Article

Post hoc subgroup analysis of the HEART2D trial demonstrates lower cardiovascular risk in older patients targeting postprandial versus fasting/premeal glycemia.

Department of Internal Medicine, Hadassah Hospital, Jerusalem, Israel.
Diabetes care (Impact Factor: 7.74). 05/2011; 34(7):1511-3. DOI: 10.2337/dc10-2375
Source: PubMed

ABSTRACT To identify the Hyperglycemia and Its Effect After Acute Myocardial Infarction on Cardiovascular Outcomes in Patients With Type 2 Diabetes Mellitus (HEART2D) trial subgroups with treatment difference.
In 1,115 type 2 diabetic patients who had suffered from an acute myocardial infarction (AMI), the HEART2D trial compared two insulin strategies targeting postprandial or fasting/premeal glycemia on time until first cardiovascular event (cardiovascular death, nonfatal MI, nonfatal stroke, coronary revascularization, or hospitalization for acute coronary syndrome). The HEART2D trial ended prematurely for futility. We used the classification and regression tree (CART) to identify baseline subgroups with potential treatment differences.
CART estimated the age of >65.7 years to best predict the difference in time to first event. In the subgroup aged>65.7 years (prandial, n=189; basal, n=210), prandial patients had a significantly longer time to first event and a lower proportion experienced a first event (n=56 [29.6%] vs. n=85 [40.5%]; hazard ratio 0.69 [95% CI 0.49-0.96]; P=0.029), despite similar A1C levels.
Older type 2 diabetic AMI survivors may have a lower risk for a subsequent cardiovascular event with insulin targeting postprandial versus fasting/premeal glycemia.

0 Bookmarks
 · 
110 Views
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: The benchmark for assessing quality of long-term glycemic control and adjustment of therapy is currently glycated hemoglobin (HbA1c). Despite its importance as an indicator for the development of diabetic complications, recent studies have revealed that this metric has some limitations; it conveys a rather complex message, which has to be taken into consideration for diabetes screening and treatment. On the basis of recent clinical trials, the relationship between HbA1c and cardiovascular outcomes in long-standing diabetes has been called into question. It becomes obvious that other surrogate and biomarkers are needed to better predict cardiovascular diabetes complications and assess efficiency of therapy. Glycated albumin, fructosamin, and 1,5-anhydroglucitol have received growing interest as alternative markers of glycemic control. In addition to measures of hyperglycemia, advanced glucose monitoring methods became available. An indispensible adjunct to HbA1c in routine diabetes care is self-monitoring of blood glucose. This monitoring method is now widely used, as it provides immediate feedback to patients on short-term changes, involving fasting, preprandial, and postprandial glucose levels. Beyond the traditional metrics, glycemic variability has been identified as a predictor of hypoglycemia, and it might also be implicated in the pathogenesis of vascular diabetes complications. Assessment of glycemic variability is thus important, but exact quantification requires frequently sampled glucose measurements. In order to optimize diabetes treatment, there is a need for both key metrics of glycemic control on a day-to-day basis and for more advanced, user-friendly monitoring methods. In addition to traditional discontinuous glucose testing, continuous glucose sensing has become a useful tool to reveal insufficient glycemic management. This new technology is particularly effective in patients with complicated diabetes and provides the opportunity to characterize glucose dynamics. Several continuous glucose monitoring (CGM) systems, which have shown usefulness in clinical practice, are presently on the market. They can broadly be divided into systems providing retrospective or real-time information on glucose patterns. The widespread clinical application of CGM is still hampered by the lack of generally accepted measures for assessment of glucose profiles and standardized reporting of glucose data. In this article, we will discuss advantages and limitations of various metrics for glycemic control as well as possibilities for evaluation of glucose data with the special focus on glycemic variability and application of CGM to improve individual diabetes management.
    World journal of diabetes. 02/2015; 6(1):17-29.
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Diabetes is associated with a two to three-fold increase in risk of cardiovascular disease. However, intensive glucose-lowering therapy aiming at reducing HbA1c to a near-normal level failed to suppress cardiovascular events in recent randomized controlled trials. HbA1c reflects average glucose level rather than glycemic variability. In in vivo and in vitro studies, glycemic variability has been shown to be associated with greater reactive oxygen species production and vascular damage, compared to chronic hyperglycemia. These findings suggest that management of glycemic variability may reduce cardiovascular disease in patients with diabetes; however, clinical studies have shown conflicting results. This review summarizes the current knowledge on glycemic variability and oxidative stress, and discusses the clinical implications.
    International Journal of Molecular Sciences 10/2014; 15(10):18381-406. · 2.34 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: In recent years glycaemic variability (GV) has emerged as a determinant of vascular complications of both type 1 and type 2 diabetes mellitus. In type 1 diabetes analysis of data of GV show conflicting results on both micro‐ and macro‐vascular complications. In non‐diabetic subjects blood glucose after loading is a stronger predictor of cardiovascular complications than fasting glucose. In type 2 diabetes both coefficient of variation of fasting blood glucose and postprandial blood glucose predict cardiovascular events. Also, long term variability of HbA1c has been associated predominantly with diabetic nephropathy, less frequently with retinopathy. Intervention trials to evaluate the effect of postprandial glucose have been conducted only in prediabetes or in type 2 diabetes and the data are not conclusive. In vitro and in vivo data have shown the mechanisms that are at the basis of the adverse cardiovascular effects of GV, mainly associated with oxidative stress; the atherogenic action of postprandial glucose also involves insulin sensitivity, postprandial increase in serum lipids and glycaemic index of food. Thus, correction of GV emerges as a target to be pursued in clinical practice in order to safely reduce mean blood glucose (and thus glycated haemoglobin) and for its direct effects on vascular complications of diabetes.
    Diabetes Obesity and Metabolism 09/2013; 15. · 5.46 Impact Factor

Full-text (2 Sources)

Download
30 Downloads
Available from
Jun 2, 2014