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Patients with type 2 diabetes experience high rates of comorbid conditions such as hypertension and dyslipidaemia that further compound their already increased risk of developing ischaemic heart disease (IHD). IHD and hypertension, in turn, represent conditions that are major precursors of congestive heart failure (CHF), adding to the cardiovascular disease (CVD) burden in this patient population. This is reflected in the reported estimate of IHD prevalence in diabetics (approximating 22%)1 and the reported 10-year incidence of CHF among elderly patients with newly diagnosed type 2 diabetes (exceeding 50%).2 The American Heart Association and the American Diabetes Association have also noted in a joint scientific statement paper that CVD contributes to more than three-quarters of all deaths in diabetic patients.3
The health benefits of treating hypertension with angiotensin-converting enzyme inhibitors4 and treating hyperlipidaemia with statins5 have been well established in clinical trials. The use of other preventive measures such as aspirin and smoking cessation are also generally accepted. It remains unclear, however, to what extent glycaemic control with currently available oral agents reduces the macrovascular complications of diabetes. Although these more recently developed and approved agents, including the thiazolidinediones, are being heavily prescribed for the treatment of type 2 diabetes, there is no documentation from clinical trials that they reduce the risk of IHD. Consequently, none has been granted regulatory approval for this indication.
GLYCAEMIC CONTROL AND CARDIOVASCULAR RISK
Three recently published large, randomised clinical trials all failed to demonstrate that intensive glycaemic control reduces CVD mortality or morbidity in patients with type 2 diabetes. In ACCORD (Action to Control Cardiovascular Risk in Diabetes),6 participants in the intensive treatment arm (targeting a glycated haemoglobin level of <6.0%) experienced excess mortality compared with those receiving standard treatment (targeting a level from 7.0% to 7.9%) (hazard ratio (HR) = 1.22; 95% CI 1.01 to …
Competing interests: None.