Cardiovascular Risk Factors — How Important are They to Control in Diabetic Patie
Cardiovascular Risk Factors— How Important are They to Control in Diabetic Patients Without Known Coronary Artery Disease?
Abstract & Commentary
Synopsis: Cardiovascular risk factors should be modified as aggressively in diabetic patients without coronary artery disease as is recommended for nondiabetic (or diabetic) patients with prior myocardial infarctions.
Source: Haffner SM, et al. N Engl J Med 1998;339:229-234.
Patients with proven coronary artery disease have 3-7 times greater mortality than do patients without known coronary artery disease.1,2 Diabetic patients are particularly at significant risk for developing symptomatic coronary artery disease3,4 as are patients with elevated serum cholesterol levels,4,5 whether they are afflicted with diabetes. However, it had not been previously clearly determined whether it is necessary to treat diabetic patients who have not previously suffered myocardial infarctions as aggressively with respect to risk factor modification as is recommended for post-myocardial infarction patients whether they are diabetics.
A report recently published in the New England Journal of Medicine from the University of Texas Health Science Center at San Antonio, Texas, and from the Turku University in Finland addressed this question by comparing the seven-year incidence of both fatal and nonfatal myocardial infarctions that occurred in 1373 nondiabetic patients with the incidence in 1059 diabetic subjects.6 Their data suggested that diabetic patients without previous myocardial infarctions had as high a risk of myocardial infarction as nondiabetic patients with previous myocardial infarctions. They conclude that cardiovascular risk factors should be modified as aggressively in diabetic patients without coronary artery disease as is recommended for nondiabetic (or diabetic) patients with prior myocardial infarctions.
Comment by Harold L. Karpman, MD
The data in the present study were obtained from a Finnish population-based data base, which is a central registry of all patients with diabetes who receive reimbursement for drugs. Although the data are well collected, one potential limitation of the current study is that the mortality rate from coronary artery disease in Finland is among the highest in the world.6 The seven-year incidence of myocardial infarctions among nondiabetic patients with and without prior myocardial infarction at baseline was 18.1% and 3.5%, respectively, whereas the incidence of myocardial infarction in diabetic patients with and without prior myocardial infarction at baseline were 45% and 20.2%, respectively. Therefore, the incidence rates in nondiabetic patients with prior myocardial infarctions and in diabetics without prior myocardial infarctions are essentially equivalent. Obviously, a prospective study comparing the effects of different levels of lipid-lowering therapy on coronary heart disease in diabetic subjects, with and without previous history of myocardial infarctions, would be a definitive way to demonstrate that the conclusions derived from this population-based study are accurate. However, in the short-term, it would appear to be prudent to treat all diabetics (whether they have or have not previously suffered a myocardial infarction) with vigorous risk factor modification in order to reduce the incidence of new and/or recurrent myocardial infarctions.
References
1. Pekkanen J, et al. N Engl J Med 1990;322:1700-1707.
2. Rosengren A, et al. Eur Heart J 1997;18:754-761.
3. Wingard DI, Barrett-Connor E. Heart disease and diabetes. In: National Diabetes Data Group. Diabetes in America. 2nd ed. Washington, D.C.: Government Printing Office 1995;95-1468:429-448.
4. Stamler J, et al. Diabetes Care 1993;16:434-444.
5. Rosengren A, et al. BMJ 1989;299:1127-1131.
6. Tunstall-Pedoc H, et al. Circulation 1994;90:583-612.
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