Improved Outcomes and Reduction of CV Risk in Diabetes Remains Problematic
October 1, 2009 3 minutes read
Improved Outcomes and Reduction of CV Risk in Diabetes Remains Problematic
Abstract & Commentary
By Jonathan Abrams, MD, Professor of Medicine, Division of Cardiology, University of New Mexico, Albuquerque. Dr. Abrams serves on the speaker's bureau for Merck, Pfizer, and Parke-Davis.
Source: Preis Sr, et al. Trends in cardiovascular disease risk factors in individuals with and without diabetes mellitus in the Framingham Heart Study. Circulation. 2009; 120:212-220.
Do patients with diabetes share in the reduction of cardiovascular (CV) risk factors as much as non-diabetics? That question is the subject of an analysis of data from the most recent Framingham Heart Study (FHS). The report consists of outcomes in the FHS Third Generation Cohort: 4,950 children and spouses enrolled in 2002 who attended their first examination. The data were derived from the 50- and 60-year-old individuals with and without diabetes from 1970 to 2005. Continuous risk factors in the 50- and 60- year-old cohorts were BMI, blood pressure, total and LDL cholesterol, and diabetes. The prevalence of each risk factor over a 35-year period was calculated for each 10-year interval; secondary analyses included diabetic status and mean CVD risk factor levels by decade.
Results: Systolic and diastolic blood pressure fell equally in diabetics and non-diabetics. The magnitude of decline in systolic and diastolic blood pressure was similar in diabetics and non-diabetics. The prevalence of hypertension treatment increased from 21% to 53% among those without diabetes and from 26% to 63% among those with diabetes. Hypertension prevalence decreased in the 60-year-old group without diabetes mellitus (DM) with no change in the diabetics; treatment and control were similar in diabetics and non-diabetics in the 60-year-old cohort. Treatment of high blood pressure increased with and without diabetes. Treatment control of high blood pressure increased in subjects with and without diabetes.
BMI increased 0.39 kg/m2 in non-diabetics and a mean of 2.52 kg/m2 in diabetics per decade. Obesity increased markedly in the 50-year-old individuals: 17%-24% in non-diabetes and 36%-62% in diabetic subjects.
LDL cholesterol fell from a mean of 141 to 119 mg/dL in non-diabetics, a decline of 7.43 mg/dL per decade, whereas the diabetics had a decrease in LDL cholesterol from 161 to 111 mg/dL (15 mg/dL per decade). For all of the above, the direction of the trends for those with diabetes relative to those without diabetes was similar for 60-year-olds. The LDL cholesterol treatment and control increased markedly for those with and without diabetes, but only about 20% in either group achieved LDL control in 2000-2005. Results overall were similar in both the 50- and 60-year-old cohorts. Prevalence of high LDL decreased in non-diabetics, with no change in the diabetics. In 50- to 60-year-old subjects, high blood pressure prevalence decreased in those without diabetes, but there was no change in the diabetic cohort.
Preis et al concluded that diabetic subjects have not experienced the same magnitude of cardiovascular risk reduction as their non-diabetic cohorts.
Commentary
This report helps us to understand why diabetes is such a serious clinical problem. When I went to medical school, and for many years thereafter, diabetes was a problem solely for the endocrinologist. Slowly and subsequently, with great speed over recent years, diabetes has also been recognized as a vascular, cardiovascular, renal, and endocrine problem. The understanding of insulin resistance is critical in dealing with diabetes therapy. Furthermore, several recent studies assessing the impact of diabetes on CV disease patients have been surprisingly negative, emphasizing the complexity of insulin resistance and hyperglycemia.
These data, gleaned from the large cohort of participants in the Third Framingham Heart Study population of almost 5,000 subjects, confirms yet again that diabetes is bad news for vascular health but, perhaps, more selective than we had thought. The resulting different medical problems (i.e., hypertension, obesity, renal disease, dyslipidemia) reflect the widespread presence of insulin resistance in type II diabetic individuals.
Clearly, the body responds differently in the presence of insulin resistance and/or diabetes. For instance, diabetes and hypertension impose risk on patients with diabetes equally vs. non diabetics, although diabetes is a major risk factor when compared to smoking. These data are most remarkable when looking at the large increase in BMI over the years.
Finally, it is clear that an increased knowledge about diabetic therapy and/or treatment guidelines in diabetics vs. non-diabetics is highly recommended for our diabetic patients, with specific attention paid to each major CV risk factor separately and/or in conjunction with other risk markers.
Do patients with diabetes share in the reduction of cardiovascular (CV) risk factors as much as non-diabetics?You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content