyslipidaemia care operated in the first 2 years of Multiple-Intervention-in-type-2-Diabetes.ITaly (MIND.IT) study.

DESIGN AND METHODS

MIND.IT is a multicentric, randomized, two-parallel arm trial involving 1461 type 2 diabetic patients at high cardiovascular (CV) risk. The study compares the usual care (UC) of CV prevention with a multifactorial intensive care (IC) approach aiming at achieving target values for the main CV risk factors according to a step-wise treat-to-target approach.

RESULTS

Proportion of patients on target for low-density lipoprotein cholesterol (LDL-C) was about 10% at baseline and increased significantly more with IC than UC (43 vs. 27%; p < 0.001). However, the majority (57%) of patients, in this intended intensively treated cohort, failed to achieve the proposed target. Average LDL-C decreased from 144 ± 35 to 108 ± 31 mg/dl with IC and from 142 ± 28 to 118 ± 32 with UC (p-for-interaction <0.0001). IC was associated with a significantly greater increase in statin prescription and lower withdrawal from treatment than UC (43 vs. 11% and 28 vs. 61%, respectively; both p < 0.001). However, the new treatments were characterized in both groups by the use of low starting doses (≤ 10 mg of atorvastatin, equivalent dose in more than 90% of patients) without increase in case of missed target.

CONCLUSIONS

The application of a multifactorial treat-to-target intervention is associated with a significant improvement in LDL-C beyond usual practice. However, the change in LDL-C appears to be more related to an increased number of treated patients and a decreased treatment withdrawal than to a true treat-to-target approach.

Gender differences in the control of cardiovascular risk factors in patients with type 2 diabetes -a cross-sectional study

OBJECTIVE

Trends in diabetes and cardiovascular mortality rates are considerably different between women and men; this can be partially explained by differences in diabetes control. The aim of this cross-sectional study was to assess whether sex differences exist in effective control of cardiovascular risk factors among persons with type 2 diabetes treated at the Vuk Vrhovac University Clinic in 2008.

MATERIALS AND METHODS

We performed a cross-sectional analysis including 8,775 patients who attended the clinic in 2008. Levels of HbA1c, systolic and diastolic blood pressure (SBP, DBP), LDL-cholesterol (LDL) and triglycerides (TG) were analyzed. Multiple adjusted odds-ratios were calculated for categories of cardiovascular risk factors considered not being in control (HbA1c ≥ 7%, SBP ≥ 130 mmHg, DBP ≥ 80 mmHg, LDL ≥ 2.5 mmol/L, TG ≥ 1.7 mmol/L).

RESULTS

Women had higher levels of HbA1c (7.05 vs. 6.86%; p<0.001), despite the fact that a larger proportion of women were receiving insulin therapy than men (51.3% vs. 44%). Women also had higher mean values of SBP (144.7 vs. 141.9 mmHg; p<0.001) and LDL (2.92 vs. 2.84 mmol/L). There were no differences in DBP (86.1 vs. 86.0 mmHg; p=0.748) and only triglyceride levels were higher in men (2.04 vs. 1.94 mmol/L; p=0.003). In multi-adjusted logistic regression model female sex was associated with a higher odds ratio of having uncontrolled values of HbA1c (OR=1.21; 95%CI 1.11-1.32), SBP (OR=1.21; 95%CI 1.07-1.37) and LDL (OR=1.13; 95%CI 1.04-1.23).

CONCLUSION

Women with diabetes have poorer control of main potentially modifiable cardiovascular risk factors than men. This could contribute to disparities in trends in cardiovascular mortality and it demands clinicians' and public health awareness.

Cardiovascular and noncardiovascular mortality among men and women starting dialysis

BACKGROUND AND OBJECTIVES

Although women have a survival advantage in the general population, women on dialysis have similar mortality to men. We hypothesized that this paired mortality risk during dialysis may be explained by a relative excess of cardiovascular-related mortality in women.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We compared 5-year age-stratified cardiovascular and noncardiovascular mortality rates, relative risks, and hazard ratios in a European cohort of incident adult dialysis patients (European Renal Association-European Dialysis and Transplant Association [ERA-EDTA] Registry) with the European general population (Eurostat). Cause of death was recorded by ERA-EDTA codes in dialysis patients and by International Statistical Classification of Diseases codes in the general population.

RESULTS

Overall, sex did not have a predictive effect on outcome in dialysis. Stratification into age categories and causes of death showed greater noncardiovascular mortality in young women (<45 years). In other age categories (45 to 55 and >55 years), women presented lower cardiovascular mortality. This cardiovascular benefit was, however, smaller than in the general population. Stratification by diabetic nephropathy showed that diabetic women in all age categories remained at increased mortality risk compared with men, an effect mainly attributed to the noncardiovascular component.

CONCLUSIONS

Mortality rates and causes of death in men and women on dialysis vary with age. Increased noncardiovascular mortality may explain the loss of the survival advantage of women on dialysis. Both young and diabetic women starting dialysis are at a higher mortality risk than equal men.

Postprandial blood glucose predicts cardiovascular events and all-cause mortality in type 2 diabetes in a 14-year follow-up: lessons from the San Luigi Gonzaga Diabetes Study

OBJECTIVE

To evaluate whether postprandial blood glucose predicts cardiovascular events and all-cause mortality in type 2 diabetes in a long-term follow-up taking into account A1C and the main cardiovascular risk factors.

RESEARCH DESIGN AND METHODS

Consecutive type 2 diabetic patients (n = 505) followed up at our diabetes clinic were evaluated at baseline (1995) for the main cardiovascular risk factors and for five glycemic control parameters (fasting blood glucose, blood glucose 2 h after breakfast, blood glucose 2 h after lunch, blood glucose before dinner, and A1C); all-cause mortality and the first cardiovascular events occurring during the 14-year follow-up were measured.

RESULTS

We observed 172 cardiovascular events (34.1% of the population) and 147 deaths (29.1% of the population). Using the Cox analysis with the backward method, we categorized the variables according to the therapeutic targets of the American Diabetes Association. Our observations were as follows. When the five glycemic control parameters were considered together, the predictors were 1) for cardiovascular events, blood glucose 2 h after lunch (hazard ratio 1.507, P = 0.010) and A1C (1.792, P = 0.002); and 2) for mortality, blood glucose 2 h after lunch (1.885, P < 0.0001) and A1C (1.907, P = 0.002). When blood glucose 2 h after lunch and A1C were considered together with the main cardiovascular risk factors, the following glycemic control parameters were predictors: 1) for cardiovascular events, blood glucose 2 h after lunch (1.452, P = 0.021) and A1C (1.732, P = 0.004); and 2) for mortality, blood glucose 2 h after lunch (1.846, P = 0.001) and A1C (1.896, P = 0.004).

CONCLUSIONS

In type 2 diabetes, both postprandial blood glucose and A1C predict cardiovascular events and all-cause mortality in a long-term follow-up.

Cardiovascular risk in women with diabetes

Women with diabetes have a high risk of cardiovascular disease that, almost completely eliminates the gender difference in cardiovascular morbidity and mortality between non-diabetic men and women. In this chapter we have reviewed data showing that cardiovascular risk factors are more common, more likely to cluster, or more severe in diabetic women than men; this may be due to biological or behavioural factors. Disparities in accessibility, quality and, possibly, effectiveness of care further disadvantage diabetic women. Based on available data it can be concluded that a large number of CVD deaths are preventable in diabetic women; therefore special attention should be paid to risk factors detection and correction, as well as timely CHD diagnosis and treatment in diabetic women. To meet these needs gender specific guidelines and implementation measures may be in order.

Evaluation of a toolkit to improve cardiovascular disease screening and treatment for people with type 2 diabetes: protocol for a cluster-randomized pragmatic trial

BACKGROUND

The gap between the level of care recommended by evidence-based clinical practice guidelines and the actual care delivered to patients in practice has been well established. The Canadian Diabetes Association (CDA) created an implementation strategy to improve the implementation of its 2008 guidelines. This study will evaluate the impact of the strategy to improve cardiovascular disease (CVD) screening, prevention and treatment for people with diabetes.

DESIGN

A pragmatic cluster-randomized trial will be conducted to evaluate the CDA's CVD Toolkit. All family physicians in Ontario, Canada were randomly allocated to receive the Toolkit, which includes several printed educational materials targeting CVD screening, prevention and treatment, either in spring 2009 (intervention arm) or in spring 2010 (control arm). Randomization occurred at the level of the practice. Forty family physicians from each arm will be recruited to participate, and the medical records for 20 of their diabetic patients at high risk for CVD will be retrospectively reviewed. Outcome measures will be assessed for each patient between July 2009 and March 2010. The primary outcome will be that the patient is receiving a statin. Secondary outcomes will include 1) the receipt of an angiotensin converting enzyme inhibitor or angiotensin receptor blocker, 2) various intermediate measures (A1c, blood pressure, LDL-cholesterol, total-/HDL-cholesterol ratio, body mass index and waist circumference), and 3) clinical inertia (the failure to change therapy in response to an abnormal A1c, blood pressure or cholesterol reading). The analysis will be carried out using multilevel hierarchical logistic regression models to account for the clustered nature of the data. The group assignment will be a physician-level variable. In addition, a process evaluation study with six focus groups of family physicians will assess the acceptability of the CDA's Toolkit and will explore factors contributing to any change or lack of change in behaviour, from the perspectives of family physicians.

DISCUSSION

Printed educational materials for physicians have been shown to exert small-to-moderate changes in patient care. The CDA's CVD Toolkit is an example of a practice guideline implementation strategy that can be disseminated to a wide audience relatively inexpensively, and so demonstrating its effectiveness at improving diabetes care could have important consequences for guideline developers, policy makers and clinicians.

Evaluation of a simple policy for pre- and post-prandial blood glucose self-monitoring in people with type 2 diabetes not on insulin

BACKGROUND AND AIMS

Since there is no agreement on regimens of self-monitoring of blood glucose (SMBG) in type 2 diabetes not on insulin, we evaluated the effects of a simple SMBG policy taking into account compliance.

METHODS AND RESULTS

273 type 2 diabetic patients not on insulin with HbA1c >7% attending our Diabetes Clinic and already using SMBG were randomized as follows: Group A, one BG profile/month with fasting and post-prandial values; Group B, one BG profile every 2 weeks with pre- and post-prandial values. Patients were followed-up by the same team every 3 months with the same education and treatment policies. At 3 and 6 months, SMBG profiles were evaluated and HbA1c measured. SMBG was carried out as recommended by 73% of Group A and 44% of Group B patients. In compliant patients, HbA1c and BG were unchanged in Group A whereas in Group B fasting, pre-prandial and two out of three post-prandial BG values were reduced and HbA1c decreased from 8.09+/-0.84% to 7.60+/-0.73% (p<0.001). The influence on BG control was similar for the two policies when compliance was not considered.

CONCLUSIONS

The more intensive SMBG policy considered is associated with improvements in glycaemic control in compliant subjects.

Fasting hyperinsulinemia associates with increased sub-clinical inflammation in first-degree relatives normal glucose tolerant women independently of the metabolic syndrome

BACKGROUND

To evaluate the influence of gender on the relationship between inflammation and hyperinsulinemia in first-degree relatives of type 2 diabetic patients independently of metabolic syndrome.

METHODS

Study group consisted in 217 first-degree relatives with normal glucose tolerance after an oral glucose tolerance test. A logistic analysis, adjusted for age, sex and all the components of the metabolic syndrome, was used to determine the relationship between interleukin-6 (IL-6) and leptin and tertiles of fasting insulin, and to take into account the influence of gender.

RESULTS

In the whole cohort, IL-6 and leptin were significantly higher and adiponectin significantly lower in the III tertile when corrected for age, body mass index (BMI) and metabolic syndrome components. In women, but not in men, IL-6 and leptin remained significantly higher when corrected for metabolic syndrome. In the whole cohort and in women, univariate correlations between IL-6 concentrations and the parameters under evaluation showed that IL-6 and leptin were positively correlated with age, BMI, waist, systolic blood pressure (SBP), diastolic blood pressure (DBP), fasting glucose, fasting insulin, Delta AUC insulin area, triglyceride (TG), free fatty acids (FFA) and monocyte chemoattractant protein-1 (MCP-1) and inversely correlated with HDL cholesterol (HDL-C) and adiponectin. In women a forward stepwise linear regression analysis in a model including age, BMI, features of metabolic syndrome, fasting insulin, Delta AUC insulin and insulin sensitivity index (ISI) index revealed that only IL-6 and leptin were independently associated with fasting insulin levels.

CONCLUSIONS

In first-degree relatives normal glucose tolerant women, fasting hyperinsulinemia, independently of the presence of metabolic syndrome, is associated with elevated IL-6 and leptin levels, suggesting an increased cardiovascular risk.

Implementing the European guidelines for cardiovascular disease prevention in the primary care setting in Cyprus: lessons learned from a health care services study

BACKGROUND

Recent guidelines recommend assessment and treatment of the overall risk for cardiovascular disease (CVD) through management of multiple risk factors in patients at high absolute risk. The aim of our study was to assess the level of cardiovascular risk in patients with known risk factors for CVD by applying the SCORE risk function and to study the implications of European guidelines on the use of treatment and goal attainment for blood pressure (BP) and lipids in the primary care of Cyprus.

METHODS

Retrospective chart review of 1101 randomly selected patients with type 2 diabetes mellitus (DM2), or hypertension or hyperlipidemia in four primary care health centres. The SCORE risk function for high-risk regions was used to calculate 10-year risk of cardiovascular fatal event. Most recent values of BP and lipids were used to assess goal attainment to international standards. Most updated medications lists were used to compare proportions of current with recommended antihypertensive and lipid-lowering drug (LLD) users according to European guidelines.

RESULTS

Implementation of the SCORE risk model labelled overall 39.7% (53.6% of men, 31.3% of women) of the study population as high risk individuals (CVD, DM2 or SCORE > or =5%). The SCORE risk chart was not applicable in 563 patients (51.1%) due to missing data in the patient records, mostly on smoking habits. The LDL-C goal was achieved in 28.6%, 19.5% and 20.9% of patients with established CVD, DM2 (no CVD) and SCORE > or =5%, respectively. BP targets were achieved in 55.4%, 5.6% and 41.9% respectively for the above groups. There was under prescription of antihypertensive drugs, LLD and aspirin for all three high risk groups.

CONCLUSION

This study demonstrated suboptimal control and under-treatment of patients with cardiovascular risk factors in the primary care in Cyprus. Improvement of documentation of clinical information in the medical records as well as GPs training for implementation and adherence to clinical practice guidelines are potential areas for further discussion and research.