https://diabetes.acponline.org/archives/2014/08/08/1.htm

Intensive therapy associated with decreases in certain cardiovascular events, new ACCORD analysis finds

Despite the ACCORD study finding an increased risk of death from cardiovascular causes with intensive glucose-lowering therapy, rates of myocardial infarction, coronary revascularization, and unstable angina were lower in patients on an intensive regimen, a new analysis of the trial data found.


Despite the ACCORD study finding an increased risk of death from cardiovascular causes with intensive glucose-lowering therapy, rates of myocardial infarction, coronary revascularization, and unstable angina were lower in patients on an intensive regimen, a new analysis of the trial data found.

The analysis included 10,251 adults ages 40 to 79 with type 2 diabetes, a mean HbA1c of 8.3%, and risk factors for ischemic heart disease who were randomized to an intensive-therapy HbA1c target of less than 6.0% or a standard target of 7.0% to 7.9%. Both groups used the same drugs to achieve control, including metformin, insulin, sulfonylureas, meglitinides, thiazolidinediones, acarbose, and incretins. Patients followed up at least every 4 months to check therapeutic goals and monitor outcomes and adverse effects. Results were published by The Lancet on Aug. 1.

Patients were followed for a mean of 3.7 years during the active treatment of intensive glucose lowering and a mean of 4.8 years including follow-up periods. There were 1,263 ischemic heart disease events during the active trial and 1,619 during the follow-up period. Compared with the standard-therapy group, participants in the intensive-therapy group had fewer myocardial infarctions than in the standard-therapy group during active treatment (hazard ratio [HR], 0.80; 95% CI, 0.67 to 0.96; P=0.015) and the entire study (HR, 0.84, 95% CI, 0.72 to 0.97; P=0.02).

Findings were similar for the composite outcome of myocardial infarction, coronary revascularization, and unstable angina (active treatment period: HR, 0.89; 95% CI, 0.79 to 0.99; entire study period: HR, 0.87; 95% CI, 0.79 to 0.96). In addition, there was a lower rate of coronary revascularization in the intensive group for the entire treatment period but not before treatment transition (HR, 0.84; 95% CI, 0.75 to 0.94). There was also a lower rate for unstable angina alone during the full follow-up period (HR, 0.81; 95% CI, 0.67 to 0.97).

The study's findings could help clinicians identify patients in whom the benefit of intensive glycemic control would clearly outweigh any harm, the authors noted.

They wrote, “Whereas our findings suggest that glucose-lowering interventions can reduce the risk of ischemic heart disease, they do not nullify the previous observation that the overall cardiovascular benefits of 3.7 years of intensive glycemic control are outweighed by the risk of death. Nevertheless, they are consistent with the hypothesis that dysglycemia is causally related to ischemic heart disease and strongly indicate the need for further investigation of this relation.” The authors concluded, “Raised glucose concentration is a modifiable risk factor for ischaemic heart disease in middle-aged people with type 2 diabetes and other cardiovascular risk factors.”