Cardiovascular risk in patients with type 2 diabetes
====================================================

* Malvinder Parmar

*   © 2005 CMA Media Inc. or its licensors

There is no doubt that aggressive control of common risk factors is of paramount importance in the management of diabetic patients with atherosclerotic disease to prevent cardiovascular morbidity and mortality. In assessing management of such patients, Lauren Brown and associates1 identified the study cohort between 1991 and 1996 and followed the patients until 2000; however, the evidence for the standard therapies they evaluated (regarding antiplatelet agents,2 angiotensin-converting enzyme [ACE] inhibitors3 and statins4) did not become available until at least 2000. In other words, evidence published during or after the year 2000 was applied to data collected up to 2000; thus, it is no surprise that management was suboptimal relative to current recommendations.

It would have been preferable for the authors to have used the 1998 guidelines for management of diabetes5in evaluating the care provided to these patients. I acknowledge that their findings would probably have been similar, as it takes a few years to implement such guidelines (by which time they may have been changed or be undergoing revision). None of the therapies listed above was strongly recommended for cardiovascular protection in the 1998 guidelines. In fact, the UK Prospective Diabetes Study,6 published at the same time, highlighted the importance of effectively controlling both blood glucose and blood pressure to improve microvascular and macrovascular complications and did not favour one agent over the other (β-blocker versus ACE inhibitor).

Since then, however, evidence has accumulated, and the 2003 Canadian guidelines7 make appropriate recommendations about these therapies.

## Footnotes

*   *Competing interests:* None declared.

## References

1.  1. Brown LC, Johnson JA, Majumdar SR, Tsuyuki RT, McAlister FA. Evidence of suboptimal management of cardiovascular risk in patients with type 2 diabetes mellitus and symptomatic atherosclerosis. CMAJ 2004;171(10):1189-92.
    
    [Abstract/FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiY21haiI7czo1OiJyZXNpZCI7czoxMToiMTcxLzEwLzExODkiO3M6NDoiYXRvbSI7czoyMzoiL2NtYWovMTcyLzkvMTE2MC4xLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

2.  2. Antithrombotic Trialists' Collaboration. Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients [published erratum in BMJ 2002;324:141]. *BMJ* 2002;324:71-86.
    
    [FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6MzoiYm1qIjtzOjU6InJlc2lkIjtzOjEyOiIzMjQvNzMzMC8xNDEiO3M6NDoiYXRvbSI7czoyMzoiL2NtYWovMTcyLzkvMTE2MC4xLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

3.  3. Heart Outcomes Prevention Evaluation (HOPE) Study Investigators. Effects of ramipril on cardiovascular and microvascular outcomes in people with diabetes mellitus: results of the HOPE study and MICRO-HOPE substudy [published erratum in Lancet 2000;356:860]. *Lancet* 2000;355:253-9.
    
    [CrossRef](http://www.cmaj.ca/lookup/external-ref?access_num=10.1016/S0140-6736(00)90028-X&link_type=DOI) 

4.  4. Heart Protection Study Collaborative Group. MRC/BHF Heart Protection Study of cholesterol lowering with simvastatin in 5963 people with diabetes: a randomized placebo-controlled trial. Lancet 2003;361:2005-16.
    
    [CrossRef](http://www.cmaj.ca/lookup/external-ref?access_num=10.1016/S0140-6736(03)13636-7&link_type=DOI) 
    
    [PubMed](http://www.cmaj.ca/lookup/external-ref?access_num=12814710&link_type=MED&atom=%2Fcmaj%2F172%2F9%2F1160.1.atom) 
    
    [Web of Science](http://www.cmaj.ca/lookup/external-ref?access_num=000183488900007&link_type=ISI) 

5.  5. Meltzer S, Leiter L, Daneman D, Gerstein HC, Lau D, Ludwig S, et al. 1998 clinical practice guidelines for the management of diabetes in Canada. *CMAJ* 1998;159(8 Suppl):S1-29.
    
    

6.  6. UK Prospective Diabetes Study Group. Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes. UKPDS 38. BMJ 1998;317:703-13.
    
    [Abstract/FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6MzoiYm1qIjtzOjU6InJlc2lkIjtzOjEyOiIzMTcvNzE2MC83MDMiO3M6NDoiYXRvbSI7czoyMzoiL2NtYWovMTcyLzkvMTE2MC4xLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

7.  7. Canadian Diabetes Association. 2003 clinical practice guidelines for the prevention and management of diabetes in Canada. *Can J Diabetes* 2003;27(Suppl 2):S1-140.