Diabetes Mellitus and Control of Cardiovascular Disease Risk Factors
Authors: Peter W.F. Wilson, David Gagnon
Journal: Circulation (2017)

he article by Pagidipati et al 1 in this issue of Circulation reports the implications of inadequate risk factor treatment and control in adults with type 2 diabetes mellitus (T2DM) enrolled in a large multinational clinical trial that evaluated the cardiovascular disease (CVD) safety of an oral dipeptidyl peptidase-4 inhibitor medication that lowers blood glucose.In this post hoc analysis, the authors assessed at baseline the risk factor control for aspirin use, smoking, blood pressure <140/90 mm Hg, use of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and low-density lipoprotein cholesterol level <70 mg/ dL.Those elements were not targeted for intervention in the study, and because of the safety design, it is reasonable that the investigative team did not aggressively intervene on CVD risk factors.The patients in the study did not have their nonglycemic CVD risk factors well controlled at the start of the investigation, and the overall control of these factors was an important determinant of CVD events over the course of the 2008-2012 investigation.In the authors' analysis across 5 CVD factors, they report that 7% had 0 to 2 factors controlled, 21% had 3 factors controlled, 42% had 4 factors controlled, and 30% had all 5 factors controlled.Using this composite approach, they demonstrated that worse control was associated with greater risk for CVD events during follow-up.Their analysis builds on the multifactorial role of risk factors as determinants of CVD events in diabetic patients.Similarly, a post hoc analysis of the BARI 2D trial (Bypass Angioplasty Revascularization Investigation 2 Diabetes) reported in 2015 showed that CVD risk factor control in diabetic patients enrolled in a bypass versus angioplasty study helped to determine risk for CVD outcomes during follow-up.The 6 prognostic factors assessed were no-smoking status, nonhigh-density lipoprotein cholesterol <130 mg/dL, triglycerides <150 mg/dL, systolic pressure <130 mm Hg, diastolic pressure <80 mm Hg, and hemoglobin A 1c <7%.Over a follow-up interval of 5 years, they found that greater risk factor control led to improved risk of outcomes.For those with 6 factors in control, risk was ≈50% lower compared with those with only 0 to 2 risk factors under control. 2ther investigations have highlighted the inadequacy of usual care for patients with T2DM in the past.For example, more than a decade ago, an analysis of 1999-2000 National Health and Nutrition Examination Survey data by Saydah et al 3 showed that patients with T2DM generally do not have adequate CVD risk factor control across the spectrum of several factors, reporting control rates of 36% for blood pressure <130/80 mm Hg, 48% for cholesterol <200 mg/dL, and 37% for hemoglobin A 1c <7.0%.Overall, only 7.3% had all 3 of these risk factors controlled.Clinical trials typically focus on a single intervention with the intention to provide usual care of other conditions for both the active treatment and the control Diabetes Mellitus and Control of Cardiovascular Disease Risk FactorsA Challenge to Improve Usual Care