A Swedish study has found that type 2 diabetics who have five risk-factor variables within the target ranges have little or no excess risk of death, myocardial infarction, or stroke, as compared with the general population. Assessment of risk is based on the presence of five modifiable risk factors: smoking, elevated glycated hemoglobin, elevated low-density lipoprotein cholesterol level, elevated blood pressure and albuminuria.
Type 2 diabetes is present in more than 28 million people in the United States. Past literature has shown that type 2 diabetics are at a 2-4 fold higher risk for death and cardiovascular outcomes. Despite the availability of an ever-increasing armamentarium of lifestyle changes and evidence-based treatment directed at cardiovascular and mortality risk reduction, the extent of mitigation through interventions such as achievement of glycemic targets and smoking cessation is not known.
In a 271,174 patient strong cohort study comparing sex- and age-matched controls for a median follow-up duration of 5.7 years, Rawshani and colleagues measured outcomes of death from any cause, fatal or nonfatal acute myocardial infarction, fatal or nonfatal stroke, and heart failure hospitalizations.
“Pathways to target levels of risk-factor variables are not always straightforward and often involve issues of lifestyle, adherence to medication, and other behaviors that are hard to modify, despite best attempts.” – Dr. Steven A. Schroeder, M.D.
The findings provide clear support for active management of risk factors. The investigators note a stepwise decrease in the risk of cardiovascular events for each additional factor within the target range. Encouragingly, the estimated overall mortality risk in type 2 diabetics with all risk factors within the target range show only a marginal increase as compared to the control group. (HR 1.06; 95% CI, 1.00–1.12). Additionally, the risk for stroke, heart failure hospitalizations, and acute myocardial infarction is also marginally higher in type 2 diabetics. On the contrary, patients aged less than 55 years with all five risk factors outside of the target range have a fivefold higher risk as compared to the control group. (HR, 4.99; 95% CI, 3.43–7.27). While rating the risk factors for outcomes, smoking is the strongest predictor of death whereas an elevated glycated hemoglobin level is the strongest predictor of acute myocardial infarction and stroke.
The analysis of Swedish nationwide registry data from 1998 through 2012 indicates that theoretically, the excess risk of acute myocardial infarction can be eliminated in type 2 diabetics with all five risk-factor variables within the target range. A higher relative risk of adverse cardiovascular outcomes seen in the younger population suggests a greater benefit from more aggressive treatment in this group of patients.
While the study emphasizes on the importance of actively addressing risk factors such as smoking, physical activity, glycated hemoglobin, and low-density lipoprotein levels above the target range in the management of type 2 diabetes, Dr. Steven A. Schroeder, in an accompanying editorial echoes a cautionary note. He warns, “Pathways to target levels of risk-factor variables are not always straightforward and often involve issues of lifestyle, adherence to medication, and other behaviors that are hard to modify, despite best attempts.” Due to the widening health gap between social classes, he expresses concern that risk factor control may be especially challenging for vulnerable populations.
Source: https://www.nejm.org/doi/full/10.1056/NEJMoa1800256?utm_medium=referral&utm_source=r360
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