An Integrated Approach is Key to Managing Diabetes

June 28, 2010

Robert Chilton, DO, FACC

Diabetes is becoming increasingly relevant to cardiologists as more than half of our patients presenting with their first heart attack have diabetes. Discouraging results from the National Health and Nutrition Examination Survey (NHANES) report that less than half of patients with diabetes achieved an A1C<7% (the standard, as recommended by the American Diabetes Association), 40% had their blood pressure under control, and only a third met their lipid goals. Further, it is a minority of patients with diabetes (~15%) who are successful at reaching all three goals (blood pressure, lipids and A1C).  To add complexity to the matter, three large studies, Veteran Affairs Diabetes Trial (VADT), Action to Control Cardiovascular Risk in Diabetes (ACCORD) and Action in Diabetes and Vascular Disease: Preterax and Diamicron MR Controlled Evaluation (ADVANCE) failed to show a significant reduction in heart attacks with intensive glycemic control, reigniting a debate of “how low should we go” for the A1C target. 

The key finding from these trials is that the magnitude of the cardiovascular protection of tight glucose control, in isolation, is smaller than the cardiovascular benefit from achieving blood pressure or lipid goals. We know from the STENO (Steno Diabetes Center) trial that an integrative approach to cardiometabolic risk reduction is much more successful and can cut cardiovascular events in half. Achieving good glucose control is justified and still essential, but should be considered within the context of an integrated approach to cardiovascular risk reduction that includes improvement in blood pressure, lipids and minimizing weight gain or facilitating weight loss. Of course, smoking cessation and an aspirin are also part of the integrated intervention.

Note that weight gain associated with most current therapeutic options for patients with type 2 diabetes is not solely cosmetic but contributes to the worsening of the cardiovascular risk profile and has been associated with increased mortality. The Look AHEAD (Action for Health in Diabetes) trial has robustly demonstrated the benefit of modest weight loss in patients with type 2 diabetes and every effort should be taken to promote safe weight loss. Taken together, the evidence suggests that achieving good glycemic control is an important part of the overall global risk reduction, but should be accomplished with weight loss, improving lipids, and reducing blood pressure. Clearly, the best way to reduce cardiovascular disease is to prevent it by aggressively activating our patients to choose a healthy lifestyle.

Robert Chilton is Professor of Medicine and Director, Cardiac Cath Lab at the University of Texas Health Science Center in San Antonio, Texas.

For more related articles, click Diabetes Perspectives.