This page contains a Flash digital edition of a book.
Patel_US_endo_Cardiology_book_temp 23/12/2009 12:38 Page 99
Cardiovascular Risk in Type 2 Diabetes—Reflecting on the ADVANCE Study
A recent report from the UKPDS
19
has also provided a strong indication implementation of a comprehensive management strategy addressing all
that the reason for the apparent lack of effect on macrovascular cardiovascular risk factors is essential for combating the global epidemic
outcomes in ADVANCE, ACCORD, and VADT could be because the full of diabetes with its ever-increasing burden of cardiovascular disease. n
effects of glucose lowering do not evolve until many years after the
intervention has commenced. The post-trial follow-up study
demonstrated that the differences in HbA
Sophia Zoungas, MD, PhD, is a Senior Research Fellow in
1c
between the two originally
the Cardiovascular and Renal Divisions of the George
assigned intervention groups (intensive treatment with sulfonylurea and
Institute for International Health at the University of
insulin versus conventional treatment) were lost within one year of the
Sydney, and a senior lecturer at the School of Public
study ending, yet relative risk reductions were maintained at 10 years
Health at Monash University in Melbourne. Her major
research interests are the impact of glycemic control on
for diabetes-related outcomes (9%; p=0.004) and microvascular disease
cardiovascular outcomes and other complications in type
(24%; p=0.001), and new significant benefits on cardiovascular
2 diabetes. She is Study Co-ordinator of ADVANCE-ON, the
outcomes and all-cause mortality emerged.
19
These positive findings of
post-trial follow-up study of the ADVANCE trial.
a ‘legacy’ effect of intensive glucose control urgently require
John Chalmers, MD, PhD, is Emeritus Professor of
confirmation in other larger studies of more diverse populations with
Medicine at the University of Sydney and Senior Director
long-standing diabetes. If the effects observed in the post-UKPDS trial of the George Institute for International Health in Sydney.
are indeed confirmed, this will have enormous implications for the
His research has focused on the prevention of
cardiovascular diseases in high-risk groups, including
management of type 2 diabetes.
those with diabetes, elevated blood pressure, and
previous stroke. Professor Chalmers was the principal
Conclusions
investigator for the ADVANCE and PROGRESS trials and
one of the founders of the Blood Pressure Lowering
The results of ADVANCE provide additional guidance to help prevent
Treatment Trialists’ Collaboration.
many of the devastating vascular complications of type 2 diabetes. The
findings of the BP-lowering arm of the study provide a strong basis for Anushka Patel, MD, PhD, is Director of the Cardiovascular
clinicians to recommend routine BP lowering for the vast majority of
Division at the George Institute, a consultant cardiologist at
Royal Prince Alfred Hospital, and an Associate Professor of
patients with type 2 diabetes. The evidence from the glucose control arm
Medicine at the University of Sydney. She was Study
suggests that clinicians should consider a pragmatic and progressive Director and a member of the Steering Committee of the
glucose control strategy to improve microvascular renal disease and
ADVANCE study. Dr Patel has an MSc in epidemiology
from Harvard University and a PhD in medicine from the
long-term cardiovascular risk. These findings add to the compelling
University of Sydney.
evidence for a multifactorial approach that includes statin therapy,
smoking cessation, BP lowering, and glucose control. Widespread
1. Patel A, MacMahon S, Chalmers J, et al., Effects of a fixed of Chicago cohorts, Cardiology, 1993;82(2-3):191–222. intensive blood-pressure lowering and low-dose aspirin in
combination of perindopril and indapamide on 8. Adler AI, Stratton IM, Neil HA, et al., Association of systolic patients with hypertension: principal results of the
macrovascular and microvascular outcomes in patients with blood pressure with macrovascular and microvascular Hypertension Optimal Treatment (HOT) randomised trial,
type 2 diabetes mellitus (the ADVANCE trial): a randomised complications of type 2 diabetes (UKPDS 36): prospective Lancet, 1998;351:1755–62.
controlled trial, Lancet, 2007;370(9590):829–40. observational study, BMJ, 2000;321(7258):412–19. 15. Turnbull F, Neal B, Algert C, et al., Effects of different
2. Patel A, MacMahon S, Chalmers J, et al., Intensive blood 9. Lewington S, Clarke R, Qizilbash N, et al., Age-specific blood pressure-lowering regimens on major cardiovascular
glucose control and vascular outcomes in patients with type relevance of usual blood pressure to vascular mortality: events in individuals with and without diabetes mellitus:
2 diabetes, N Engl J Med, 2008;358(24):2560–72. a meta-analysis of individual data for one million adults results of prospectively designed overviews of randomized
3. UK Prospective Diabetes Study (UKPDS) Group, Intensive in 61 prospective studies, Lancet, 2002;360(9349):1903–13. trials, Arch Intern Med, 2005;165(12):1410–19.
blood-glucose control with sulphonylureas or insulin 10. HOPE (Heart Outcomes Prevention Evaluation) Study 16. Nathan DM, Buse JB, Davidson MB, et al., Medical
compared with conventional treatment and risk of Investigators, Effects of an angiotensin-converting-enzyme management of hyperglycemia in type 2 diabetes: a
complications in patients with type 2 diabetes (UKPDS 33), inhibitor, ramipril, on cardiovascular events in high-risk consensus algorithm for the initiation and adjustment of
Lancet, 1998;352(9131):837–53. patients, N Engl J Med, 2000;342:145–53. therapy: a consensus statement of the American Diabetes
4. Gerstein HC, Miller ME, Byington RP, et al., Effects of 11. Tuomilehto J, Rastenyte D, Birkenhager WH, et al., Effects of Association and the European Association for the Study of
intensive glucose lowering in type 2 diabetes, N Engl J Med, calcium-channel blockade in older patients with diabetes Diabetes, Diabetes care, 2009;32(1):193–203.
2008;358(24):2545–59. and systolic hypertension, N Engl J Med, 1999;340(9):677–84. 17. Stratton IM, Adler AI, Neil HA, et al., Association of glycaemia
5. Duckworth W, Abraira C, Moritz T, et al., Glucose control and 12. Kloner RA, Neutel J, Roth EM, et al., Blood pressure control with macrovascular and microvascular complications of
vascular complications in veterans with type 2 diabetes, with amlodipine add-on therapy in patients with type 2 diabetes (UKPDS 35): prospective observational study,
N Engl J Med, 2009;360(2):129–39. hypertension and diabetes: results of the Amlodipine BMJ, 2000;321(7258):405–12.
6. Kuller LH, Velentgas P, Barzilay J, et al., Diabetes mellitus: Diabetic Hypertension Efficacy Response Evaluation Trial, 18. UK Prospective Diabetes Study (UKPDS) Group, Effect of
subclinical cardiovascular disease and risk of incident Ann Pharmacother, 2008;42(11):1552–62. intensive blood-glucose control with metformin on
cardiovascular disease and all-cause mortality, Arterioscler 13. United Kingdom Prospective Diabetes Study Group. Tight complications in overweight patients with type 2 diabetes
Thromb Vasc Biol, 2000;20(3):823–9. blood pressure control and risk of macrovascular and (UKPDS 34), Lancet, 1998;352(9131):854–65.
7. Stamler J, Dyer AR, Shekelle RB, et al., Relationship of microvascular complications in type 2 diabetes: UKPDS 38, 19. Holman RR, Paul SK, Bethel MA, et al., 10-year follow-up of
baseline major risk factors to coronary and all-cause BMJ, 1998;317:703–13. intensive glucose control in type 2 diabetes, N Engl J Med,
mortality, and to longevity: findings from long-term follow-up 14. Hansson L, Zanchetti A, Carruthers SG, et al., Effects of 2008;359(15):1577–89.
US ENDOCRINOLOGY 99
Page 1  |  Page 2  |  Page 3  |  Page 4  |  Page 5  |  Page 6  |  Page 7  |  Page 8  |  Page 9  |  Page 10  |  Page 11  |  Page 12  |  Page 13  |  Page 14  |  Page 15  |  Page 16  |  Page 17  |  Page 18  |  Page 19  |  Page 20  |  Page 21  |  Page 22  |  Page 23  |  Page 24  |  Page 25  |  Page 26  |  Page 27  |  Page 28  |  Page 29  |  Page 30  |  Page 31  |  Page 32  |  Page 33  |  Page 34  |  Page 35  |  Page 36  |  Page 37  |  Page 38  |  Page 39  |  Page 40  |  Page 41  |  Page 42  |  Page 43  |  Page 44  |  Page 45  |  Page 46  |  Page 47  |  Page 48  |  Page 49  |  Page 50  |  Page 51  |  Page 52  |  Page 53  |  Page 54  |  Page 55  |  Page 56  |  Page 57  |  Page 58  |  Page 59  |  Page 60  |  Page 61  |  Page 62  |  Page 63  |  Page 64  |  Page 65  |  Page 66  |  Page 67  |  Page 68  |  Page 69  |  Page 70  |  Page 71  |  Page 72  |  Page 73  |  Page 74  |  Page 75  |  Page 76  |  Page 77  |  Page 78  |  Page 79  |  Page 80  |  Page 81  |  Page 82  |  Page 83  |  Page 84  |  Page 85  |  Page 86  |  Page 87  |  Page 88  |  Page 89  |  Page 90  |  Page 91  |  Page 92  |  Page 93  |  Page 94  |  Page 95  |  Page 96  |  Page 97  |  Page 98  |  Page 99  |  Page 100  |  Page 101  |  Page 102  |  Page 103  |  Page 104  |  Page 105  |  Page 106  |  Page 107  |  Page 108  |  Page 109  |  Page 110  |  Page 111  |  Page 112  |  Page 113  |  Page 114  |  Page 115  |  Page 116  |  Page 117  |  Page 118  |  Page 119  |  Page 120  |  Page 121  |  Page 122  |  Page 123  |  Page 124
Produced with Yudu - www.yudu.com