Cardiovascular Risk in Type 2 Diabetes – Reflecting on the ADVANCE Study
Cardiovascular Risk in Type 2 Diabetes – Reflecting on the ADVANCE Study
Citation: US Cardiology, 2009;6(2):46-50
European Endocrinology - Volume 5 Issue I or US Endocrinology - Volume 5 Issue 1
Published: September 2009
European Endocrinology - Volume 5 Issue I or US Endocrinology - Volume 5 Issue 1
Published: September 2009
Abstract
The world is facing an unprecedented increase in type 2 diabetes. Most disability and premature mortality experienced by patients with diabetes is related to vascular disease and, in particular, macrovascular disease (such as coronary heart disease and stroke) and microvascular disease (such as retinopathy, nephropathy and neuropathy). Indeed, around 1.9 million cardiovascular deaths worldwide are attributable to high blood glucose levels and diabetes, as well as to their associated dangerous companions of high blood pressure and abnormal lipid levels. The global economic costs of diabetes, including foregone economic growth and increasing healthcare expenditure, are substantial and are anticipated to grow. Therefore, strategies to reduce disease burden have continued to focus on reducing cardiovascular risk. Recently, a number of large-scale clinical trials have evaluated approaches for managing cardiovascular risk in patients with type 2 diabetes. Among them the Action in Diabetes and Vascular Disease: PreterAx and DiamicroN MR Controlled Evaluation (ADVANCE) trial has reported the effects of blood pressure lowering and intensive glucose control on major vascular events in patients with established type 2 diabetes. In this article we summarise the findings of the ADVANCE trial and discuss its relevance to the management of cardiovascular risk in patients with type 2 diabetes worldwide.
Keywords
Type 2 diabetes, cardiovascular risk, mortality, complications, blood pressure treatment, glycaemic control, clinical trials
Disclosure: Sophia Zoungas, John Chalmers and Anushka Patel have received lecturing fees from Servier. John Chalmers holds a research grant from Servier as principal investigator for ADVANCE. Sophia Zoungas is supported by a National Health and Medical Research Council of Australia Health Professional Research Fellowship. Anushka Patel is supported by a National Heart Foundation of Australia Career Development award.
Received: 27 April 2009 Accepted: 16 July 2009
Correspondence: Sophia Zoungas, Cardiovascular Division, The George Institute for International Health, University of Sydney, PO Box M201, Missenden Road, Sydney, NSW 2050, Australia. E: szoungas@george.org.au
Summary of the ADVANCE Trial Findings
The ADVANCE trial was a factorial, randomised study of 11,140 individuals with type 2 diabetes from over 200 collaborating centres in 20 countries from Asia, Australasia, Europe and North America. Participants with either a history of macrovascular or microvascular disease or at least one major risk factor for cardiovascular disease and any initial level of blood pressure (BP) and blood glucose were randomly assigned to the fixed combination of the angiotensinconverting enzyme (ACE) inhibitor perindopril and the thiazide diuretic indapamide (4/1.25mg) or matching placebo and to intensive glucose control or standard guideline-based glucose control. The glucose-lowering regimen for those randomised to intensive glucose control was based on the modified-release sulphonylurea gliclazide-MR 30–120mg daily. However, nonpharmacological approaches, other oral agents and insulin were recommended to be added as required to achieve the target glycated haemoglobin (HbA1c) level of ≤6.5%. The choice of additional treatments was left to the discretion of the responsible physician. Participants randomised to standard guidelines-based glucose control were permitted to use sulphonylureas (other than gliclazide) and any other available glucose-lowering therapy, including insulin. The primary outcomes were composites of major macrovascular (non-fatal acute myocardial infarction, non-fatal stroke and cardiovascular death) and major microvascular events (new or worsening nephropathy and microvascular eye disease), analysed jointly and separately. The average duration of follow-up was 4.3 years for the BP-lowering intervention and five years for the glucose control intervention.
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Keywords:
Type 2 diabetes, cardiovascular risk, mortality, complications, blood pressure treatment, glycaemic control, clinical trials, type 2 diabetes blood glucose levels, insulin dependent type 2 diabetes, type 2 diabetes diet, type 2 diabetes insulin resistance, insulin injections type 2 diabetes, diastolic blood pressure, glycated haemoglobin, blood glucose levels, insulin infusion,
Type 2 diabetes, cardiovascular risk, mortality, complications, blood pressure treatment, glycaemic control, clinical trials, type 2 diabetes blood glucose levels, insulin dependent type 2 diabetes, type 2 diabetes diet, type 2 diabetes insulin resistance, insulin injections type 2 diabetes, diastolic blood pressure, glycated haemoglobin, blood glucose levels, insulin infusion,
