Dr. Maria Angeles Alonso Garcia
Diabetic patients are a specific population in cardiovascular disease trials. The benefit/risk profile of drugs in different indications could be different in diabetic patients. Usually the data in this population come from subgroup analyses of big outcome trials. ANTIPLATELET THERAPY: The use of aspirin in diabetic patients has been a subject of controversy in recent years and different guidelines give different recommendations. There is no doubt that diabetic patients with a cardiovascular event should be on aspirin; what remains a matter of debate is the need for aspirin in primary prevention in diabetic patients. It seems from basic studies that aspirin acts differently in diabetics meaning the benefit/risk ratio is smaller. Currently, aspirin is not recommended in primary prevention in diabetic patients if there is not another risk factor. GLYCEMIC CONTROL Glucose control and cardiovascular risk: patients who benefit most from an intensive glucose lowering therapy are those who have a low HbA1C at baseline, those who have no previous cardiovascular disease and those who have a short duration of diabetes. Hypoglycaemic events in diabetic patients are a risk factor for future cardiovascular events (odds ratio 1.79). An acute hypoglycaemic episode reduces extracellular glucose and potassium, favouring ventricular arrhythmias. Ongoing clinical trials of antidiabetic drugs will provide more evidence on the effect of glycaemic control on cardiovascular risk in diabetes. The major cardiovascular safety trials are CAROLINA (Linagliptin), TECOS (Sitagliptin), SAVOR TIMI 53 (Saxagliptin), EXAMINE (Alogiptin), and LEADER (Liraglutide). STATINS Statins reduce cardiovascular diseases in general and they are safe. PROVE I study results showed a safe profile of high dose of atorvastatin (80mg daily). Diabetes doubles the risk of cardiovascular disease. Different trials have shown that statins reduce cardiovascular events consistently in the diabetic population. It can be concluded that statins provide a similar proportional reduction in cardiovascular risk among those with diabetes as in patients without diabetes, and the magnitude of the benefit is related to the degree of LDL cholesterol reduction. BLOOD PRESSURE MANAGEMENT The increasing incidence of diabetes and hypertension is almost parallel to the association of both diseases. Patients with systolic blood pressure >140mmHg and diastolic blood pressure >90 mmHg at diagnosis should receive pharmacological therapy in addition to lifestyle changes. A regimen with ACE inhibitors or ARBs is a first step regimen but kidney function and serum potassium levels should be closely monitored. According to Cardiorenal outcomes in diabetes study results (ALTITUDE), Aliskiren is not recommended for blood pressure control in diabetic patients.
Cardiovascular disease prevention in diabetes - what works and what does not?
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