[Glycemic control and cardiovascular morbimortality: What's new with the 2008 studies?]

Fédération d'endocrinologie, maladies métaboliques, diabète et nutrition, hôpital cardiovasculaire et pneumologique Louis-Pradel, 28, avenue Doyen-Lépine, 69677 Bron cedex, France.
Annales d Endocrinologie (Impact Factor: 0.87). 03/2009; DOI: 10.1016/j.ando.2008.12.009
Source: PubMed


The year 2008 was full of learning experience and suspense in diabetologia. The past studies, the United Kingdom Prospective Diabetes Study (UKPDS) in type 2 diabetic patients and the Diabetes Control and Complications Trial (DCCT) in type 1 diabetic patients, have shown that intensive treatment during a short period did reduce the incidence of microvascular events, and in the long term, the incidence of macrovascular events linked to diabetes. The conclusions of recent studies quote, from Action to Control Cardiovascular Risk in Diabetes Study Group (ACCORD), an increased mortality in the type 2 diabetic patients using intensive therapy, from Action in Diabetes and Vascular Disease, Perindopril and Indapamide Controlled Evaluation (ADVANCE), a reduction of microvascular complications and, from Veterans Affairs Diabetes Trial (VADT), no effect. The analysis of studies published in 2008 (ACCORD, STENO 2 post-trial, ADVANCE, VADT, UKPDS post-trial, Epidemiology of Diabetes Interventions and Complications [EDIC]) brings lessons for the clinical practice: presence of glycemic memory, absence of tensional memory, usefulness of control of every cardiovascular risk factors, need of early treatment of diabetes. Moreover, to define HbA(1c) objective, age, duration of diabetes, presence of cardiovascular risk factors, former HbA(1c) level and potential undesirable effects, such hypoglycaemia must be considered. So, the management of type 2 diabetic patients requires an early, not too quick intensive treatment, which avoids hypoglycaemia and is combined with a strict control of cardiovascular risk factors.

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    ABSTRACT: HbA1c remains today the main tool for diabetes follow-up. The large scale studies have shown that intensive therapeutic strategies, based on low HbA1c target, were followed by a short-term decrease in microvascular complications, and a short- and long-terms decrease in both micro- and macrovascular complications of diabetes. While a prompt normoglycaemia is strongly encouraged, severe hypoglycaemia must be absolutely avoided. It has been clearly proved that there is a need to control the whole cardiovascular risks, as represented by blood pressure and lipid level in particular, according to the results of the Steno 2 study. The HbA1c target definition should take into account the age, the diabetes duration and the cardiovascular risk factors. Thus, the intensive treatment of type 2 diabetes needs to be quite rapid, not too quick, has to avoid hypoglycaemia, and has to be combined with a strict control of the other cardiovascular risk factors. HbA1c is then a crucial target in type 2 diabetes management, but is not the only one.
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