Worries that aggressive treatment of hyperglycemia with insulin or insulin secretogogues would increase the risk of clinical cardiovascular disease are not supported by existing data from clinical trials. In fact, aggressive management of glycemia has been associated with a decrease, rather than an increase, in events such as myocardial infarction and stroke. Results from the UKPDS and from £

studies with thiazolidinediones suggest that approaches to glycemic management focused on amelioration of hepatic or peripheral tissue insulin resistance may be preferable to approaches that raise circulating insulin concentrations. However, both approaches have some beneficial impact on the risk of cardiovascular events J

compared to allowing patients to maintain chronic hyperglycemia. Much work

& u is needed to understand the impact of improved glycemia, changes in circulating lipids, and alterations in insulin resistance and insulin levels in the pathogenesis of the arterial wall changes of atherosclerosis and in the precipitation of clinical cardiovascular events. Based on current information regarding events, clinical care of patients with type 1 or type 2 diabetes who remain at risk for long-term diabetic complications should include a stepped-care approach to achieve low-risk glycemia (HbA1C <7%) in addition to low-risk lipid and blood pressure levels.

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