Diabetic patients have very high rates of heart attack, stroke and kidney failure. Studies have previously shown that cholesterol lowering with statins and aggressive blood pressure control can reduce risk. Although most physicians stress the importance of glucose control in diabetes, it's not clear that lowering blood sugar reduces risk. Some of the most controversial trials reported this year looked at the impact of blood glucose control on the progression of vascular disease-with surprising results. Three trials reported at the American Diabetes Association annual meeting in San Francisco in June found no significant benefit of aggressive glucose lowering on vascular events. In one of them (ACCORD) the risk for death was actually increased. The others (ADVANCE and VADT) showed no benefit. The role of glucose lowering in prevented heart attack and stroke remains undefined.
Aggressive blood pressure control and cholesterol lowering does save lives in patients with diabetes. SANDS (Stop Atherosclerosis in Native Diabetics Study) looked at lowering blood pressure even further than the 120-130 systolic currently recommended by the guidelines and the current LDL cholesterol ("bad" cholesterol) target of 100 mgs/dl. In that study patients who achieved a blood pressure target of 115 systolic and a LDL cholesterol of less than 70 mgs/dl had less progression of atherosclerosis.
Data presented in these and many other trials this year have sharpened our focus in matching the patient to the agent and to the treatment goal. 2009 will certainly provide more insight and lead to better care for our patients.
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