Diabetes, Heart Disease Link Debated At AHA Meeting
Reprinted with permission by Close Concerns
The posters and presentations at the 2008 Annual Meeting of the American Heart Association showed particular interest in determining the link between diabetes and cardiovascular disease, along with illustrating the risk for cardiovascular disease in diabetic populations.
Considerable attention was given to the results of the United Kingdom Prospective Diabetes Study (UKPDS) 10-year follow-up study, which showed a positive effect of intensive glycemic control on long-term macrovascular outcome. Similarly, Dr. Saul Genuth of Case Western Reserve University, reported comparable cardiovascular data from the Diabetes Control and Complication Trial/Epidemiology of Diabetes Intervention and Complications (DCCT/EDIC) study. In patients with type 1 diabetes, intensive treatment was found to reduce the risk of cardiovascular disease events by 42% for all cardiovascular disease events and 57% for nonfatal heart attacks, strokes and cardiovascular disease deaths. The study found that at baseline, older age, longer diabetes duration, body mass index, high A1c, total and low-density lipoprotein cholesterol, higher albumin excretion rate, presence of retinopathy, current smoking, and history of heart attack in parents were statistically significant baseline predictors for cardiovascular events.
Dr. Alan Brown of the Midwest Heart Disease Prevention Center concluded in his talk that we need more aggressive and systematic approaches to prevent cardiovascular disease in both pre-diabetic and diabetic patients. Dr. Brown stressed that physicians should always be mindful of how prescribed medication can affect other therapy recommendations. Particularly, he made the case for appropriate use of drug treatment options for type 2 diabetes patients since some drugs can promote weight gain (such as insulin, sulfonylureas and thiazolidinediones) which others are less likely to promote weight gain (such as exenatide, metformin and pramlintide).
There are, however, dissenting opinions among researchers on the link between diabetes and cardiovascular disease. While acknowledging the UKPDS results, Dr. Theodore Mazzone (University of Illinois) concluded that we do not yet have sufficient evidence to globally recommend prevention of diabetes as a treatment for cardiovascular/macrovascular disease. Likewise, Dr. Naveed Sattar of the University of Glasgow delivered a provocative talk on what he believes is a weak association between cardiovascular disease and insulin resistance. He believes that any attempts to simultaneously describe risk factors for both cardiovascular disease and diabetes are unhelpful and may obscure the issue.
JUPITER and APPROACH Trial Results
The AHA meetings also saw the announcement of the much-anticipated results from two trials: JUPITER (Justification for the Use of Statins in Primary Prevention: an Intervention Trial Evaluating Rosuvastatin) and APPROACH (Assessment on the Prevention of Progression by Rosiglitazone on Atherosclerosis in Type 2 Diabetes Patients with Cardiovascular History). The JUPITER trial assessed the use of the drug rosuvastatin (a cholesterol-lowering drug) in preventing cardiovascular events in individuals with low LDL and high levels of an inflammation evidenced by the high levels of C-reactive protein (CRP). Since inflammation can result in damage to the arteries, CRP levels are thought to be a rough indicator of heart disease risk. After about 2 years of follow-up, rosuvastatin significantly reduced the number of cardiovascular events in healthy subjects with elevated CRP levels.
The second significant diabetes related announcement at this year's AHA conference was the Assessment on the Prevention of Progression by Rosiglitazone on Atherosclerosis in Type 2 Diabetes Patients with Cardiovascular History (APPROACH) study. Results from the APPROACH trial, compared the role of the diabetes drug rosiglitazone with that of glipizide (diabetes drug in the sulfonylurea class) in preventing further plaque buildup leading to hardening of the arteries (atherosclerosis). Though the trial was unable to confirm the role of rosiglitazone in preventing plaque buildup in coronary arteries, it did verify the beneficial effects of rosiglitazone in increasing high-density lipoprotein (HDL or "good cholesterol") levels, improving blood pressure and decreasing high sensitivity- C reactive protein (hs-CRP), a marker of inflammation that is linked to arterial plaque buildup. Learn more about TZDs, Avandia and Actos at http://www.diatribe.us/issues/6/learning-curve.php.
On the drug front, there were reports of additional clinical findings on exenatide once-weekly at the poster session. Following up on previously reported findings that exenatide once weekly improve glycemic control and reduce body weight in patients with type 2 diabetes, scientists found that the drug had positive impact on blood pressure and lipid profile over 52 weeks. Systolic and diastolic blood pressure both decreased significantly (6.2 mm Hg and 2.8 mm Hg, respectively). Additionally, the improvement in blood pressure was more dramatic in patients with higher baseline values (systolic blood pressured: -11.4 mm Hg, diastolic blood pressure: -3.6 mm Hg). Lipid and blood pressure parameters are important in the treatment of diabetes because controlling these variables may reduce the risk of long-term complications.
Kelly Close is editor in chief of diaTribe (www.diaTribe.us), a free online newsletter for patients looking for more information on products and research.
NOTE: The information is not intended to be a replacement or substitute for consultation with a qualified medical professional or for professional medical advice related to diabetes or another medical condition. Please contact your physician or medical professional with any questions and concerns about your medical condition.
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