Intense blood pressure and lipid control no help for diabetic hearts

Kathleen Blanchard's picture
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One of the largest studies ever conducted in adults with type 2 diabetes at high risk for heart attack, stroke and death from heart disease reveals that lowering blood pressure below the recommended target of 140 mm/Hg systolic, compared to those whose blood pressure target was kept below 120 mm/Hg did not lower the risk of cardiovascular events. Intense blood pressure treatment and combined lipid lowering therapy was not proven to be any help for diabetic heart disease outcomes.

Results of the Action to Control Cardiovascular Risk in Diabetes (ACCORD) clinical trial also showed that combined therapy to lower cholesterol levels, including prescribing fibrates in conjunction with statins, had no benefit for reducing the risk of fatal or nonfatal cardiovascular disease among type 2 diabetics.

The ACCORD trial explored diabetic heart disease outcomes targeting three treatment approaches - control of blood sugar, intensive control of blood pressure, and treatment of multiple blood lipids (high density lipoprotein (HDL) cholesterol and triglycerides). A study of 10,251 of participants with type 2 diabetes between the ages of 40 and 79, diagnosed with the disease for an average of 10 years, found "no conclusive evidence that targeting a normal systolic blood pressure compared with targeting a systolic blood pressure of less than 140 mmHg lowers the overall risk of major cardiovascular events in high risk adults with type 2 diabetes", according to lead study author William C. Cushman, M.D., chief of the Preventive Medicine Section, Veterans Affairs Medical Center, Memphis, Tennessee.

The findings from the ACCORD trial do show that diabetics might reduce stroke risk from keeping blood pressure lower, findings that are consistent with previous studies.

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"Our results also showed a higher risk of serious adverse events with more intensive blood pressure control," Cushman added. "Diabetic patients should discuss their systolic blood pressure goal with their health care provider and, as with any treatment, weigh the risks and benefits of various treatments to lower blood pressure."

The ACCORD trial also found no benefit for cardiovascular outcomes from combined lipid lowering therapy for patients with type 2 diabetes. Henry N. Ginsberg, M.D., director of the Irving Institute for Clinical and Translational Research at Columbia University College of Physicians and Surgeons, New York City says, "Although our analysis suggests that certain patients may benefit from combination therapy, this study provides important information that should spare many people with diabetes unneeded therapy with fibrates". Fibrates are medications that reduce the liver’s production of VLDL (very low density lipoprotein), particles that carry triglycerides in the bloodstream.

Dr. Ginsberg adds however, "The lack of benefit from fibrates should not obscure the proven value of statins in preventing cardiovascular disease, which is well established from earlier studies. Patients should discuss with their health care provider the implications of this research for their lipid therapy management." In the study, patients with the lowest levels of HDL (good cholesterol) and highest triglyceride levels had lower rates of cardiovascular events from combined cholesterol lowering therapy, compared to similar participants receiving just statin drugs. The lipid portion of the ACCORD trial included 5,518 participants.

The authors say the ACCORD trial results indicate that individuals with type 2 diabetes do not need blood pressure lowering and combined therapy for lipid control, beyond "standard practice."

Denise G. Simons-Morton, M.D., Ph.D., co-author and former NHLBI project officer for ACCORD warns that the findings "in no way detract from the important point that controlling blood pressure and LDL cholesterol levels reduce cardiovascular risk – not only in patients with diabetes, but in all patients with elevated levels”, and that the trial results may not apply to individuals newly diagnosed with type 2 diabetes or to patients who are at lower risk for heart disease than those included in the ACCORD trial.

NEJM

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