Cardiovascular prevention in diabetes mellitus. Is it appropriate to speak of moderate or intermediate risk?

Diabetes, especially type 2, is considered a risk situation for atherosclerotic cardiovascular disease (ASCVD). Subjects with diabetes type 2 have a mortality rate due to ASCVD 3 times higher than that found in the general population, attributed to hyperglycemia and the frequent association of other cardiovascular risk factors, such as atherogenic dyslipidemia. Numerous scientific societies have established a risk classification for ASCVD in diabetes based on 3 degrees (moderate, high and very high). The objectives of dyslipidemia control are clearly defined and accepted, and vary depending on the previously established cardiovascular risk. In moderate or intermediate risk, the guidelines propose a less intensive intervention, maintaining LDL-C levels<100mg/dL and NO-HDL-C levels<130mg/dL, and waiting 10 years until reaching the high-risk category to initiate more intensive treatment. However, during the decade of follow-up recommended in the guidelines, cholesterol deposition in the arterial wall increases, facilitating the development of an unstable and inflammatory atheromatous plaque, and the development of ASCVD. Alternatively, diabetes could be considered from the outset to be a high-risk situation and the goal should be LDL-C<70mg/dL. Furthermore, maintaining LDL-C levels<70mg/dL contributes to reducing and stabilizing atheromatous plaque, avoiding or reducing mortality episodes due to ASCVD during those years of diabetes evolution. Should we maintain the proposed objectives in subjects with diabetes and moderate risk for a decade until reaching the high cardiovascular risk phase or, on the contrary, should we adopt a more intensive stance from the beginning seeking to reduce cardiovascular risk in the majority of patients with diabetes? Is it better to wait or prevent with effective therapeutic measures from the first moment?

Morbidity and mortality of lung resection candidates defined by the American College of Chest Physicians as 'moderate risk': an analysis from the European Society of Thoracic Surgeons database

OBJECTIVES

The American College of Chest Physicians functional guidelines classify patients with predicted postoperative forced expiratory volume in 1 s or predicted postoperative carbon monoxide lung diffusion capacity <60% and with maximal oxygen consumption (VO2max) between 10 and 20 ml/kg/min in a heterogeneous category broadly defined as 'moderate risk' with variable morbidity and mortality. Data to support this statement are lacking. Using the European Society of Thoracic Surgeons database, our goal was to test this definition by evaluating the morbidity and mortality of those patients falling into this class.

METHODS

All patients who had anatomical lung resection for lung cancer (2007-2019) and were deemed of moderate risk were identified in the European Society of Thoracic Surgeons database. Cardiopulmonary morbidity and 30-day mortality of these patients were assessed by the type of operation.

RESULTS

A total 2016 patients were identified. The incidence of cardiopulmonary complications in this group was 21% after lobectomy (294/1435), 29% after bilobectomy (33/112), 22% after pneumonectomy (72/333) and 16% after segmentectomy (22/136) (analysis of variance P = 0.07). The 30-day mortality was 3.4% after lobectomy (49/1435), 8.9% after bilobectomy (10/112), 7.8% after pneumonectomy (26/333) and 3.7% after segmentectomy (5/136) (analysis of variance P = 0.0005). The 30-day mortality rate was 1.6-fold higher in patients with a VO2max between 10 and 15 ml/kg/min compared to those with a higher VO2max [49/861 (5.7%) vs 41/1155 (3.5%); P = 0.022]. For operations that were less extensive than a pneumonectomy and were performed by minimally invasive surgery, there was no difference in mortality between patients with a VO2max between 10 and 15 ml/kg/min and those with a higher VO2max [7/181 (3.8%) vs 11/272 (4.0%); P = 0.92]. On the other hand, after open surgery, the mortality of patients with a lower VO2max (10-15 ml/kg/min) was higher than that of those with a higher VO2max [26/501 (5.1%) vs 20/721 (2.8%); P = 0.034]. Linear regression adjusting for the extent and access of the operation confirmed that within the moderate-risk group a VO2max <15 ml/kg/min was associated with higher mortality (P = 0.028; odds ratio 1.61; 95% confidence interval 1.1-2.5).

CONCLUSIONS

Morbidity and mortality rates found in this study are not negligible and reinforce the recommendation to ensure careful patient discussion and informed decision-making prior to lung cancer resection surgery.