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Ioannidou E, Shabnam S, Abner S, Kaur N, Zaccardi F, Ray KK, Seidu S, Davies MJ, Khunti K, Gillies CL. Effect of more versus less intensive blood pressure control on cardiovascular, renal and mortality outcomes in people with type 2 diabetes: A systematic review and meta-analysis. Diabetes Metab Syndr 2023; 17:102782. [PMID: 37257222 DOI: 10.1016/j.dsx.2023.102782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 04/22/2023] [Accepted: 05/03/2023] [Indexed: 06/02/2023]
Abstract
BACKGROUND AND AIMS Currently, there is uncertainty as to whether blood pressure control in patients with type 2 diabetes should be treated to standard recommended levels or more intensively. METHODS Medline, EMBASE, CENTRAL, and Clinicaltrials.gov were searched between January 1, 2000 and April 20th, 2023. Outcomes considered were all-cause mortality, stroke, heart failure, cardiovascular disease, albuminuria, coronary heart disease, and renal outcomes. Random-effects meta-analyses estimated pooled relative risks and mean differences. RESULTS Nine trials enrolling 11,005 participants with type 2 diabetes were included. The pooled mean difference between the intensive and standard treatment groups at follow-up were -7.98 mmHg (95% CI: 12.19 to -3.76) in systolic blood pressure, and -5.08 mmHg (-7.00 to -3.17) in diastolic blood pressure; although between study heterogeneity was high for both meta-analyses (I2>85%). Intensive blood pressure lowering resulted in a reduction in risk of stroke (risk ratio 0.64; 0.52 to 0.79), and macro-albuminuria (0.77; 0.63 to 0.93). More intensive blood pressure control did not result in a statistically significant reduction in risk of all-cause mortality, heart failure, cardiovascular death, cardiovascular events, renal outcomes, and micro-albuminuria; although the direction of estimated effect was beneficial for all outcomes. CONCLUSIONS The use of intensive compared with standard blood pressure targets resulted in a significant reduction in blood pressure, stroke, and macro-albuminuria in patients with type 2 diabetes. The post-treatment blood pressure level in the intensive group was 125/73 mmHg, suggesting the current recommendations of 130/80 mmHg blood pressure or lower if tolerated, could be reduced further.
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Affiliation(s)
- Ekaterini Ioannidou
- Leicester Real World Evidence Unit, Leicester Diabetes Centre, Leicester, LE5 4PW, UK
| | - Sharmin Shabnam
- Leicester Real World Evidence Unit, Diabetes Research Centre, Leicester General Hospital, University of Leicester, Leicester, LE5 4PW, UK
| | - Sophia Abner
- Leicester Real World Evidence Unit, Diabetes Research Centre, Leicester General Hospital, University of Leicester, Leicester, LE5 4PW, UK
| | - Navjot Kaur
- Leicester Real World Evidence Unit, Diabetes Research Centre, Leicester General Hospital, University of Leicester, Leicester, LE5 4PW, UK
| | - Francesco Zaccardi
- Leicester Real World Evidence Unit, Diabetes Research Centre, Leicester General Hospital, University of Leicester, Leicester, LE5 4PW, UK
| | - Kausik K Ray
- Imperial College London, South Kensington Campus, London, SW7 2AZ, UK
| | - Sam Seidu
- National Institute for Health Research (NIHR) Applied Research Collaboration - East Midlands (ARC-EM), Diabetes Research Centre, Leicester General Hospital, University of Leicester, Leicester, LE5 4PW, UK
| | - Melanie J Davies
- National Institute for Health Research (NIHR) Applied Research Collaboration - East Midlands (ARC-EM), Diabetes Research Centre, Leicester General Hospital, University of Leicester, Leicester, LE5 4PW, UK
| | - Kamlesh Khunti
- Professor of Primary Care Diabetes and Vascular Medicine, National Institute for Health Research (NIHR) Applied Research Collaboration - East Midlands (ARC-EM), Leicester Diabetes Centre, Leicester, LE5 4PW, UK.
| | - Clare L Gillies
- Leicester Real World Evidence Unit, Leicester Diabetes Centre, Leicester, LE5 4PW, UK
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Do DV, Han G, Abariga SA, Sleilati G, Vedula SS, Hawkins BS. Blood pressure control for diabetic retinopathy. Cochrane Database Syst Rev 2023; 3:CD006127. [PMID: 36975019 PMCID: PMC10049880 DOI: 10.1002/14651858.cd006127.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
Abstract
BACKGROUND Diabetic retinopathy is a common complication of diabetes and a leading cause of visual impairment and blindness. Research has established the importance of blood glucose control to prevent development and progression of the ocular complications of diabetes. Concurrent blood pressure control has been advocated for this purpose, but individual studies have reported varying conclusions regarding the effects of this intervention. OBJECTIVES To summarize the existing evidence regarding the effect of interventions to control blood pressure levels among diabetics on incidence and progression of diabetic retinopathy, preservation of visual acuity, adverse events, quality of life, and costs. SEARCH METHODS We searched several electronic databases, including CENTRAL, and trial registries. We last searched the electronic databases on 3 September 2021. We also reviewed the reference lists of review articles and trial reports selected for inclusion. SELECTION CRITERIA We included randomized controlled trials (RCTs) in which either type 1 or type 2 diabetic participants, with or without hypertension, were assigned randomly to more intense versus less intense blood pressure control; to blood pressure control versus usual care or no intervention on blood pressure (placebo); or to one class of antihypertensive medication versus another or placebo. DATA COLLECTION AND ANALYSIS Pairs of review authors independently reviewed the titles and abstracts of records identified by the electronic and manual searches and the full-text reports of any records identified as potentially relevant. The included trials were independently assessed for risk of bias with respect to outcomes reported in this review. MAIN RESULTS We included 29 RCTs conducted in North America, Europe, Australia, Asia, Africa, and the Middle East that had enrolled a total of 4620 type 1 and 22,565 type 2 diabetic participants (sample sizes from 16 to 4477 participants). In all 7 RCTs for normotensive type 1 diabetic participants, 8 of 12 RCTs with normotensive type 2 diabetic participants, and 5 of 10 RCTs with hypertensive type 2 diabetic participants, one group was assigned to one or more antihypertensive agents and the control group to placebo. In the remaining 4 RCTs for normotensive participants with type 2 diabetes and 5 RCTs for hypertensive type 2 diabetic participants, methods of intense blood pressure control were compared to usual care. Eight trials were sponsored entirely and 10 trials partially by pharmaceutical companies; nine studies received support from other sources; and two studies did not report funding source. Study designs, populations, interventions, lengths of follow-up (range less than one year to nine years), and blood pressure targets varied among the included trials. For primary review outcomes after five years of treatment and follow-up, one of the seven trials for type 1 diabetics reported incidence of retinopathy and one trial reported progression of retinopathy; one trial reported a combined outcome of incidence and progression (as defined by study authors). Among normotensive type 2 diabetics, four of 12 trials reported incidence of diabetic retinopathy and two trials reported progression of retinopathy; two trials reported combined incidence and progression. Among hypertensive type 2 diabetics, six of the 10 trials reported incidence of diabetic retinopathy and two trials reported progression of retinopathy; five of the 10 trials reported combined incidence and progression. The evidence supports an overall benefit of more intensive blood pressure intervention for five-year incidence of diabetic retinopathy (11 studies; 4940 participants; risk ratio (RR) 0.82, 95% confidence interval (CI) 0.73 to 0.92; I2 = 15%; moderate certainty evidence) and the combined outcome of incidence and progression (8 studies; 6212 participants; RR 0.78, 95% CI 0.68 to 0.89; I2 = 42%; low certainty evidence). The available evidence did not support a benefit regarding five-year progression of diabetic retinopathy (5 studies; 5144 participants; RR 0.94, 95% CI 0.78 to 1.12; I2 = 57%; moderate certainty evidence), incidence of proliferative diabetic retinopathy, clinically significant macular edema, or vitreous hemorrhage (9 studies; 8237 participants; RR 0.92, 95% CI 0.82 to 1.04; I2 = 31%; low certainty evidence), or loss of 3 or more lines on a visual acuity chart with a logMAR scale (2 studies; 2326 participants; RR 1.15, 95% CI 0.63 to 2.08; I2 = 90%; very low certainty evidence). Hypertensive type 2 diabetic participants realized more benefit from intense blood pressure control for three of the four outcomes concerning incidence and progression of diabetic retinopathy. The adverse event reported most often (13 of 29 trials) was death, yielding an estimated RR 0.87 (95% CI 0.76 to 1.00; 13 studies; 13,979 participants; I2 = 0%; moderate certainty evidence). Hypotension was reported in two trials, with an RR of 2.04 (95% CI 1.63 to 2.55; 2 studies; 3323 participants; I2 = 37%; low certainty evidence), indicating an excess of hypotensive events among participants assigned to more intervention on blood pressure. AUTHORS' CONCLUSIONS Hypertension is a well-known risk factor for several chronic conditions for which lowering blood pressure has proven to be beneficial. The available evidence supports a modest beneficial effect of intervention to reduce blood pressure with respect to preventing diabetic retinopathy for up to five years, particularly for hypertensive type 2 diabetics. However, there was a paucity of evidence to support such intervention to slow progression of diabetic retinopathy or to affect other outcomes considered in this review among normotensive diabetics. This weakens any conclusion regarding an overall benefit of intervening on blood pressure in diabetic patients without hypertension for the sole purpose of preventing diabetic retinopathy or avoiding the need for treatment for advanced stages of diabetic retinopathy.
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Affiliation(s)
- Diana V Do
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, USA
| | - Genie Han
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Samuel A Abariga
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | | | | - Barbara S Hawkins
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Aldafas R, Crabtree T, Vinogradova Y, Gordon JP, Idris I. Efficacy and safety of intensive versus conventional glucose targets in people with type 2 diabetes: a systematic review and meta-analysis. Expert Rev Endocrinol Metab 2023; 18:95-110. [PMID: 36718676 DOI: 10.1080/17446651.2023.2166489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 01/05/2023] [Indexed: 02/01/2023]
Abstract
OBJECTIVE The aim of study is to re-evaluate the risk-benefits of intensive glycemic control in the context of multi-factorial intervention in adults with T2D. METHODS We searched Ovid MEDLINE, Embase, Cochrane, and CINHAL for randomized control trials comparing standard glucose targets to intensive glucose targets with pre-specified HbA1clevels. Subgroup analysis was also performed to account for the inclusion of glucose only versus multi-factorial intervention trials. Results are reported as risk ratio (RR) and 95% confidence interval (CI). RESULTS Fifty-seven publications including 19 trials were included. Compared to conventional glycemic control, intensive glycemic control decreased the risk of non-fatal myocardial infarction (0.8, 0.7-0.91), macroalbuminuria (0.72, 0.5--0.87), microalbuminuria (0.67, 0.52-0.85), major amputation (0.6, 0.38-0.96), retinopathy (0.75 ,0.63-0.9), and nephropathy (0.78, 0.63-0.97). The risk of hypoglycemia increased with intensive glycemic control than conventional treatment (2.04, 1.34-3.1). No reduction in all-cause or cardiovascular mortality was observed. However, in the context of multifactorial intervention, intensive glucose control was associated with a significant reduction in all-cause mortality (0.74, 0.57-0.95). CONCLUSION Targeting HbA1c levels should be individualized based on the clinical status, balancing risks and benefits and potential risk for developing these complications among people with T2D.
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Affiliation(s)
- Rami Aldafas
- Division of Graduate Entry Medicine and Health Sciences, University of Nottingham, Nottingham, UK
- Faculty of Public Health, College of Health Science, the Saudi Electronic University, Riyadh, Saudi Arabia
| | - Thomas Crabtree
- Division of Graduate Entry Medicine and Health Sciences, University of Nottingham, Nottingham, UK
- Department of Endocrinology and Diabetes, University Hospitals Derby and Burton NHS Foundation Trust, Derby, UK
| | - Yana Vinogradova
- Division of Primary Care, University of Nottingham, Nottingham, UK
| | - Jason P Gordon
- Division of Graduate Entry Medicine and Health Sciences, University of Nottingham, Nottingham, UK
- Health Economic Outcomes Research, Birmingham, UK
| | - Iskandar Idris
- Division of Graduate Entry Medicine and Health Sciences, University of Nottingham, Nottingham, UK
- Department of Endocrinology and Diabetes, University Hospitals Derby and Burton NHS Foundation Trust, Derby, UK
- MRC-Versus Arthritis Centre for Musculoskeletal Ageing Research, University of Nottingham, NIHR, Nottingham BRC, University of Nottingham, UK
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Tye SC, Jongs N, Coca SG, Sundström J, Arnott C, Neal B, Perkovic V, Mahaffey KW, Vart P, Heerspink HJL. Initiation of the SGLT2 inhibitor canagliflozin to prevent kidney and heart failure outcomes guided by HbA1c, albuminuria, and predicted risk of kidney failure. Cardiovasc Diabetol 2022; 21:194. [PMID: 36151557 PMCID: PMC9508745 DOI: 10.1186/s12933-022-01619-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 09/01/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Sodium glucose co-transporter-2 (SGLT2) inhibitors reduce the risk of kidney and heart failure events independent of glycemic effects. We assessed whether initiation of the SGLT2 inhibitor canagliflozin guided by multivariable predicted risk based on clinical characteristics and novel biomarkers is more efficient to prevent clinical outcomes compared to a strategy guided by HbA1c or urinary-albumin-creatinine ratio (UACR) alone. METHODS We performed a post-hoc analysis of the CANVAS trial including 3713 patients with available biomarker measurements. We compared the number of composite kidney (defined as a sustained 40% decline in eGFR, chronic dialysis, kidney transplantation, or kidney death) and composite heart failure outcomes (defined as heart failure hospitalization or cardiovascular (CV) death) prevented per 1000 patients treated for 5 years when canagliflozin was initiated in patients according to HbA1c ≥ 7.5%, UACR, or multivariable risk models consisting of: (1) clinical characteristics, or (2) clinical characteristics and novel biomarkers. Differences in the rates of events prevented between strategies were tested by Chi2-statistic. RESULTS After a median follow-up of 6.1 years, 144 kidney events were recorded. The final clinical model included age, previous history of CV disease, systolic blood pressure, UACR, hemoglobin, body weight, albumin, estimated glomerular filtration rate, and randomized treatment assignment. The combined biomarkers model included all clinical characteristics, tumor necrosis factor receptor-1, kidney injury molecule-1, matrix metallopeptidase-7 and interleukin-6. Treating all patients with HbA1c ≥ 7.5% (n = 2809) would prevent 33.0 (95% CI 18.8 to 43.3 ) kidney events at a rate of 9.6 (95% CI 5.5 to 12.6) events prevented per 1000 patients treated for 5 years. The corresponding rates were 5.8 (95% CI 3.4 to 7.9), 16.6 (95% CI 9.5 to 22.0) (P < 0.001 versus HbA1c or UACR approach), and 17.5 (95% CI 10.0 to 23.0) (P < 0.001 versus HbA1c or UACR approach; P = 0.54 versus clinical model). Findings were similar for the heart failure outcome. CONCLUSION Initiation of canagliflozin based on an estimated risk-based approach prevented more kidney and heart failure outcomes compared to a strategy based on HbA1c or UACR alone. There was no apparent gain from adding novel biomarkers to the clinical risk model. These findings support the use of risk-based assessment using clinical markers to guide initiation of SGLT2 inhibitors in patients with type 2 diabetes.
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Affiliation(s)
- Sok Cin Tye
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, PO Box 30001, 9700 RB, Groningen, The Netherlands
| | - Niels Jongs
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, PO Box 30001, 9700 RB, Groningen, The Netherlands
| | - Steven G Coca
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Johan Sundström
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden.,The George Institute for Global Health, UNSW Sydney, Sydney, NSW, Australia
| | - Clare Arnott
- The George Institute for Global Health, UNSW Sydney, Sydney, NSW, Australia.,Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Bruce Neal
- The George Institute for Global Health, UNSW Sydney, Sydney, NSW, Australia
| | - Vlado Perkovic
- The George Institute for Global Health, UNSW Sydney, Sydney, NSW, Australia
| | - Kenneth W Mahaffey
- Stanford Center for Clinical Research, Department of Medicine, Stanford University, Stanford, CA, USA
| | - Priya Vart
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, PO Box 30001, 9700 RB, Groningen, The Netherlands
| | - Hiddo J L Heerspink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, PO Box 30001, 9700 RB, Groningen, The Netherlands. .,The George Institute for Global Health, UNSW Sydney, Sydney, NSW, Australia.
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Secchi A, Booth A, Maidment I, Sud D, Zaman H. Medication management in Minority, Asian and Black ethnic older people in the United Kingdom: A mixed-studies systematic review. J Clin Pharm Ther 2022; 47:1322-1336. [PMID: 35844186 DOI: 10.1111/jcpt.13735] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 06/15/2022] [Accepted: 06/24/2022] [Indexed: 01/26/2023]
Abstract
WHAT IS NEW AND OBJECTIVES Older people from ethnic minorities experience the intersectionality of age and ethnicity in relation to complex medication management and polypharmacy. Minority ethnic groups in the United Kingdom are at risk of poor medication management because factors such as cultural beliefs, language barriers, lack of knowledge of how the healthcare system works may affect their ability to safely manage their medications. The aim of this systematic review was to review the literature focussing on medication management in the older population amongst ethnic minority communities in United Kingdom. METHODS The review was conducted and reported according to methods in the Cochrane Handbook and in the PRISMA 2020 statement using databases such as EMBASE, ASSIA, MEDLINE, PsychINFO and others. Studies conducted in the United Kingdom on individuals over 60 years of age and from a minority ethnic background were included. A thematic analysis was used to synthesize the results. RESULTS AND DISCUSSION Nine studies (eight from initial searches, one from a search update in 2021) met the inclusion criteria. Three main themes were identified: misbeliefs around medications, poor health literacy, communication and education as possible intervention to improve medication management. Misbeliefs around long-term illnesses exert a negative impact on medication management. Poor health literacy around medications influences patients' adherence to treatments. Poor communication is perceived as barrier to successful medication management. Despite extensive searching, the team identified a limited number of studies and a lack of intersectional studies focussing on minority ethnic groups and the older population. WHAT IS NEW AND CONCLUSION Our findings suggest tailored education as a possible intervention to improve medication management amongst these minority groups. Future research should look at recruiting participants from specific ethnic groups and from rural as well as urban areas to explore how medication management operates in different areas of the United Kingdom.
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Affiliation(s)
- Agostina Secchi
- Pharmacy Department, Kent and Medway NHS and Social Care Partnership Trust, Maidstone, UK
| | - Andrew Booth
- Evidence Synthesis, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Ian Maidment
- Department of Clinical Pharmacy, Aston University, Birmingham, UK
| | - Dolly Sud
- Pharmacy Department, Leicestershire Partnership NHS Trust, Bradgate Mental Health Site, Glenfield Hospital Site, Leicester, UK
| | - Hadar Zaman
- School of Pharmacy and Medical Science, University of Bradford, Bradford, UK
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Finn Y, Gorecka M, Flaherty G, Dunne F, O'Brien T, Crowley J, Wood D, Connolly S, Jones J, Gibson I. Evaluation of a Community-Based Cardiovascular Prevention Program in Patients With Type 2 Diabetes. Am J Health Promot 2020; 35:68-76. [PMID: 32545994 DOI: 10.1177/0890117120931711] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
PURPOSE An outcomes' evaluation of a community-based cardiovascular disease (CVD) prevention program in persons with newly diagnosed type 2 diabetes. DESIGN A prospective, observational study. SETTING A community-setting in Ireland. PARTICIPANTS Persons with newly diagnosed type 2 diabetes, aged 40 years or older, and 2 or more cardiovascular risk factors. INTERVENTION A 16-week community-based, cardiovascular prevention program, with health promotion seminars, group exercise, and individual consultations, delivered by a multidisciplinary team. MEASURES Medical, lifestyle, and well-being measures. ANALYSIS Changes in categorical and continuous variables were analyzed using the paired exact test and the t test/Wilcoxin matched-pairs test, respectively. RESULTS In total, 218 persons (134 men) participated, mean age was 59.8 (10.2) years. Completion rate was 75.2% (n = 164). The proportion achieving target glycosylated hemoglobin (HbA1c) increased from 53% at baseline to 75% (P < .001) at end of program. Systolic and diastolic blood pressures reduced by 8.8 mm Hg (95% CI: -11.2 to -6.4, P < .001) and 5.2 mm Hg (95% CI: -6.9 to -3.5, P < .001), respectively. Mean low-density lipoprotein cholesterol reduced from 2.45 to 2.05 mmol/L (P < .001). Significantly higher proportions met recommended targets in diet (6.9% vs 43.4%, P < .001) and physical activity (9.2% vs 56.6%, P < .001). Psychosocial measures significantly improved at end of program. The majority of improvements were sustained at 1 year. CONCLUSION Participation in this CVD prevention program was associated with significant improvements in glycemia and CVD risk factors in newly diagnosed patients with type 2 diabetes.
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Affiliation(s)
- Yvonne Finn
- School of Medicine, 8799National University of Ireland Galway, Galway, Ireland.,Centre for Diabetes, Endocrinology and Metabolism, 360706University Hospital Galway, Galway, Ireland.,National Institute for Prevention and Cardiovascular Health, Croí House, Galway, Ireland
| | - Miroslawa Gorecka
- Department of Cardiology, 360706University Hospital Galway, Galway, Ireland
| | - Gerard Flaherty
- School of Medicine, 8799National University of Ireland Galway, Galway, Ireland.,National Institute for Prevention and Cardiovascular Health, Croí House, Galway, Ireland
| | - Fidelma Dunne
- School of Medicine, 8799National University of Ireland Galway, Galway, Ireland.,Centre for Diabetes, Endocrinology and Metabolism, 360706University Hospital Galway, Galway, Ireland.,National Institute for Prevention and Cardiovascular Health, Croí House, Galway, Ireland
| | - Timothy O'Brien
- School of Medicine, 8799National University of Ireland Galway, Galway, Ireland.,Centre for Diabetes, Endocrinology and Metabolism, 360706University Hospital Galway, Galway, Ireland.,National Institute for Prevention and Cardiovascular Health, Croí House, Galway, Ireland
| | - James Crowley
- School of Medicine, 8799National University of Ireland Galway, Galway, Ireland.,National Institute for Prevention and Cardiovascular Health, Croí House, Galway, Ireland.,Department of Cardiology, 360706University Hospital Galway, Galway, Ireland
| | - David Wood
- School of Medicine, 8799National University of Ireland Galway, Galway, Ireland.,National Institute for Prevention and Cardiovascular Health, Croí House, Galway, Ireland
| | - Susan Connolly
- National Institute for Prevention and Cardiovascular Health, Croí House, Galway, Ireland
| | - Jennifer Jones
- National Institute for Prevention and Cardiovascular Health, Croí House, Galway, Ireland.,3890Brunel University, London, United Kingdom
| | - Irene Gibson
- School of Medicine, 8799National University of Ireland Galway, Galway, Ireland.,National Institute for Prevention and Cardiovascular Health, Croí House, Galway, Ireland
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7
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Abstract
BACKGROUND Diabetes mellitus, a metabolic disorder characterised by hyperglycaemia and associated with a heavy burden of microvascular and macrovascular complications, frequently remains undiagnosed. Screening of apparently healthy individuals may lead to early detection and treatment of type 2 diabetes mellitus and may prevent or delay the development of related complications. OBJECTIVES To assess the effects of screening for type 2 diabetes mellitus. SEARCH METHODS We searched CENTRAL, MEDLINE, LILACS, the WHO ICTRP, and ClinicalTrials.gov from inception. The date of the last search was May 2019 for all databases. We applied no language restrictions. SELECTION CRITERIA We included randomised controlled trials involving adults and children without known diabetes mellitus, conducted over at least three months, that assessed the effect of diabetes screening (mass, targeted, or opportunistic) compared to no diabetes screening. DATA COLLECTION AND ANALYSIS Two review authors independently screened titles and abstracts for potential relevance and reviewed the full-texts of potentially relevant studies, extracted data, and carried out 'Risk of bias' assessment using the Cochrane 'Risk of bias' tool. We assessed the overall certainty of the evidence using the GRADE approach. MAIN RESULTS We screened 4651 titles and abstracts identified by the search and assessed 92 full-texts/records for inclusion. We included one cluster-randomised trial, the ADDITION-Cambridge study, which involved 20,184 participants from 33 general practices in Eastern England and assessed the effects of inviting versus not inviting high-risk individuals to screening for diabetes. The diabetes risk score was used to identify high-risk individuals; it comprised variables relating to age, sex, body mass index, and the use of prescribed steroid and anti-hypertensive medication. Twenty-seven practices were randomised to the screening group (11,737 participants actually attending screening) and 5 practices to the no-screening group (4137 participants). In both groups, 36% of participants were women; the average age of participants was 58.2 years in the screening group and 57.9 years in the no-screening group. Almost half of participants in both groups were on antihypertensive medication. The findings from the first phase of this study indicate that screening compared to no screening for type 2 diabetes did not show a clear difference in all-cause mortality (hazard ratio (HR) 1.06, 95% confidence interval (CI) 0.90 to 1.25, low-certainty evidence). Screening compared to no screening for type 2 diabetes mellitus showed an HR of 1.26, 95% CI 0.75 to 2.12 (low-certainty evidence) for diabetes-related mortality (based on whether diabetes was reported as a cause of death on the death certificate). Diabetes-related morbidity and health-related quality of life were only reported in a subsample and did not show a substantial difference between the screening intervention and control. The included study did not report on adverse events, incidence of type 2 diabetes, glycosylated haemoglobin A1c (HbA1c), and socioeconomic effects. AUTHORS' CONCLUSIONS We are uncertain about the effects of screening for type 2 diabetes on all-cause mortality and diabetes-related mortality. Evidence was available from one study only. We are therefore unable to draw any firm conclusions relating to the health outcomes of early type 2 diabetes mellitus screening. Furthermore, the included study did not assess all of the outcomes prespecified in the review (diabetes-related morbidity, incidence of type 2 diabetes, health-related quality of life, adverse events, socioeconomic effects).
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Affiliation(s)
- Nasheeta Peer
- Non-communicable Diseases Research Unit, South African Medical Research Council, Durban, South Africa
| | - Yusentha Balakrishna
- Biostatistics Unit, South African Medical Research Council, Durban, South Africa
| | - Solange Durao
- Cochrane South Africa, South African Medical Research Council, Cape Town, South Africa
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Piepoli MF, Abreu A, Albus C, Ambrosetti M, Brotons C, Catapano AL, Corra U, Cosyns B, Deaton C, Graham I, Hoes A, Lochen ML, Matrone B, Redon J, Sattar N, Smulders Y, Tiberi M. Update on cardiovascular prevention in clinical practice: A position paper of the European Association of Preventive Cardiology of the European Society of Cardiology. Eur J Prev Cardiol 2019; 27:181-205. [PMID: 31826679 DOI: 10.1177/2047487319893035] [Citation(s) in RCA: 125] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
European guidelines on cardiovascular prevention in clinical practice were first published in 1994 and have been regularly updated, most recently in 2016, by the Sixth European Joint Task Force. Given the amount of new information that has become available since then, components from the task force and experts from the European Association of Preventive Cardiology of the European Society of Cardiology were invited to provide a summary and critical review of the most important new studies and evidence since the latest guidelines were published. The structure of the document follows that of the previous document and has six parts: Introduction (epidemiology and cost effectiveness); Cardiovascular risk; How to intervene at the population level; How to intervene at the individual level; Disease-specific interventions; and Settings: where to intervene? In fact, in keeping with the guidelines, greater emphasis has been put on a population-based approach and on disease-specific interventions, avoiding re-interpretation of information already and previously considered. Finally, the presence of several gaps in the knowledge is highlighted.
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Affiliation(s)
- Massimo F Piepoli
- Department of Cardiology, Polichirurgico Hospital G Da Saliceto, Italy.,Institute of Life Sciences, Sant'Anna School of Advanced Studies, Italy
| | - Ana Abreu
- Serviço de Cardiologia, Universidade de Lisboa, Portugal
| | - Christian Albus
- Department of Pshychosomatics and Psychotherapy, University of Cologne, Germany
| | - Marco Ambrosetti
- Department of Cardiac Rehabilitation, Istituti Clinici Scientifici Maugeri IRCCS, Institute of Pavia, Italy
| | - Carlos Brotons
- Biomedical Research Institute Sant Pau Research Unit, Sardenya Primary Health Care Center, Spain
| | - Alberico L Catapano
- Department of Pharmacological and Biomolecular Sciences, Università degli studi di Milano, Italy
| | - Ugo Corra
- Department of Cardiac Rehabilitation, Istituti Clinici Scientifici Maugeri IRCCS, Institute of Veruno, Italy
| | - Bernard Cosyns
- Department of Cardiology, Universitair Ziekenhuis Brussel, Belgium
| | - Christi Deaton
- Department of Public Health and Primary Care, University of Cambridge, UK
| | - Ian Graham
- Cardiovascular Medicine, Trinity College Dublin, Ireland
| | - Arno Hoes
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, The Netherlands
| | - Maja-Lisa Lochen
- Department of Community Medicine, UiT the Artic University of Norway, Norway
| | - Benedetta Matrone
- Department of Cardiology, Polichirurgico Hospital G Da Saliceto, Italy
| | - Josep Redon
- INCLIVA Research Institute, University of Valencia, Spain
| | - Naveed Sattar
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, UK
| | - Yvo Smulders
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, The Netherlands
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