ESC Guidelines on diabetes, pre-diabetes, and cardiovascular diseases developed in collaboration with the EASD: the Task Force on diabetes, pre-diabetes, and cardiovascular diseases of the European Society of Cardiology (ESC) and developed in collaboration with the European Association for the Study of Diabetes (EASD)

Exclusion of 'nonRCT evidence' in guidelines for chronic diseases - is it always appropriate? The Look AHEAD study

Evidence-based medicine (EBM) is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. The introduction of EBM was a conceptual and practical milestone in the history of medicine, with far-reaching impact yet to be fully realized. EBM has limitations, including inapplicability to populations dissimilar to those in studies, and may not reflect duration of exposure to risk factors, details of lifestyle, incubation period, latency, or environmental changes during chronic diseases. Routine exclusion of evidence other than randomized controlled trials (RCTs) or meta-analyses from consideration in treatment may not always be wise. This review is not a result of a search, but rather a conceptual unification of (a) the increasing restrictions in guideline-writing favoring more RCTs, and rejecting observational studies when chronic diseases with a long incubation period may sometimes be best probed by the latter; (b) the possibility RCTs may be inconclusive, nonapplicable, or result in 'negative' results which may misdirect future therapy by physicians and undermine adherence by patients; (c) the potential improvement in patient care from having all available information evaluated (especially epidemiological studies of chronic diseases) and synthesized in guidelines. The example of the Look AHEAD study is chosen - a 'negative' RCT with significant information overlooked by reviewers, who initially declared that weight loss and physical activity were ineffective in treating diabetes, or in preventing cardiovascular complications. In this review, placing this study in perspective, among others, suggests the opposite - exercise and weight loss are effective if done early and sufficiently. Synthesizing worthy data from many sources, including prospective and pathophysiological studies, particularly when RCTs are unavailable, has the potential to add depth and expand the understanding of disease. In addition, integrated data may generate useful, rich material for use during shared decision making discussions with patients, and clarify future hypotheses.

Prevalence of glucose abnormalities among patients presenting with an acute myocardial infarction

BACKGROUND

Patients with an acute myocardial infarction (AMI) who have glucose abnormalities are at increased risk for death and adverse ischemic outcomes. The contemporary prevalence of glucose abnormalities among AMI patients in the United States, as determined by hemoglobin A1c (HbA1c), is unknown.

METHODS

Patients hospitalized with AMI in a 24-site US AMI registry from 2005 to 2008 were examined for the presence of dysglycemia using HbA1c, which was analyzed at a core laboratory. Patients were categorized by American Diabetes Association guidelines as having diabetes (HbA1c ≥ 6.5%), prediabetes (HbA1c 5.7%-6.4%), or normoglycemia. Baseline demographic, clinical, and metabolic characteristics, as well as long-term all-cause mortality, were compared among groups.

RESULTS

Among 2,853 patients with AMI, 1,083 (38%) had diabetes, of which 196 (18%) were newly diagnosed. There were an additional 887 patients (31%) with prediabetes and 883 patients (31%) who had normal glucose metabolism. Patients with metabolic abnormalities were older, were more frequently female, and had higher prevalence of cardiac and noncardiac comorbidities, including multivessel disease and left ventricular systolic dysfunction. Patients with increasing metabolic abnormalities had higher mortality over the 3 years after the AMI (8.6% in those with normoglycemia, 10.6% in prediabetes, 11.3% in newly diagnosed diabetes, and 20.3% in known diabetes; log rank P < .001).

CONCLUSIONS

In a large US AMI registry, we found that nearly 7 in 10 patients had dysglycemia, with 38% having diabetes and an additional 31% with prediabetes based on HbA1c levels. Over half of the patients who did not have a known diagnosis of diabetes at the time of admission had either newly diagnosed diabetes or prediabetes. Progressively greater severity of dysglycemia was also associated with incremental increase in long-term mortality. These data highlight the AMI hospitalization as a key opportunity to screen for glucose abnormalities so that appropriate interventions and patient education efforts can be implemented prior to discharge.

2013 ESH/ESC guidelines for the management of arterial hypertension: what has changed in daily clinical practice?

This is a review article aiming to make focus on the changes made in the European Society of Hypertension (ESH)/European Society of Cardiology (ESC) guidelines for the management of arterial hypertension with some criticism for each element discussed in the text. Given that in the real world clinical practice physicians would hardly spend the time needed for studying the 77 pages manuscript of the recently released 2013 ESH/ESC hypertension guidelines, the present review summarizes all the significant updates (along with their clinical implications) compared to the 2007 ESH/ESC hypertension guidelines and the 2009 reappraisal document.

Progression to overt or silent CAD in asymptomatic patients with diabetes mellitus at high coronary risk: main findings of the prospective multicenter BARDOT trial with a pilot randomized treatment substudy

OBJECTIVES

The purpose of this study was to evaluate prevalence, progression, treatment, and outcome of silent coronary artery disease (CAD) in asymptomatic patients with diabetes (DM) at high coronary risk.

BACKGROUND

Despite the close association of diabetes and CAD, general CAD screening in asymptomatic patients with DM is discouraged even though outcome data in patients at high coronary risk are lacking.

METHODS

Prospective multicenter outcome study-with a pilot randomized treatment substudy. The study comprised 400 asymptomatic patients with DM (type 2) without history or symptoms of CAD at high CAD risk. They underwent clinical evaluation and myocardial perfusion single-photon emission computed tomography (MPS) at baseline and after 2 years. Patients with normal MPS received usual care; those with abnormal MPS received medical or combined invasive and medical management.

RESULTS

An abnormal MPS was found in 87 of 400 patients (22%). In patients with normal MPS, MACE occurred in 2.9% and ischemia or new scar in 3.2%. Patients with abnormal MPS had more MACE (9.8%; hazard ratio: 3.44; 95% confidence interval [CI]: 1.32 to 8.95; p = 0.011) and ischemia or new scar (34.2%; odds ratio: 15.91; 95% CI: 7.24 to 38.03; p < 0.001) despite therapy, resulting in "overt or silent CAD progression" of 35.6% versus 4.6% (odds ratio: 11.53; 95% CI: 5.63 to 24.70; p < 0.001). Patients with abnormal MPS randomized to medical versus invasive-medical strategies had similar event rates (p = 0.215), but more ischemic or new scar findings (54.3% vs. 15.8%; p < 0.001).

CONCLUSIONS

High-risk asymptomatic patients with DM and normal MPS (78%) have a low rate of first manifestations of CAD. Patients with abnormal MPS at baseline (22%) have a 7-fold higher rate of progression to "overt or silent CAD," despite therapy. Randomized patients' outcomes suggest that a combined invasive and medical strategy for silent CAD may reduce scintigraphic but not symptomatic CAD progression versus medical therapy alone. (Trial of Invasive versus Medical therapy of Early coronary artery disease in Diabetes Mellitus ISRCTN87953632).

Control of cardiovascular risk factors in revascularized patients with diabetes: a subanalysis of the ICP-Bypass study

INTRODUCTION AND OBJECTIVES

Patients with type 2 diabetes and revascularized coronary disease are a group with very high cardiovascular risk that has been rarely studied. This ICP-Bypass substudy analyzes the clinical characteristics and risk factor control of these patients.

METHODS

The analysis selected patients with type 2 diabetes who had participated in an earlier multicenter, observational, cross-sectional study (ICP-Bypass) conducted in 2293 patients > 18 years of age who had undergone coronary surgery or percutaneous coronary intervention. Demographic and therapeutic variables, as well as clinical and analytical parameters, were collected and comparatively analyzed.

RESULTS

The mean age (standard deviation) of the 771 diabetic patients included in the analysis was 67.7 (9.6) years (71.4% men; mean time since revascularization, 3.5 years). Most (57.8%) were receiving treatment with oral hypoglycemics alone, whereas 30.4% were receiving insulin alone or in combination. The mean glycohemoglobin figure was 7.1% (in 70%,<7.5%); 74.8% had been diagnosed with dyslipidemia. Mean low-density lipoprotein cholesterol was 93.5 mg/dL (in 73%, > 70 mg/dL). Among these patients, 93.6% were receiving statins and 18.7% a statin combined with ezetimib. A total of 78.1% had been diagnosed with hypertension; systolic/diastolic blood pressure was < 130/80 mmHg in 52% and < 140/90 mmHg in 93%.

CONCLUSIONS

Cardiovascular risk and prevention may be improved in revascularized diabetic patients in Spain through further control of risk factors, particularly dyslipidemia. Patients with glycohemoglobin > 7.5% should be individually assessed in terms of glycemic targets.

Effects of an aquatic-based exercise program to improve cardiometabolic profile, quality of life, and physical activity levels in men with type 2 diabetes mellitus

BACKGROUND

The role of structured exercise in improving cardiometabolic profile and quality of life in patients with type 2 diabetes mellitus (2DM) has been widely demonstrated. Little is known about the effects of an aquatic-based exercise program in patients with 2DM.

OBJECTIVE

To evaluate the effects of a supervised aquatic-based exercise program on cardiometabolic profile, quality of life, and physical activity levels in patients with 2DM.

DESIGN AND SETTING

Observational study, community pre-post aquatic-based exercise program, primary care intervention.

PATIENTS

Eighteen men diagnosed with 2DM (52.2 ± 9.3 years).

METHODS

and

MAIN OUTCOME MEASUREMENTS

Cardiometabolic profile, quality of life, and physical activity levels were assessed before and after 12 weeks of an aquatic-based exercise program.

RESULTS

The results show a significant improvement of cardiometabolic assessments (maximum oxygen consumption: 24.1 versus 21.1 mL/kg/min, P < .05; blood pressure: 125.4/77 versus 130.7/82.5 mm Hg, P < .05; fasting blood glucose: 119.6 versus 132.5 mg/dL, P < .05; body mass index: 29.9 versus 31.1 kg/m², P < .005; low-density lipoprotein cholesterol: 95.2 versus 104.9 mg/dL, P < .05; and diastolic function: E/E' 9.1 versus 10.1, P < .005) and an increase in quality of life and physical activity levels (Medical Outcome Study 36-item Short Form Health Survey mental component summary: 72.3 versus 67, P < .05; Problems Area About Diabetes: 20.1 versus 33.2, P < .005) and energy expenditure in general physical activity (physical activity: 3888.7 versus 1239.5 kcal/wk, P < .05).

CONCLUSIONS

These findings demonstrate that an aquatic-based exercise program produces benefits for the cardiovascular system and metabolic profile and appears to be safe and effective in improving quality of life and increasing physical activity levels in patients with 2DM.

Review of clinical practice guidelines for the management of LDL-related risk

Managing risk related to low-density lipoprotein (LDL) is vital in therapy for patients at risk for atherosclerotic cardiovascular disease (ASCVD) events given its important etiologic role in atherogenesis. Despite decades of research showing reduction of ASCVD risk with multiple approaches to lowering of LDL cholesterol, there continue to be significant gaps in care with inadequate numbers of patients receiving standard of care lipid-lowering therapy. Confusion regarding implementation of the multiple published clinical practice guidelines has been identified as one contributor to suboptimal management of LDL-related risk. This review summarizes the current guidelines for reduction of LDL-related cardiovascular risk provided by a number of major professional societies, which have broad applicability to diverse populations worldwide. Statements have varied in the process and methodology of development of recommendations, the grading system for level and strength of evidence, the inclusion or exclusion of expert opinion, the suggested ASCVD risk assessment tool, the lipoproteins recommended for risk assessment, and the lipoprotein targets of therapy. The similarities and differences among important guidelines in the United States and internationally are discussed, with recommendations for future strategies to improve consistency in approaches to LDL-related ASCVD risk and to reduce gaps in implementation of evidence-based therapies.

The effects of intravenous insulin infusions on early mortality for patients with acute coronary syndromes who present with hyperglycaemia: A matched propensity analysis using data from the MINAP database 2008-2012

BACKGROUND

In acute coronary syndrome, the use of intravenous insulin infusions (IVII) to control hyperglycaemia is based on limited evidence of survival benefit.

AIMS

To compare 7 day survival for patients receiving IVII compared with those receiving routine care to control admission hyperglycaemia (>=11 mmol/l) in acute coronary syndrome.

METHODS AND RESULTS

We used matched propensity analysis to examine observational data from the MINAP database between 2008 and 2012. We matched 5974 pairs of patients. We separately examined outcomes for ST elevation (STEMI) and non ST segment elevation (NSTEMI) infarctions, and those without known diabetes and those with type 2 diabetes. Survival benefit from the use of IVII was seen only in patients with STEMI not known to have diabetes at admission (adjusted hazard ratio (HR) 0.77 (95% confidence interval (CI) 0.64-0.92), p=0.005). Those with STEMI and existing type 2 diabetes who received IVII showed similar outcomes to routine care (HR 0.99 (95% CI 0.80-1.23), p=0.931). In patients with NSTEMI IVII was associated with significantly worse adjusted 7 day survival outcome than routine care, regardless of diabetes status; for those without known diabetes, HR 1.50 (95% CI 1.04-2.16), p=0.029, and for those with type 2 diabetes, HR 1.35 (95% CI 1.08-1.70), p=0.010.

CONCLUSION

As used in current clinical practice to treat hyperglycaemia in acute coronary syndromes, IVII appears to be of benefit only for patients with STEMI who are not known to have diabetes. IVII is associated with adverse early outcomes in patients with NSTEMI.

Mediterranean diet and cardiodiabesity: a review

Cardiodiabesity has been used to define and describe the well-known relationship between type 2 Diabetes Mellitus (T2DM), obesity, the metabolic syndrome (MetS) and cardiovascular disease (CVD). The objective of this study was to perform a scientific literature review with a systematic search to examine all the cardiovascular risk factors combined and their relationship with adherence to the Mediterranean Diet (MedDiet) pattern as primary prevention against cardiodiabesity in a holistic approach. Research was conducted using the PubMed database including clinical trials, cross-sectional and prospective cohort studies. Thirty-seven studies were reviewed: fourteen related to obesity, ten to CVD, nine to MetS, and four to T2DM. Indeed 33 provided strong evidence on the association between adherence to a MedDiet and a reduced incidence of collective cardiodiabesity risk in epidemiological studies. This scientific evidence makes the MedDiet pattern very useful for preventive strategies directed at the general population and also highlights the need to consider all these diet-related risk factors and health outcomes together in daily primary care.

Younger age, higher body mass index and lower adiponectin concentration predict higher serum thromboxane B2 level in aspirin-treated patients with type 2 diabetes: an observational study

Background

Evidence from the literature suggests diminished acetylsalicylic acid (ASA) treatment efficacy in type 2 diabetes (DM2). High on-aspirin platelet reactivity (HAPR) in DM2 has been linked to poor glycemic and lipid control. However, there are no consistent data on the association between HAPR and insulin resistance or adipose tissue metabolic activity. The aim of this study was to assess the relationship between laboratory response to ASA and metabolic control, insulin resistance and adipokines in DM2.

Methods

A total of 186 DM2 patients treated with oral antidiabetic drugs and receiving 75 mg ASA daily were included in the analysis. Response to ASA was assessed by measuring serum thromboxane B₂ (TXB₂) concentration and expressed as quartiles of TXB₂ level. The achievement of treatment targets in terms of glycemic and lipid control, insulin resistance parameters (including Homeostatic Model Assessment-Insulin Resistance, HOMA-IR, index), and serum concentrations of high-molecular weight (HMW) adiponectin, leptin and resistin, were evaluated in all patients. Univariate and multivariate logistic regression analyses were performed to determine the predictive factors of serum TXB₂ concentration above the upper quartile and above the median.

Results

Significant trends in age, body mass index (BMI), HOMA-IR, HMW adiponectin concentration, C-reactive protein concentration and the frequency of achieving target triglyceride levels were observed across increasing quartiles of TXB₂. In a multivariate analysis, only younger age and higher BMI were independent predictors of TXB₂ concentration above the upper quartile, while younger age and lower HMW adiponectin concentration were predictors of TXB₂ concentration above the median.

Conclusions

These results suggest that in DM2, the most important predictor of HAPR is younger age. Younger DM2 patients may therefore require total daily ASA doses higher than 75 mg, preferably as a twice-daily regimen, to achieve full therapeutic effect. Higher BMI and lower HMW adiponectin concentration were also associated with less potent ASA effect. This is the first study to demonstrate an association of lower adiponectin concentration with higher serum TXB₂ level in patients treated with ASA.

Type 2 diabetes and cardiovascular disease: Have all risk factors the same strength?

Diabetes mellitus is a chronic condition that occurs when the body cannot produce enough or effectively use of insulin. Compared with individuals without diabetes, patients with type 2 diabetes mellitus have a considerably higher risk of cardiovascular morbidity and mortality, and are disproportionately affected by cardiovascular disease. Most of this excess risk is it associated with an augmented prevalence of well-known risk factors such as hypertension, dyslipidaemia and obesity in these patients. However the improved cardiovascular disease in type 2 diabetes mellitus patients can not be attributed solely to the higher prevalence of traditional risk factors. Therefore other non-traditional risk factors may be important in people with type 2 diabetes mellitus. Cardiovascular disease is increased in type 2 diabetes mellitus subjects due to a complex combination of various traditional and non-traditional risk factors that have an important role to play in the beginning and the evolution of atherosclerosis over its long natural history from endothelial function to clinical events. Many of these risk factors could be common history for both diabetes mellitus and cardiovascular disease, reinforcing the postulate that both disorders come independently from “common soil”. The objective of this review is to highlight the weight of traditional and non-traditional risk factors for cardiovascular disease in the setting of type 2 diabetes mellitus and discuss their position in the pathogenesis of the excess cardiovascular disease mortality and morbidity in these patients.

Novel treatment approaches in hypertensive type 2 diabetic patients

Type 2 diabetes mellitus (T2DM) and hypertension represent two common conditions worldwide. Their frequent association with cardiovascular diseases makes management of hypertensive patients with T2DM an important clinical priority. Carvedilol and renal denervation are two promising choices to reduce plasma glucose levels and blood pressure in hypertensive patients with T2DM to reduce future complications and improve clinical outcomes and prognosis. Pathophysiological mechanisms of both options are under investigation, but one of the most accepted is an attenuation in sympathetic nervous system activity which lowers blood pressure and improves insulin sensitivity. Choice of these therapeutic approaches should be individualized based on specific characteristics of each patient. Further investigations are needed to determine when to consider their use in clinical practice.

Selected factors determining a way of coping with stress in type 2 diabetic patients

Objectives. The aim of the study was to examine factors which determine stress coping styles in type 2 diabetic (T2D) patients, with regard to selected demographic variables, clinical diabetes-related variables and selected psychical variables (anxiety level and assessment of depressive disorders). Methods. 50 T2D patients, aged 59.9 ± 10.2 years were assessed by Coping Inventory for Stressful Situations (CISS), Spielberger State-Trait Anxiety Inventory (STAI), and Beck Depression Inventory (BDI). In the statistical analysis simple and multivariable logistic regression models were used. Results. Variables significantly increasing the selection risk of stress coping style different from preferred task-oriented strategy in a simple logistic regression model are: hypoglycemia within three months prior to the research: odds ratio (OR) = 6.86 (95% confidence interval (CI) 1.25–37.61), taking antidepressants or neuroleptics: OR =15.42 (95% CI 2.42–98.33), severe depression in Beck's scale: OR = 84.00 (95% CI 6.51–1083.65), high state-anxiety level: OR = 9.60 (95% CI 1.08–85.16), and high trait-anxiety level: OR = 18.40 (95%CI 2.96–114.31), but in a multivariable model, diagnosed depression is the strongest factor: OR = 32.38 (95% CI 4.94–212.13). Conclusions. In T2D patients, the strategy to cope with stress appears to be mostly influenced by psychical predisposition.

10-year incidence of diabetes and associated risk factors in Greece: the ATTICA study (2002-2012)

BACKGROUND

The incidence of diabetes in the general population is increasing world-wide. The increase is attributed to the consumption of saturated fatty acids, obesity, lack of physical activity, genetic predisposition, and other factors, but knowledge about the reasons, biological mechanisms, and late complications is insufficient. It is therefore important to clarify the reasons more exactly through long-term clinical trials to stop the rise of diabetes and its complications.

AIM

To evaluate the 10-year incidence of type 2 diabetes in apparently healthy Greek adults.

METHODS

In 2001-2002, a random sample of 1514 men (18-87 years old) and 1528 women (18-89 years old) was selected to participate in the ATTICA study. During 2011-2012, the 10-year follow-up was performed. Patients diagnosed with diabetes at baseline (n = 210) and those lost at the 10-year follow-up (n = 1347) were excluded, yielding a final sample of 1485 participants.

RESULTS

During the period of investigation, diabetes was diagnosed in 191 cases corresponding to a 12.9% incidence (95%CI: 10.4-15.4), with 13.4% (95%CI: 10.8-16) in men and 12.4% (95%CI: 10.1-14.7) in women. A relative increase was observed in the second half of the 10-year follow-up when age became significant. Multiple logistic regression analysis revealed that age (OR = 1.14, 95%CI: 1.09-1.19), abnormal waist-to-height ratio (OR = 3.27, 95%CI: 1.07-10.0), fasting blood glucose (OR per 1 mg/dl = 0.05, 95%CI: 1.02-1.08), energy intake (OR per 500 kcal = 1.02, 95%CI: 1.01-1.35), and family history of diabetes (OR = 2.8, 95%CI: 1.30-6.03) were the most significant baseline predictors for diabetes, after adjusting for potential confounders. Waist-to-height ratio showed the best explanatory power of all anthropometric variables. Physical activity exerts an effect on risk factors. Being active was found to eliminate the aggravating effect of diabetes family history and fasting blood glucose.

CONCLUSIONS

The findings confirm the escalating increase of type 2 diabetes incidence in Greece, which is in line with global trends. A lifestyle change in individuals at risk of developing diabetes towards healthier eating and increased physical activity would be an effective and inexpensive means of reducing diabetes.

[Is there any progress in the blood glucose lowering therapy of type 2 diabetes?]

Principles of glycemic treatment of type 2 diabetes are well outlined for a long time, however, emphasis of therapeutic strategies and treatment guidelines are continuously changing partially due to the continuous expansion of the available antihyperglycemic drugs. This article overviews the modifications of the drug selection arising from the broadening of the pathogenetic knowledge and recent therapeutic guidelines. It presents the role of the patient-centered approach in the therapeutic choice, highlights occasional contradictions between recent international and national guidelines and financing rules in Hungary. While consideration of the different antidiabetics by the same criteria and the choice of the most appropriate drug characterize international practice, prescription of certain compounds is often restricted by financial rules in Hungary.

Different lipid variables predict incident coronary artery disease in patients with type 1 diabetes with or without diabetic nephropathy: the FinnDiane study

OBJECTIVE

To study the ability of lipid variables to predict incident coronary artery disease (CAD) events in patients with type 1 diabetes at different stages of nephropathy.

RESEARCH DESIGN AND METHODS

Patients (n = 3,520) with type 1 diabetes and available lipid profiles participating in the Finnish Diabetic Nephropathy Study (FinnDiane) were included in the study. During a follow-up period of 10.2 years (8.6-12.0), 310 patients suffered an incident CAD event.

RESULTS

Apolipoprotein B (ApoB)/ApoA-I ratio was the strongest predictor of CAD in normoalbuminuric patients (hazard ratio 1.43 [95% CI 1.17-1.76] per one SD increase), and ApoB was the strongest in macroalbuminuric patients (1.47 [1.19-1.81]). Similar results were seen when patients were stratified by sex or glycemic control. LDL cholesterol was a poor predictor of CAD in women, normoalbuminuric patients, and patients with HbA1c below the median (8.3%, 67 mmol/L). The current recommended triglyceride cutoff of 1.7 mmol/L failed to predict CAD in normoalbuminuric patients, whereas the cohort median 0.94 mmol/L predicted incident CAD events.

CONCLUSIONS

In patients with type 1 diabetes, the predictive ability of the lipid variables differed substantially depending on the patient's sex, renal status, and glycemic control. In normoalbuminuric patients, the ratios of atherogenic and antiatherogenic lipoproteins and lipids were the strongest predictors of an incident CAD event, whereas in macroalbuminuric patients, no added benefit was gained from the ratios. Current treatment recommendations may need to be revised to capture residual CAD risk in patients with type 1 diabetes.

Psychological distress and incidence of type 2 diabetes in high-risk and low-risk populations: the Whitehall II Cohort Study

OBJECTIVE

We examined whether psychological distress predicts incident type 2 diabetes and if the association differs between populations at higher or lower risk of type 2 diabetes.

RESEARCH DESIGN AND METHODS

This was a prospective cohort of 5,932 diabetes-free adults (4,189 men and 1,743 women, mean age 54.6 years) with three 5-year data cycles (1991-2009): a total of 13,207 person-observations. Participants were classified into four groups according to their prediabetes status and Framingham Offspring Type 2 Diabetes Risk Score: normoglycemia with a risk score of 0-9, normoglycemia with a risk score of 10-19, prediabetes with a risk score of 10-19, and prediabetes with a risk score of >19. Psychological distress was assessed by the General Health Questionnaire. Incident type 2 diabetes was ascertained by 2-h oral glucose tolerance test, doctor diagnosis, or use of antihyperglycemic medication at the 5-year follow-up for each data cycle. Adjustments were made for age, sex, ethnicity, socioeconomic status, antidepressant use, smoking, and physical activity.

RESULTS

Among participants with normoglycemia and among those with prediabetes combined with a low risk score, psychological distress did not predict type 2 diabetes. Diabetes incidence in these groups varied between 1.6 and 15.6%. Among participants with prediabetes and a high risk score, 40.9% of those with psychological distress compared with 28.5% of those without distress developed diabetes during the follow-up. The corresponding adjusted odds ratio for psychological distress was 2.07 (95% CI 1.19-3.62).

CONCLUSIONS

These data suggest that psychological distress is associated with an accelerated progression to manifest diabetes in a subpopulation with advanced prediabetes.

New guidelines for metabolic targets in diabetes: clinician's opinion does matter

Evidence-based medicine replaced eminence-based medicine as a way to manage unavoidable clinical uncertainty. Moving away from "one-size-fits-all" medicine, personalized medicine seemed to have the potential of tailoring therapies to subsets of patients. Despite the rapid progress in drug development for diabetes, it is still challenging to achieve good glycemic control in a substantial population. Different diabetes management algorithms have been proposed: most agree with a HbA1c target of <7.0 % for the majority of people with diabetes, except the American Association of Clinical Endocrinologists (AACE) that claims for a lower HbA1c target (<6.5 %). The recently released American guidelines on the treatment of blood cholesterol recommends moderate-intensity statin therapy for primary prevention for persons aged 40-75 years with type 1 or 2 diabetes and LDL-cholesterol levels between 70 and 189 mg/dl. The Eighth Joint National Committee recommends pharmacologic treatment in the population aged 18 years or older with diabetes, with a goal systolic blood pressure of lower than 140 mmHg and a goal diastolic blood pressure lower than 90 mmHg. There are differences and similarities among these recent guidelines for people with diabetes, with the main differences related to the level of the evidence. There are recommendations based on expert opinions (insufficient evidence or existing evidence unclear or conflicting) in almost all guidelines. The ultimate decision about care of a particular patient is left to clinicians, as the way to manage unavoidable guideline uncertainty: clinician's opinion does matter.

Stress hyperglycaemia in hospitalised patients and their 3-year risk of diabetes: a Scottish retrospective cohort study

BACKGROUND

Hyperglycaemia during hospital admission is common in patients who are not known to have diabetes and is associated with adverse outcomes. The risk of subsequently developing type 2 diabetes, however, is not known. We linked a national database of hospital admissions with a national register of diabetes to describe the association between admission glucose and the risk of subsequently developing type 2 diabetes.

METHODS AND FINDINGS

In a retrospective cohort study, patients aged 30 years or older with an emergency admission to hospital between 2004 and 2008 were included. Prevalent and incident diabetes were identified through the Scottish Care Information (SCI)-Diabetes Collaboration national registry. Patients diagnosed prior to or up to 30 days after hospitalisation were defined as prevalent diabetes and were excluded. The predicted risk of developing incident type 2 diabetes during the 3 years following hospital discharge by admission glucose, age, and sex was obtained from logistic regression models. We performed separate analyses for patients aged 40 and older, and patients aged 30 to 39 years. Glucose was measured in 86,634 (71.0%) patients aged 40 and older on admission to hospital. The 3-year risk of developing type 2 diabetes was 2.3% (1,952/86,512) overall, was <1% for a glucose ≤ 5 mmol/l, and increased to approximately 15% at 15 mmol/l. The risks at 7 mmol/l and 11.1 mmol/l were 2.6% (95% CI 2.5-2.7) and 9.9% (95% CI 9.2-10.6), respectively, with one in four (21,828/86,512) and one in 40 (1,798/86,512) patients having glucose levels above each of these cut-points. For patients aged 30-39, the risks at 7 mmol/l and 11.1 mmol/l were 1.0% (95% CI 0.8-1.3) and 7.8% (95% CI 5.7-10.7), respectively, with one in eight (1,588/11,875) and one in 100 (120/11,875) having glucose levels above each of these cut-points. The risk of diabetes was also associated with age, sex, and socio-economic deprivation, but not with specialty (medical versus surgical), raised white cell count, or co-morbidity. Similar results were obtained for pre-specified sub-groups admitted with myocardial infarction, chronic obstructive pulmonary disease, and stroke. There were 25,193 deaths (85.8 per 1,000 person-years) over 297,122 person-years, of which 2,406 (8.1 per 1,000 person-years) were attributed to vascular disease. Patients with glucose levels of 11.1 to 15 mmol/l and >15 mmol/l had higher mortality than patients with a glucose of <6.1 mmol/l (hazard ratio 1.54; 95% CI 1.42-1.68 and 2.50; 95% CI 2.14-2.95, respectively) in models adjusting for age and sex. Limitations of our study include that we did not have data on ethnicity or body mass index, which may have improved prediction and the results have not been validated in non-white populations or populations outside of Scotland.

CONCLUSION

Plasma glucose measured during an emergency hospital admission predicts subsequent risk of developing type 2 diabetes. Mortality was also 1.5-fold higher in patients with elevated glucose levels. Our findings can be used to inform patients of their long-term risk of type 2 diabetes, and to target lifestyle advice to those patients at highest risk. Please see later in the article for the Editors' Summary.

Intensified insulin-based glycaemic control after myocardial infarction: mortality during 20 year follow-up of the randomised Diabetes Mellitus Insulin Glucose Infusion in Acute Myocardial Infarction (DIGAMI 1) trial

BACKGROUND

The benefits of intensified glycaemic control after acute myocardial infarction are uncertain. We report the 20 year follow-up results of the first Diabetes Mellitus Insulin Glucose Infusion in Acute Myocardial Infarction (DIGAMI 1) trial.

METHODS

DIGAMI 1 was a prospective, randomised, open-label trial with blinded endpoint evaluation (PROBE) done at coronary care units in 19 Swedish hospitals between Jan 1, 1990 and Dec 31, 1993. Patients with and without previously diagnosed diabetes and with blood glucose concentrations of more than 11 mmol/L who had had a suspected acute myocardial infarction in the previous 24 h were randomly assigned (1:1), with sealed envelopes, to intensified insulin-based glycaemic control for at least 3 months, or to a control group prescribed conventional glucose-lowering treatment. Masking was not considered feasible or safe on the basis of insulin use. The primary endpoint was mortality, in both the original study and the present follow-up analysis. Analysis was by intention to treat.

FINDINGS

620 patients were randomised to intensified insulin-based glycaemic control (n=306) or the control group (n=314). During a mean follow-up period of 7·3 years (SD 6·6; range 0·0-21·8) years, 271 patients (89%) died in the intensified glycaemic control group and 285 (91%) patients died in the standard glycaemic control group. Median survival time was 7·0 years (IQR 1·8-12·4) in patients in the intensified glycaemic control group and 4·7 (1·0-11·4) in those in the standard group (hazard ratio 0·83, 95% CI 0·70-0·98; p=0·027). The effect of intensified glycaemic control was apparent during 8 years after randomisation, increasing survival by 2·3 years.

INTERPRETATION

Intensified insulin-based glycaemic control after acute myocardial infarction in patients with diabetes and hyperglycaemia at admission had a long-lasting effect on longevity. Although the effect of glucose lowering might be less apparent with presently available, more effective lipid-lowering and blood-pressure-lowering drugs, improved glycaemic control might still be important for longevity after acute myocardial infarction.

FUNDING

Swedish Heart-Lung Foundation, Kronoberg County Council.

Effect of arginase inhibition on ischemia-reperfusion injury in patients with coronary artery disease with and without diabetes mellitus

BACKGROUND

Arginase competes with nitric oxide synthase for their common substrate L-arginine. Up-regulation of arginase in coronary artery disease (CAD) and diabetes mellitus may reduce nitric oxide bioavailability contributing to endothelial dysfunction and ischemia-reperfusion injury. Arginase inhibition reduces infarct size in animal models. Therefore the aim of the current study was to investigate if arginase inhibition protects from endothelial dysfunction induced by ischemia-reperfusion in patients with CAD with or without type 2 diabetes (

CLINICAL TRIAL REGISTRATION NUMBER

NCT02009527).

METHODS

Male patients with CAD (n = 12) or CAD + type 2 diabetes (n = 12), were included in this cross-over study with blinded evaluation. Endothelium-dependent vasodilatation was assessed by flow-mediated dilatation (FMD) of the radial artery before and after 20 min ischemia-reperfusion during intra-arterial infusion of the arginase inhibitor (Nω-hydroxy-nor-L-arginine, 0.1 mg/min) or saline.

RESULTS

The forearm ischemia-reperfusion was well tolerated. Endothelium-independent vasodilatation was assessed by sublingual nitroglycerin. Ischemia-reperfusion decreased FMD in patients with CAD from 12.7±5.2% to 7.9±4.0% during saline administration (P<0.05). Nω-hydroxy-nor-L-arginine administration prevented the decrease in FMD in the CAD group (10.3±4.3% at baseline vs. 11.5±3.6% at reperfusion). Ischemia-reperfusion did not significantly reduce FMD in patients with CAD + type 2 diabetes. However, FMD at reperfusion was higher following nor-NOHA than following saline administration in both groups (P<0.01). Endothelium-independent vasodilatation did not differ between the occasions.

CONCLUSIONS

Inhibition of arginase protects against endothelial dysfunction caused by ischemia-reperfusion in patients with CAD. Arginase inhibition may thereby be a promising therapeutic strategy in the treatment of ischemia-reperfusion injury.

Whole grains and pulses: a comparison of the nutritional and health benefits

Nutrition plays an important role in the prevention and management of disease. Whole grain cereals contain a host of nutrients and bioactive substances that have health-promoting effects. Epidemiological evidence shows a consistent inverse association between whole grain intake and the risk of chronic disease. Despite a concerted effort by scientists, educators, and policy makers to promote the consumption of whole grains, it remains dismally short of the recommended intakes. Pulses (dried beans and peas) differ from whole grains in their structural and physicochemical properties and have varying amounts of fiber, resistant starch, vitamins, minerals, and other bioactive components; nevertheless, these food groups complement each other. Observational as well as intervention trials show that pulse consumption has beneficial effects on the prevention and management of chronic disease. The nutritional and phytochemical components of pulses coupled with those of whole grains suggest a potential synergistic effect that could provide significant health benefits.

Update: Acute coronary syndromes (IX). Secondary prevention strategies for acute coronary syndrome

Cardiovascular disease is the main health problem in Europe and the rest of the world and is the leading cause of death and health care expenditure. By reducing mortality and ischemic event recurrence, prevention strategies play a fundamental role in patients who have had an acute coronary syndrome. Although these prevention strategies have focused with great success on high-risk individuals, they should also be used in the general population, which is showing an increase in the prevalence of obesity, diabetes mellitus, and other comorbidities that may reverse this trend toward reduced mortality. The present article consists of an up-to-date review of the main cardiovascular prevention measures, particularly the new developments of the last year, as well as the particularities of these measures when they are targeted at patients with a prior acute coronary syndrome.

Impact of prior chronic statin therapy and high-intensity statin therapy at discharge on circulating endothelial progenitor cell levels in patients with acute myocardial infarction: a prospective observational study

BACKGROUND

Endothelial progenitor stem cells (EPCs) are mobilized to the peripheral circulation in response to myocardial ischemia, playing a crucial role in vascular repair. Statins have been shown to stimulate EPCs. However, neither the impact of previous statin therapy on EPC response of acute myocardial infarction (AMI) patients nor the effect of post-AMI high-intensity statin therapy on the evolution of circulating EPC levels has yet been addressed. Therefore, we aimed to compare circulating EPC levels between patients receiving long-term statin therapy before the AMI and statin-naive patients and to assess the impact of high-intensity statin therapy at discharge on the evolution of circulating EPCs post-AMI.

METHODS

This is a prospective observational study of 100 AMI patients. Circulating EPCs (CD45dimCD34 + KDR + cells) and their subpopulation coexpressing the homing marker CXCR4 were quantified by the high-performance flow cytometer FACSCanto II in whole blood, in two different moments: within the first 24 h of admission and 3 months post-AMI. Patients were followed up clinically for 2 years.

RESULTS

Patients previously treated with statins had significantly higher levels of EPCs coexpressing CXCR4 (1.9 ± 1.4 vs. 1.3 ± 1.0 cells/1,000,000 events, p = 0.031) than statin-naive patients. In addition, the subanalysis of diabetics (N = 38) also revealed that patients previously on statins had significantly greater numbers of both CD45dimCD34 + KDR + CXCR4+ cells (p = 0.024) and CD45dimCD34 + KDR + CD133+ cells (p = 0.022) than statin-naive patients. Regarding the evolution of EPC levels after the AMI, patients not on a high-intensity statin therapy at discharge had a significant reduction of CD45dimCD34 + KDR + and CD45dimCD34 + KDR + CXCR4+ cells from baseline to 3 months follow-up (p = 0.031 and p = 0.005, respectively). However, patients discharged on a high-intensity statin therapy maintained circulating levels of all EPC populations, presenting at 3 months of follow-up significantly higher EPC levels than patients not on an intensive statin therapy. Moreover, the high-intensity statin treatment group had significantly better clinical outcomes during the 2-year follow-up period than patients not discharged on a high-intensity statin therapy.

CONCLUSION

Chronic statin therapy prior to an AMI strongly enhances the response of EPCs to myocardial ischemia, even in diabetic patients. Furthermore, high-intensity statin therapy after an AMI prevents the expected decrease of circulating EPC levels during follow-up. These results reinforce the importance of an early and intensive statin therapy in AMI patients.

Pre-diabetes and capturing opportunities to raise awareness

This article explores the high risk of diabetes and cardiovascular diseases in adults over 18 years of age and recognises, through the literature, the potential role for nurses in engagement with diabetes prevention strategies in their everyday practice. It considers the latest international projections for diabetes, a critical review of evidence of how diabetes can be prevented and how effective methods of detection of pre-diabetes can be employed with every clinical encounter with adults who perhaps previously were not considered to be 'at risk' of developing type 2 diabetes. Effective consultation approaches to raise diabetes awareness within populations and to enable tailored approaches to public health lifestyle advice are explored, to encourage each practitioner to 'think diabetes' in every clinical encounter.

Physical exercise and health

Regular physical exercise is an established recommendation for preventing and treating the main modifiable cardiovascular risk factors, such as diabetes mellitus, hypertension, and dyslipidemia. Performing physical activity of moderate intensity for a minimum of 30 min 5 days a week or of high intensity for a minimum of 20 min 3 days a week improves functional capacity and is associated with reductions in the incidence of cardiovascular disease and mortality. Physical exercise induces physiological cardiovascular adaptations that improve physical performance, and only in extreme cases can these adaptations lead to an increased risk of physical exercise-associated complications. The incidence of sudden death or serious complications during physical exercise is very low and is concentrated in people with heart diseases or with pathological cardiac adaptation to exercise. Most of these cases can be detected by cardiology units or well-trained professionals.

Diabetes Management - Lowering Cardiovascular Risk

Diabetes mellitus is one of the most common diseases to plague the present day. Sixty percent of mortality in diabetic patients is caused by coronary artery disease. Numerous studies have shown that improving glycaemic control helps manage microvascular complications. On the other hand, some studies have shed light on the fact that a too tight glycaemic control can have adverse effects, especially on patients with high cardiovascular risk. Thus 'the lower the better' attitude should be exchanged for 'the earliest the best' attitude. A multidisciplinary approach should therefore be undertaken in order to achieve a proper management of the cardiovascular risk for diabetic patients. This includes using hypoglycaemic agents, antihypertensive medication and statins to balance the myriad of cardiovascular risk factors.

A Practical Approach to Preventing Renal Complications in the Catheterization Laboratory

Kidney injury following cardiac catheterization is an infrequent, though persistent, complication, which in some cases may be preventable. Patients at increased risk for renal complications following catheterization can be identified through individual and procedural risk factors, and several risk-prediction models are readily available. The authors advocate for the development of an easily implemented and standardized protocol, readily accessible to catheterization laboratory staff, for the identification and treatment of those patients who may be at increased risk for renal complications following cardiac catheterization.

Arterial stiffness, renal function and renal blood flow in patients with coronary artery disease, arterial hypertension and type 2 diabetes mellitus

Aim. To investigate the relationship between changes in indicators of arterial stiffness of various types of vessels, hemodynamic pulsatility, renal function and renal blood flow in patients with coronary artery disease (CAD) and arterial hypertension in the presence or absence of type 2 diabetes mellitus (T2DM). Materials and Methods. The study included 96 patients with CAD and arterial hypertension; among them, 54 subjects had T2DM and 42 did not. Сarbohydrate and lipid metabolism, renal function, stiffness of various types of arteries, parameters of hemodynamic pulsatility and renal blood flow were investigated. Results. Arterial stiffness of various types of vessels was increased in the T2DM group: carotid?femoral pulse wave velocity as a marker of aortic stiffness (a vessel of the elastic type) was increased by 16% (p

Diabetes Mellitus and Heart Failure

Diabetes mellitus and heart failure are two multifaceted entities characterised by high morbidity and mortality. Early epidemiological and prospective studies have observed the frequent co-existence of both conditions. Importantly, diabetes mellitus can precipitate or worsen heart failure due to the accumulation of advanced glycation end products, oxidative stress, inflammatory status impairment, decay of intracellular calcium, changes in microRNAs expression, not to mention atherosclerosis progression and coronary artery disease. Heart failure also impairs glucose metabolism through less well-known mechanisms. Attention must especially be given in the treatment as there are frequently adverse interactions between the two diseases and novel agents against diabetic cardiomyopathy are under investigation. As several missing links still exist in the connection between heart failure and diabetes mellitus we will review, in this article, the most recent data underlying the interaction of them and provide an overview of the most important clinical perspectives.

Are statin trials in diabetes representative of real-world diabetes care: a population-based study on statin initiators in Finland

OBJECTIVE

To assess the representativeness of the Heart Protection Study (HPS) and the Collaborative Atorvastatin Diabetes Study (CARDS) for incident statin users.

DESIGN

A population-based analysis with linked register data.

SETTING

Finland.

POPULATION

56 963 patients with diabetes initiating statin use from 2005 to 2008.

MAIN OUTCOME MEASURES

We determined the proportions of real-world patients who fulfilled the eligibility criteria for HPS and CARDS trials and assessed the cardiovascular disease (CVD) event rates, assumed to reflect the background CVD risk, for those eligible and ineligible. We used descriptive statistics to identify the patient characteristics, lipid-lowering interventions and adherence to statin therapy.

RESULTS

Of the real-world patients, 57% (N=32 582) fulfilled the eligibility criteria for HPS (DM) and 49% (N=20 499) of those without CVD for CARDS. The patients ineligible for HPS (DM) had a higher cumulative risk for CVD events than those eligible, whereas regarding CARDS the cumulative risks were of similar magnitude. The overall CVD event rates seemed to be comparable to those in the reviewed trials. Both trials were under-representative of women and users of antihypertensive agents and metformin. 27% and 29% of real-world patients had an initial statin dose corresponding to <20 mg of simvastatin. The proportions of patients who were deemed adherent were 57% in the real world and 85% in both trials.

CONCLUSIONS

Only half of the real-world patients would have qualified for the HPS (DM) and CARDS, limiting their representativeness for clinical practice. Women and users of antihypertensive agents and metformin were under-represented in both trials. These deviations reflect the changes in diabetes treatment over the years and are not expected to modify the average treatment effects of statins on CVD. Prescribing of lower statin doses in clinical practice than used in the trials and lower adherence may, however, attenuate the benefits in the real world.

Reduced levels of circulating endothelial progenitor cells in acute myocardial infarction patients with diabetes or pre-diabetes: accompanying the glycemic continuum

Background

Diabetic patients have a significantly worse prognosis after an acute myocardial infarction (AMI) than their counterparts. Previous studies have shown that the number of circulating endothelial progenitor cells (EPCs) significantly increase early after an AMI in normoglycemic patients. However, it is well known that type 2 diabetes mellitus (DM) is associated with impaired function and reduced circulating EPCs levels. Nonetheless, few studies have analyzed EPCs response of diabetics to an AMI and the EPC response of pre-diabetic patients has not been reported yet. Therefore, we hypothesized that in the acute phase of an AMI, diabetic and pre-diabetics have lower circulating EPCs levels than patients with normal glucose metabolism. We also evaluated the possible capacity of chronic antidiabetic treatment in the recovery of EPCs response to an AMI in diabetics.

Methods

One-hundred AMI patients were prospectively enrolled in the study. Using the high-performance flow cytometer FACSCanto II, circulating EPCs (CD45dimCD34+KDR+ and CD45dimCD133+KDR+ cells) were quantified, within the first 24 hours of admission. In addition, as an indirect functional parameter, we also analyzed the fraction of EPCs coexpressing the homing marker CXCR4.

Results

We found that in the acute phase of an AMI, diabetic patients presented significantly lower levels of circulating CD45dimCD34+KDR+ and CD45dimCD133+KDR+ EPCs by comparison with nondiabetics, with a parallel decrease in the subpopulations CXCR4+ (p < 0.001). Indeed, this study suggests that the impaired response of EPCs to an AMI is an early event in the natural history of DM, being present even in pre-diabetes. Our results, also demonstrated that numbers of all EPCs populations were inversely correlated with HbA1c (r = -0.432, p < 0.001 for CD45dimCD34+KDR+ cells). Finally, this study suggests that previous chronic insulin therapy (but not oral antidiabetic drugs) attenuate the deficient response of diabetic EPCs to an AMI.

Conclusion

This study indicates that there is a progressive decrease in EPCs levels, from pre-diabetes to DM, in AMI patients. Moreover, glycemic control seems to be determinant for circulating EPCs levels presented in the acute phase of an AMI and chronic insulin therapy may probably attenuate the deficit in EPCs pool seen in diabetics.

[Cardiovascular safety of non-insulin anti-diabetic drugs. Scientific position statement of SEMERGEN]

Diabetes increases the risk of both microvascular and macrovascular complications. Although reducing plasma glucose levels to recommended targets decreases the risk of microvascular outcomes, the effects of anti-diabetic drugs on macrovascular complications and cardiovascular death are of concern. In fact, it has been suggested that some anti-diabetic agents could even be harmful for cardiovascular outcomes. In this context, several health care regulatory agencies have established the need for performing clinical trials specifically designed to assess the cardiovascular safety of anti-diabetic drugs. The results of 2 clinical trials have recently been published that provide important information on the cardiovascular safety of dipeptidyl peptidase 4 (DPP-4) inhibitors. The aim of this document was to review the available evidence on the cardiovascular safety of non-insulin anti-diabetic drugs and provide practical recommendations on their use in this context.

Cardiovascular risk stratification and management in pre-diabetes

Prediabetes, covering individuals with impaired fasting glycemia, impaired glucose tolerance, or high-risk HbA1c levels, is associated with a ∼20 % increased risk of developing cardiovascular disease (CVD) compared with normoglycemic individuals. It is well-known that lifestyle or pharmacologic interventions can prevent diabetes in prediabetic people; however, the evidence is less clear regarding prevention of CVD. Most diabetes prevention trials have failed to show beneficial effects on CVD morbidity and mortality despite significant improvements of CVD risk factors in individuals with prediabetes. Another challenge is how to estimate CVD risk in prediabetic people. In general, prediction models for CVD do not take glucose levels or prediabetes status into account, thereby underestimating CVD risk in these high-risk individuals. More evidence within risk stratification and management of CVD risk in prediabetes is needed in order to recommend useful and effective strategies for early prevention of CVD.

The ideal blood pressure target to prevent cardiovascular disease in type 2 diabetes: a neutral viewpoint

Type 2 diabetes mellitus (T2DM) and essential hypertension are often associated, and retrospective data analyses suggest an association between lower blood pressure (BP) values and lower cardiovascular (CV) risk in patients with T2DM. However, the most recent intervention trials fail to demonstrate a further CV risk reduction, for BP levels <130/80 mm Hg, when compared to levels <140/90 mm Hg. Moreover, a J-shaped, rather than a linear, relationship of BP reduction with incident CV events has been strongly suggested. We here debate the main available evidences for and against the concept of 'the lower the better', in the light of the main intervention trials and meta-analyses, with a particular emphasis on the targets to be pursued in elderly patients. Finally, the most recent guidelines of the scientific societies are critically discussed.

Update: acute coronary syndromes (VI): treatment of acute coronary syndromes in the elderly and in patients with comorbidities

Acute coronary syndromes have a wide spectrum of clinical presentations and risk of adverse outcomes. A distinction should be made between treatable (extent of ischemia, severity of coronary disease and acute hemodynamic deterioration) and untreatable risk (advanced age, prior myocardial damage, chronic kidney dysfunction, other comorbidities). Most of the patients with "untreatable" risk have been excluded from the "guideline-generating" clinical trials. In recent years, despite the paucity of specific randomized trials, major advances have been completed in the management of elderly patients and patients with comorbidities: from therapeutic nihilism to careful titration of antithrombotic agents, a shift toward the radial approach to percutaneous coronary interventions, and also to less-invasive cardiac surgery. Further advances should be expected from the development of drug regimens suitable for use in the elderly and in patients with renal dysfunction, from a systematic multidisciplinary approach to the management of patents with diabetes mellitus and anemia, and from the courage to undertake randomized trials involving these high-risk populations.

Reducing the modifiable risks of cardiovascular disease in Turkish patients with type 2 diabetes: the effectiveness of training

Our goal was to reduce the number of modifiable risk factors for cardiovascular disease (CVD) through providing lifestyle adjustment training and counseling to patients with type 2 diabetes. In this pre-post intervention study, 139 patients with diabetes were provided with training to reduce the modifiable risks of CVD. One hundred three patients attended the post-training evaluation. Two phone counseling sessions were provided with 1-month intervals. Consumption of red meat and processed food decreased and water consumption, carrying on the recommended diet, and the frequency of exercise increased (p = .000), A1C decreased (p = .05), and the use of aspirin increased (p = .03). Thus, a contribution to the reduction of CVD risk factors in patients with type 2 diabetes was achieved. The training program for reducing CVD risk factors in patients with type 2 diabetes was effective in improving nutrition and lifestyle behaviors and decreasing glycemic control.

Self-monitoring of blood glucose: a prerequisite for diabetes management in outcome trials

Evidence for the value of self-monitoring of blood glucose (SMBG) with regard to the achievement of treatment targets, detection of postprandial glucose excursions, and minimization of glycemic variability is increasing. In large clinical trials, SMBG is a key component for the optimization of diabetes treatment in insulin-treated diabetes. It also plays an essential role in outcome studies. However, details of SMBG use in both the methods and results sections of clinical articles are frequently scarce. Also, a discussion of the SMBG data and its impact on insulin therapy is valuable. In the recently completed Outcome Reduction with an Initial Glargine INtervention (ORIGIN) trial, SMBG was described in detail and insulin titration was largely driven by SMBG. Both aspects largely contributed to the fact that near-normal control was achieved over a long-term period.