Need for multiple risk factor control highlighted in comorbid diabetes, heart disease
medwireNews: People with diabetes and stable ischemic heart disease (SIHD) are more likely to have long-term survival when they have a greater number of risk factors controlled at prespecified therapeutic goals, research shows.
Specifically, having at least three risk factors under control, particularly those associated with lifestyle behaviors along with glycated hemoglobin (HbA1c), was associated with a significantly reduced risk for death among 592 participants of the COURAGE trial who had both diabetes and SIHD.
Based on their findings, GB John Mancini (University of British Columbia, Vancouver, Canada) and co investigators believe: “There is an urgent need to develop better strategies to support the attainment of secondary prevention goals [in these patients]”.
The randomized COURAGE trial compared the effects of adding percutaneous coronary intervention to optimal medical therapy (OMT) in over 2000 patients with SIHD. Participants had systolic blood pressure, low-density lipoprotein cholesterol, smoking status, physical activity level, adherence to the American Heart Association Step 2 diet, and BMI assessed at baseline and 1 year later. Those with diabetes also had HbA1c measured.
The current post-hoc analysis showed that just 2% of the participants with both diabetes and SIHD achieved the preset target for all seven risk factors at 1 year. The highest rate of goal attainment was for not smoking, at 85%, whereas the lowest attainment rate was for BMI, where only 10% were below 25.0 kg/m2 or had at least 10% weight loss if their baseline BMI was above 27.5 kg/m2.
During an additional 7-year mean follow-up period, 186 (31.4%) participants with diabetes and SIHD died, giving a mortality rate of 4.5% per year.
On multivariate analysis, participants who achieved the goals for no smoking, physical activity (at least 150 min of moderate physical activity/week), diet adherence, and HbA1c (<7.0%) at 1 year had a significantly lower risk for death during follow-up than those not achieving each goal, with hazard ratios (HR) ranging from 0.49 to 0.67.
Individuals who achieved three of the seven goals (n=158) had a 65% lower risk for death than those achieving none or one, and the risk reduction increased with a greater number of goals achieved – for people who achieved six or seven goals (n=61), the risk reduction was 87%.
Furthermore, the researchers calculated that the risk for death fell by 17% with each additional target met.
Mancini and co-authors conclude in the Journal of the American College of Cardiology that their findings are “compatible with the basic principles underlying all diabetes and ischemic heart disease guidelines.”
Nonetheless, they add that “the prominent finding that [Hb]A1c control was associated with long-term survival deserves emphasis because achievement of [Hb]A1c goals specifically for cardiovascular protection remains controversial and is not currently emphasized in cardiology practice.”
In an accompanying editorial, Michael Farkouh and Lucas Godoy, both from the University of Toronto in Ontario, Canada, say the study “underscores the importance of lifestyle interventions, brings the role of glycemic control (not necessarily related to a specific drug) back to the frontline, and reinforces just how difficult it is to control multiple risk factors in the secondary prevention setting.”
And they add that the findings are “a timely reminder that the [cardiovascular] community should double up their efforts to ensure compliance with lifestyle interventions.”
By Laura Cowen
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