Cardiovascular risk factors in patients with type 2 diabetes: Do we follow the guidelines?

doi:10.1016/j.diabres.2003.12.002

Diabetes Research and Clinical Practice

Volume 65, Issue 2, August 2004, Pages 125-133

https://doi.org/10.1016/j.diabres.2003.12.002 Get rights and content

Abstract

Objective: To assess the degree of control of modifiable cardiovascular risk factors (CRFs) in type 2 diabetic patients. Study design and methods: Cross-sectional study in 501 patients with type 2 diabetes mellitus. The following parameters were used to define optimal control: glycated haemoglobin (HbA_1C) <7.0%, fasting plasma glucose (FPG) <7.2 mmol/l, postprandial capillary glucose (PCG) <10.0 mmol/l, high-density lipoprotein cholesterol (HDL-C) >1.1 mmol/l, low-density lipoprotein cholesterol (LDL-C) <2.6 mmol/l, triglyceride levels (TG) <1.7 mmol/l, systolic blood pressure (SBP) <130 mmHg, diastolic blood pressure (DBP) <80 mmHg, body mass index (BMI) <25 kg/m², waist circumference (WC) <88 cm in women and <102 cm in men, and current non-smoking status. The use of various cardioprotective medications was also evaluated. Results: Mean (±S.D.) age was 65.4±11.9 years, 218 (44%) were male. Ninety-six (19%) met coronary artery disease (CAD). Two hundred seven patients (41%) had an HbA_1C <7.0%, 134 (27%) a FPG <7.2 mmol/l and 231 of 353 (65%) a PCG <10.0 mmol/l. Only 206 (41%) achieved an LDL-C <2.6 mmol/l, but 370 (74%) and 308 (62%) reached an HDL-C >1.1 mmol/l and a TG levels <1.7 mmol/l, respectively. In 359 (72%) patients DBP was <80 mmHg, but in only 136 (27%) was SBP <130 mmHg. Sixty four (13%) achieved a BMI <25 kg/m², and 420 (84%) were non-smokers. Forty three (15%) women and 104 (48%) men had a WC <88 or <102 cm, respectively. None of the patients had optimal control of all CRFs. Conclusions: These data demonstrate poor control of modifiable CRFs in the population studied, and support the need for great effort to achieve the recommended goals.

Introduction

Population-based studies [1], [2] have shown that patients with type 2 diabetes have a higher cardiovascular morbidity and mortality and an increased all-cause mortality compared with non-diabetic subjects. At least 5.2% of cardiovascular disease deaths in US [3] and 60–70% of all diabetes-related deaths [4] are attributable to the macrovascular manifestations of the disease. Diabetic vascular disease is responsible for a two–four-fold increase in the incidence of coronary artery disease (CAD) and stroke, and a two–eight-fold increase in the risk of heart failure [5]. It has been reported that patients with type 2 diabetes and no previous history of CAD have the same risk for cardiac events as patients with a prior myocardial infarction [6], due to the association between type 2 diabetes with cardiovascular risk factors (CRFs) such as dyslipidaemia, hypertension, obesity and cigarette smoking. However, recently in the Tayside Study [7], a cross-sectional and cohort study using routinely collected datasets, patients with type 2 diabetes were at lower risk of cardiovascular outcomes than patients with established coronary heart disease. In the Steno-2 Study [8], a target-driven, long-term, intensified intervention aimed at multiple risk factors in patients with type 2 diabetes and microalbuminuria, the risk of cardiovascular and microvascular events were reduced about 50%. Furthermore, tight blood pressure control in patients with hypertension and type 2 diabetes result in a clinically important reduction in the risk of death and complications related to diabetes [9].

The objective of the present study was to assess the degree of control of multiple modifiable CRFs, according to published guidelines, in treated type 2 diabetic patients who live in a district of Madrid, Spain, and attendant at our outpatient clinic of Endocrinology for routine follow-up.

Section snippets

Study design

A cross-sectional study was designed to evaluate the control of multiple CRFs in treated type 2 diabetic patients attending routine follow-up in our outpatient clinic of Endocrinology.

Subjects

This study was performed at Montes de Barbanza public health center, a specialized secondary referral center, which provides services to the 31 urban district of Madrid, Spain (79.034 people). Five hundred one type 2 consecutive diabetic patients who attended the clinic between April and December 2002 for a

Characteristics of the study population

Baseline characteristics of the study population are presented in Table 1. Our study sample consisted in 501 type 2 diabetic patients. The mean (±S.D.) age was 65.4±11.9 years; 44% were male, and 19% had previous CAD. Overall, 56% patients received insulin therapy alone or both insulin and oral hypoglycaemic drugs, and the remaining 44% took taking oral hypoglycaemic agents alone. Our study did not include diet-treated patients, because all of them are followed by general practitioners and they

Discussion

These data indicate the poor control of modifiable CRFs in treated type 2 diabetic patients in the population studied. Our results are in line with the report from George et al. [13] of diabetic patients seen for elective cardiac catheterisation.

It could be argued that a single-center observational study may not reflect the situation in other institutions. Because our center has a very broad patient base, and patients attend for regular follow-up visits, we feel that our findings may be broadly

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Cited by (31)

Current situation of the global control of cardiovascular risk factors
2009, Hipertension y Riesgo Vascular
Las enfermedades cardiovasculares constituyen la primera causa de muerte en España. Mientras que su peso relativo en la mortalidad está disminuyendo, aumenta como causa generadora de morbilidad, hospitalización y discapacidad. Hasta ahora el abordaje de estos pacientes había sido unifactorial; sin embargo, el objetivo actual de la prevención cardiovascular es reducir el riesgo absoluto, es decir, disminuir la probabilidad de un evento cardiovascular de cualquier tipo en cualquier territorio vascular. De esta forma es el riesgo general lo que determina el tipo y la intensidad de la intervención. Los pacientes que más se benefician del control de los factores son aquellos que presentan un alto riesgo cardiovascular; éstos son, según las últimas guías, los pacientes en prevención secundaria, los que tienen varios factores de riesgo cardiovascular o un solo factor muy elevado, los diabéticos y los pacientes con síndrome metabólico. El control de los factores de riesgo cardiovascular en todos los ámbitos de la sanidad es deficitario, incluso en las poblaciones de alto riesgo, aunque la tendencia en el tiempo es favorable. El manejo intensivo y general del riesgo cardiovascular mejora el pronóstico de estos pacientes.
Cardiovascular diseases are the first cause of death in Spain. Although its relative weigh in mortality is decreases, it is increases as a generating cause of morbidity, hospitalization and disability. Up to now, the approach to these patients has been unifactorial. However, the current objective of cardiovascular prevention is to reduce the absolute risk, that is, decrease the likelihood of a cardiovascular event of any type in any vascular territory. Thus, the global risk is that what determines the type and intensity of the intervention. Those patients who benefit the most from the control of factors are those who present high cardiovascular risk. These are, according to the last guidelines, patients in secondary prevention, those who have several cardiovascular risk factors or a one single very high factor, diabetics and patients with metabolic syndrome. Control of cardiovascular risk factor in all the health care settings, even in high risk populations, is deficient, even though the current tendency is favorable. Intensive and global management of cardiovascular risk improves the prognosis of these patients.
Strict control of modifiable cardiovascular risk factors in patients with type 2 diabetes mellitus
2008, Medicina Clinica
To assess the effect of a strict control of modifiable cardiovascular risk factors on coronary risk (CR) in patients with type 2 diabetes mellitus (T2DM) in clinical practice.
Longitudinal, open and observational study in 530 patients with T2DM. Fasting plasma glucose (FPG), glycated haemoglobin (HbA_1C), postprandial capillary glucose (PCG), total cholesterol, high-density lipoprotein-cholesterol, triglycerides, systolic (SBP) and diastolic (DBP) blood pressure were measured; low-density lipoprotein-cholesterol and body mass index were calculated; and 10 years CR was predicted before and after 6 months of therapy implementation. The percentage of patients who reached the targets, according to published guidelines, and the use of insulin and various cardioprotective medications were compared before and after therapy implementation.
There was a significant decrease in mean HbA_1C, FPG, PCG, total cholesterol, triglycerides, SBP, DBP, and CR after intervention. The percentage of patients who reached the HbA_1C, FPG, PCG, total cholesterol, triglycerides, SBP, DPB, and CR targets, and the number of subjects taking insulin and cardioprotective drugs increased significantly after intervention.
This study shows that a strict control of modifiable cardiovascular risk factors in patients with T2DM in clinical practice has a beneficial effect over predicted CR.
Valorar en la práctica clínica qué efecto tiene, en pacientes con diabetes mellitus tipo 2 (DM2), el control estricto de los factores de riesgo cardiovascular modificables sobre el riesgo coronario (RC).
Se ha realizado un estudio longitudinal, abierto y observacional. En 530 pacientes con DM2 se midieron la glucosa plasmática en ayunas (GPA), hemoglobina glucosilada (HbA_1C), glucosa capilar posprandial (GCP), colesterol total, colesterol unido a lipoproteínas de alta densidad, triglicéridos, presión arterial sistólica (PAS) y diastólica (PAD); además se calcularon el colesterol unido a lipoproteínas de baja densidad, el índice de masa corporal y el RC a 10 años, antes y 6 meses después de intensificar el tratamiento. Se compararon el porcentaje de pacientes que alcanzaron los objetivos, de acuerdo con las guías publicadas, y la utilización de insulina y de medicaciones cardioprotectoras antes y 6 meses después de la intervención.
Después de la intervención se observó una disminución significativa de los valores de HbA_1C, GPA, GCP, colesterol total, triglicéridos, PAS, PAD y RC, así como un incremento significativo del porcentaje de pacientes que alcanzaron los objetivos de HbA_1C, GPA, GCP, colesterol total, triglicéridos, PAS, PAD y RC, y del número de sujetos en tratamiento con insulina y medicamentos cardioprotectores.
Este estudio de práctica clínica muestra que el control estricto de los factores de riesgo cardiovascular modificables en pacientes con DM2 se traduce en efectos beneficiosos sobre el RC.
Effect of long-acting fluvastatin on serum lipids in type 2 diabetic patients with dyslipidemia, in clinical practice
2007, Clinica e Investigacion en Arteriosclerosis
La reducción del colesterol unido a lipoproteínas de baja densidad (cLDL) con estatinas se asocia a una disminución de las complicaciones macrovasculares en pacientes con diabetes mellitus tipo 2 (DM2). La fluvastatina de liberación prolongada (FLP) presenta una absorción más lenta y una acción más duradera que otras estatinas.
Valorar en la práctica clínica el efecto de la FLP en los lípidos séricos (LS), en pacientes con DM2 y dislipemia, en los que dosis máximas de otras estatinas no consigan los objetivos de buen control.
De 452 pacientes con DM2 y dislipemia tratados con dosis máximas de lovastatina, simvastatina, pravastatina o atorvastatina, se seleccionó a 84 que presentaban un cLDL > 2,97 mmol/l (> 115 mg/dl). Se les midió el colesterol total (CT), el colesterol unido a lipoproteínas de alta densidad (cHDL) y los triglicéridos (TG), se calculó el cLDL y se comparó el porcentaje de ellos que cumplían los objetivos de control para los LS antes y a los 9 meses de sustituir las estatinas que tomaban por una dosis de 80 mg de FLP.
A los 9 meses del tratamiento con FLP, el 57% de los pacientes alcanzó el objetivo del cLDL (p = 0,000), y se observó una disminución del CT y el cLDL (p = 0,000 para ambos) y un incremento del cHDL (p = 0,000).
En la práctica clínica, la FLP consiguió los objetivos de control para el cLDL en más de la mitad de los pacientes con DM2 y dislipemia de la población estudiada, que no lo habían conseguido con otras estatinas. Esto, unido al incremento del cHDL observado, pone de manifiesto la importancia de la FLP en el tratamiento de pacientes con DM2 y dislipemia.
The decrease of low density lipoprotein- cholesterol (LDLc) produced by statins is associated with a reduction in macrovascular complications in patients with type 2 diabetes mellitus (T2DM). Long-acting fluvastatin (LAF) has a slower absorption and longer action time than other statins.
To assess, in clinical practice, the effect of LAF on serum lipids (SL) in T2DM patients in whom maximum doses of other statins failed to achieve the recommended goals.
Of 452 patients with T2DM and dyslipidemia who were on maximum doses of simvastatin, lovastatin, pravastatin or atorvastatin, 84 with LDLc levels > 2.97 mmol/l (> 115 mg/dl) were selected. Total cholesterol (TC), high density lipoprotein-cholesterol (HDLc), triglycerides (TGs) and LDLc were measured. The percentage of patients achieving recommended goals for SL before and 9 months after switching from the previous statin treatment to LAF 80 mg/day was compared.
After 9 months of LAF treatment, 57 % of the patients achieved the LDLc target (P = 0.0000). Mean TC and LDLc significantly decreased (P = 0.000, for both) while HDLc significantly increased (P = 0.000).
In clinical practice, LAF treatment achieved the LDLc target in more than 50 % of the patients with T2DM in whom maximum doses of other statins failed to achieve the recommended goals. In addition to this effect, the increase in HDLc observed after LAF treatment shows the importance of this statin in the treatment of T2DM patients with dyslipidemia.
Beneficial effects of adding ezetimibe to maximum-dose statins on serum lipid control in patients with type 2 diabetes mellitus
2007, Endocrinologia y Nutricion
La coadministración de ezetimiba, un inhibidor de la absorción de colesterol, y estatinas ha demostrado en ensayos clínicos reducir el colesterol unido a lipoproteínas de baja densidad (cLDL) un 20% con respecto a estatinas en monoterapia. Pero, ¿ocurre lo mismo en la práctica clínica?
Valorar en la clínica diaria, los efectos de la adición de ezetimiba en el cLDL y en el grado de control de los lípidos séricos (LS), en pacientes con diabetes mellitus tipo 2 (DM2) en los que dosis máximas de estatinas no consigan los objetivos de buen control.
A 66 pacientes con DM2 de 13,4 ± 9,8 años de evolución (27 hombres y 39 mujeres) de 64,8 ± 10,3 años de edad, con dislipidemia tratada con dosis máximas de atorvastatina, fluvastatina, pravastatina o simvastatina, y un cLDL > 100 mg/dl, se les administró, conjuntamente con la dosis máxima de estatina, una dosis diaria de 10 mg de ezetimiba en la cena. A todos se les determinó el colesterol total (CT), el colesterol unido a lipoproteínas de alta densidad (cHDL) y los triglicéridos (TG), y se calculó el cLDL antes y a los 9 meses de añadir ezetimiba a la estatina. Además, se comparó el porcentaje de pacientes que cumplían los objetivos de buen control para los LS según la American Diabetes Association (ADA), antes y a los 9 meses de añadir ezetimiba.
A los 9 meses de añadir ezetimiba, el 58 % de los pacientes alcanzaron un cLDL < 100 mg/dl (p = 0,000). Asimismo, se observó una disminución significativa del CT (p = 0,000), cLD (p = 0,000) y TG (p = 0,01), y un incremento del cHDL (p = 0,025).
En la práctica clínica habitual, la adición de ezetimiba consiguió los objetivos de buen control para el cLDL en casi el 60% de los pacientes con DM2 y dislipidemia de la población estudiada, que no lo habían conseguido con dosis máximas de estatinas en monoterapia. Este efecto, unido al incremento del cHDL y a la disminución del CT y de los TG observado, ponen de manifiesto la importancia de ezetimiba coadministrada con estatinas en el tratamiento de pacientes con DM2 y dislipidemia.
Clinical trials have shown that the addition of ezetimibe, a selective inhibitor of cholesterol absorption, to statins reduces low-density lipoproteincholesterol (cLDL) by an additional 20% over statin monotherapy. However, the question of whether the same is true in clinical practice remains to be determined.
To assess the effect of the addition of ezetimibe on cLDL and its action on other serum lipids (SL) in clinical practice in patients with type 2 diabetes mellitus (T2DM) in whom maximum-dose of statins failed to achieve the recommended goals.
Sixty-six patients with T2DM (27 men and 39 women) with dyslipidemia treated with maximum-dose atorvastatin, fluvastatin, pravastatin or simvastatin and with cLDL > 100 mg/dl, were included in this study. Disease duration was 13.4 ± 9.8 years and age was 64.8 ± 10.3 years. In all patients, we measured total cholesterol (TC), high-density lipoproteincholesterol (HDL-C) and triglyceride (TG) levels and calculated cLDL before and 9 months after adding an evening dose of 10 mg of ezetimibe to a maximum-dose statin. The percentage of patients who reached the SL targets according to the American Diabetes Association recommendations before and 9 months after adding ezetimibe treatment was compared.
After 9 months of adding ezetimibe, 58% of patients achieved the cLDL target of < 100 mg/dl (P=.000). There was also a significant decrease in mean TC (P=.000), cLDL (P=.000) and TG (P=.01) and an increase in HDL-C (P=.025).
In clinical practice, the addition of ezetimibe achieved the cLDL target in almost 60% of the patients with T2DM and dyslipidemia in the population studied, in whom maximum-dose statin monotherapy failed to achieve the recommended goals. In addition to this effect, the increase in HDL-C and the decrease in TC and TG observed reveal the importance of the addition of ezetimibe to statins in the treatment of T2DM patients with dyslipidemia.
Diabetes management in Canada: Baseline results of the group practice diabetes management study
2006, Canadian Journal of Diabetes
Citation Excerpt :
Recent lipid targets are much lower (4), and evidence suggests that these stringent targets are much more difficult to achieve. For example, in Beaton's study, only 23% patients achieved the LDL-C target of < 2.6 mmol/L (10), while both Toth and Del Cañizo-Gomez reported that only 41% achieved that target (8,14). Despite guideline recommendations that ASA be prescribed as a primary prevention measure for all high-risk patients with diabetes and as a secondary prevention strategy in patients with diabetes and large-vessel disease (3,4), it was prescribed for a mere 22.4% of patients without contraindications — similar to findings reported by other authors (8,10).
There exists a considerable gap between best practice as rec-ommended by diabetes guidelines and actual practice. The objective of this study was to determine the level of care being provided to patients with type 2 diabetes by family physicians in group practices in 4 regions of Canada.
Baseline characteristics from a cluster-randomized trial using chart audits were recorded to assess glycemic control and rates of physician adherence to guidelines-recommended practice. Intracluster correlation coefficients (ICCs) were calculated using the physician practice as the cluster.
Fifty-six physicians in 16 group practices provided 549 charts. Glycosylated hemoglobin (A1C) was measured in 71.8% of patients (mean: 7.7%). A total of 82.3% received antihyperglycemic medication, but only 35.3% achieved an A1C < 7.0%. Blood pressure (BP) results were documented in 92.7% of charts (mean: 139/79 mm Hg).While 58.1% of patients received antihypertensive medications, only 20.0% had BP < 130/85 mm Hg. Lipid profiles were documented in 62.3% of patients. The percentage of patients achieving lipid targets was 83.9% for low-density lipoprotein cholesterol, 38.3% for triglycerides and 76.2% for total cholesterol:high-density lipoprotein cholesterol ratio. Lipid-lowering agents and ASA were prescribed for 19.7% and 22.4% of patients, respectively. Only 17.5% of patients had a 24-hour urine/ albumin-creatinine ratio, 32.1% had a dilated eye exam, 20.0% had a peripheral neuropathy exam and 25.9% had a foot exam. Patient outcome ICCs ranged from 0 to 0.14, while physician process ICCs ranged from 0 to 0.57.
Despite high rates of screening for glycemia and macrovascu-lar complications, treatment was not sufficiently intensive for most patients. Family physicians performed poorly in microvascular complication screening.
OBJECTIF
PLAN ET MÉTHODES
RÉSULTATS
CONCLUSIONS
Prevalence of hypertension, control of blood pressure and treatment in hypertensive with type 2 diabetes in Hospital University Sains Malaysia
2011, Diabetes and Metabolic Syndrome: Clinical Research and Reviews
Citation Excerpt :
When happening together the two disease entities appear to aggravate one another worsening both the diabetes and cardiovascular end points [14]. In the current study, according to the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation of Hypertension among diabetes [12] the 92.7% prevalence rate of hypertension among type 2 DM patients, this finding is much higher than the 39% rates reported among diabetics in the Taiwanese [15] populations, comparable to the 74%, 74.4% and 73% rates of systolic hypertension reported in UK Caucasians [16], Italian [17], and Spanish [18] populations, respectively. The differences between prevalence of hypertension among diabetic patients by country may be due to the different settings, methodology of the studies, differences in diagnosis of hypertension, and genetic factors of patients.
To determine the prevalence of hypertension, control of hypertension and patterns of antihypertensive medications in Malaysian type 2 diabetic patients who attended diabetes clinics in Hospital University Sains Malaysia (Tertiary Hospital).
The study design was observational prospective longitudinal follow-up study; the study was conducted with sample of 1077 type 2 diabetes mellitus outpatient recruited whom attended the diabetes clinics at Hospital Universiti Sains Malaysia (HUSM) in Kelantan. The study period was from January till December 2008. Blood pressure was defined as >130/80 or use of antihypertension medications. Demographic characteristics of patients, level of blood pressure control, use of antihypertensive medications and patterns of antihypertensive therapy.
The prevalence of hypertension in Malaysian type 2 diabetic patients was 998 (92.7%),antihypertensive drugs were prescribed in 940 (94.2%) of hypertensive patients with type 2 diabetic mellitus. The achievement of blood pressure control (≤130/80 mmHg) was 471 (47.2%) %. The percentage of patients receiving one, two, three, and four drugs were 253 (25.3%), 311 (31.3%), 179 (17.9%), and 197 (19.7%) respectively. Calcium channel blockers were the most commonly prescribed antihypertensive agents 757 (75.7%) followed by Angiotensin-converting enzyme inhibitors 446 (44.6%), and Angiotensin receptor blockers 42.4 (42.4%).
The prevalence of hypertension is high in Malaysian type 2 diabetic patients, hypertension was not controlled to the recommended levels of blood pressure in about one-half (52.8%) of diabetes patients. Calcium channel blockers were the most commonly prescribed antihypertensive agents. There is an urgent need to educate both patients and health care providers of importance of achieving target of treatment in order to reduce morbidity and mortality due to diabetes with hypertension.

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Cardiovascular risk factors in patients with type 2 diabetes: Do we follow the guidelines?

Abstract

Introduction

Section snippets

Study design

Subjects

Characteristics of the study population

Discussion

Am. Heart J.

Am. Heart J.

Am. J. Cardiol.

Am. J. Cardiol.

Mortality from coronary heart disease and stroke in relation to degree of glicaemia: the Whitehall Study

Br. Med. J.

Age and the burden of death attributable to diabetes in the United States

Am. J. Epidemiol.

Glycemia and cardiovascular risk

Diabetes Care

Mortality from coronary heart disease in subjects with type 2 diabetes and in nondiabetic subjects with and without prior myocardial infarction

N. Engl. J. Med.

Comparison of cardiovascular risk between patients with type 2 diabetes and those who had had a myocardial infarction: cross-sectional and cohort studies

Br. Med. J.

Multifactorial intervention and cardiovascular disease in patients with type 2 diabetes

N. Engl. J. Med.

Female fat distribution—a simple classification based on two circumference measurements

Int. J. Obes.

Impact of diabetes duration and cardiovascular risk factors on mortality in type 2 diabetes: the Hoorn Study

Eur. J. Clin. Invest.