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Recent controversies in diabetics

Diabetes and the Heart


Early detection, continuous control, balanced treatment and lifestyle modifications are the answers to diabetes

This joint session of the ESC and the European Association for the Study of Diabetics underlined the need for cooperation of these two societies in the effort to prevent diabetes as an epidemic disease and to minimize the associated complications of this growing medical problem. We were happy to see that this topic found a large audience and we experienced a lively discussion which led to an overtime of about 15 min.
 
Prof. Tschoepe from Germany made quite clear that the ischemic burden creates risks and HbA1c levels above 7 mg/dl will increase the rate of MACE in cardiovascular disease, and undoubtedly, glucose normalisation is the key protection for micro- and macrovascular disease. In that respect, he underlined the importance of early detection and very consequent treatment at the beginning of the disease. Nevertheless, he pointed out that hypoglycemic episodes caused by intensive glucose lowering (below 80mg/dl) are often underestimated and will increase mortality especially in patients with cardiovascular disease. Patients with older age and neuropathy seem to be at higher risk for these complications but more studies are needed to give precise answers to unresolved questions.
 
Prof. Grant from England gave an excellent overview on the pathophysiological consequences of platelet function in diabetic patients. Surprisingly, meta analysis did not show any beneficial effects of aspirin in primary prevention with respect to cardiovascular events. In contrast, aspirin administration in patients without existing cardiovascular disease was associated with an increase in major bleeds. However, aspirin did have a significant effect in secondary prevention where it reduced cardiovascular events by about 20%, which clearly outweighs bleeding complications. Clopidogrel seems to be as effective as aspirin with less bleeding complications. According to Prof. Grant, there is no data which justifies following the AHA guidelines for the administration of aspirin in primary prevention. The European guidelines do not give any specific recommendation for aspirin in primary prevention.
 
Prof. del Prato from Italy supported the talk of Prof. Tschoepe and outlined again the risk of hypoglycemic episodes for patients with CVD. He extended his thoughts on the therapeutic regimen and stratified medical treatment with low risk of hypoglycemia (e.g. metformin) as opposed to high risk treatment (e.g. insulin). In his opinion, it is essential to control all risk factors (e.g. cholesterol, blood pressure, smoking etc) and not only blood glucose and HbA1c levels. And he pointed out that it is important to monitor impaired glucose tolerance as early as possible since 50% of patients with IGT will develop manifest diabetes within the next 10 years.

Prof. Tuomilehto from Finland supported the need for lifestyle modification with solid data and his own scientific studies. Diet and physical activity remain the major factors in diabetes prevention and can prevent the onset of diabetes by more than 50%. Detection of gene polymorphisms will help to identify and stratify those individuals who will profit from physical activity and or dietary restriction. With practical examples, he made it quite clear how small changes in lifestyle can have dramatic effects on weight and metabolic parameters.
 
In conclusion, despite the fact that diabetes is a worldwide epidemic disease with a growing tendency and that treatment seems to be established for a long time, a number of recent therapeutic issues remain controversial. Existing controversies have to be resolved in further scientific investigations. Treatment needs to be standardized on the one hand but also to be individualized on the other. Early detection, continuous control and consequent lifestyle modification seem to be key issues in this respect.

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Recent controversies in diabetics

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.