Macrovascular Disease And Glucose Control

As noted earlier in the discussion on macrovascular disease, there are many studies showing the benefit of lipid and blood pressure control in patients with diabetes. The issue of the direct benefit of glucose control has not been settled to date in a study where other risk factors are controlled and glucose control is the major outcome. The study by Balkau (19) and a metaanalysis by Couthinho (20) demonstrates that increasing fasting as well as postprandial glucose levels is associated with cardiovascular disease. The Veterans Affairs Cooperative Study on Glycemic Control and Complications in type 2 Diabetes (VACSDM) was a feasibility trial in 153 adult men with type 2 diabetes (35). The patients had a mean HbA1c of 9.8%, and were either on insulin or failing oral therapy and judged to need insulin. In addition, 38% of them had prior cardiovascular events. The goal of the standard treatment arm was to keep the HbA1c within two standard deviations on the mean of the outpatient diabetic clinics of the participating hospitals. The intensive therapy aimed for normal fasting glucose (80-120 mg/ dL) and preprandial glucose (< 130mg/dL) and HbA1c of < 6.1%. The glucose control was achieved via a four stepped phases treatment plan. Therapy started with evening insulin and then had an oral sulfonylurea, glipizide added and progressed to twice daily insulin and no oral medication and ended with multiple daily insulin injections. Efforts were made to control blood pressure, lipids, obesity, and smoking in both groups. The intensively treated patients had more hypoglycemia, required larger insulin doses and had more statistically nonsignificant cardiovascular events. Interestingly these events occurred in the group with HbA1c levels between 5.5% and 8%. The total mortality rate and cardiovascular mortality was identical in both treatment groups. This study does not answer the question of glycemic control and cardiovascular disease because of the high number of patients who already had cardiovascular events before entry.

The results of glucose control and macrovascular outcome are summarized in the table below (Table 3). These studies are not comparable and they vary in design and main outcomes studied. Apart from the VACSDM, all the other studies showed no increase in cardiovascular risk as blood glucose control was improved. The UKPDS and Kumamoto were studies primarily of glycemic control and microvascular disease, while the Diabetes Insulin Glucose Acute Myocardial Infarction (DIGAMI) study looked at the effects of intensive insulin therapy in the situation of an acute MI.

The data from the table indicate that there is a cardiovascular benefit in lowering the blood glucose that ranges from a relative risk reduction (RRR) of 16% to 46%. But the problem with this observation is that the data comes from multiple sources and what is now needed, is study that is specifically designed to address the question. The new Action to Control Cardiovascular Risk in Diabetes (ACCORD) Trial has been designed to address the issue in

Diabetes 2

Diabetes 2

Diabetes is a disease that affects the way your body uses food. Normally, your body converts sugars, starches and other foods into a form of sugar called glucose. Your body uses glucose for fuel. The cells receive the glucose through the bloodstream. They then use insulin a hormone made by the pancreas to absorb the glucose, convert it into energy, and either use it or store it for later use. Learn more...

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