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DOC News    April 1, 2005
Volume 2 Number 4 p. 5
© 2005 American Diabetes Association
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Lipid and blood pressure control reduce CVD risk

Question: Should patients with type 2 diabetes be treated more aggressively for hyperlipidemia and hypertension than nondiabetic patients?

Answer: It is well known that patients with type 2 diabetes have a much higher risk for heart attack or stroke than people without diabetes. Reasons include the effects of increased blood glucose levels on cholesterol particles; low levels of HDL cholesterol and smaller, more dangerous LDL cholesterol particles; increased risk of blood clotting in the arteries of the heart and brain; high blood pressure; greater inflammation of the blood vessels; and abnormalities in the lining of the arteries.

The American Diabetes Association (ADA) and the National Cholesterol Education Program put patients with diabetes in a higher-risk group, meaning that their cholesterol targets should be lower than those in individuals without diabetes.1

Fortunately, we can do something. Studies show that lowering cholesterol levels lessens the risk of heart disease in patients with diabetes.2,3 For most patients, this means taking a statin. In fact, nearly all patients with type 2 diabetes will benefit from a statin, even if their LDL level isn't particularly high.4,5

The ADA recommends that all people older than 40 with a total cholesterol level >135 mg/dl should be started on a statin, with a goal of a 30% to 40% reduction in LDL cholesterol (regardless of initial LDL) and a target LDL of <100 mg/dl. For patients with type 2 diabetes and overt cardiovascular disease, a target LDL level of <70 mg/dl is recommended.6

Patients with diabetes also are vulnerable to changes in blood pressure levels, particularly in terms of heart attack, kidney failure, and stroke. The ADA recommends keeping blood pressure below 130/80 mmHg.6 Angiotensin converting enzyme (ACE)-inhibitors and angiotensin receptor blockers (ARBs) lower the risk for heart attack, kidney damage, and death in addition to lowering blood pressure.7,8 Even patients with normal blood pressure who are at increased risk for heart attack or kidney disease should be on an ACE-inhibitor and/or an ARB.9 {blacksquare}

Footnotes

Do you have a clinical question? Send it to docnews{at}diabetes.org.


Anne Peters Harmel, MD, is a professor of medicine at the University of Southern California's Keck School of Medicine, director of the USC Westside Center for Diabetes, and director of the Comprehensive Diabetes Center at Roybal Community Medical Center.

References

    1. Grundy SM, Cleeman JI, Merz CN, et al.: Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III Guidelines. J Am Coll Cardiol 44: 720–732, 2004.[Abstract/Free Full Text]

    2. Pyörälä K, Pedersen TR, Kjekshus J, et al.: Cholesterol lowering with simvastatin improves prognosis of diabetic patients with coronary heart disease: A subgroup analysis of the Scandinavian Simvastatin Survival Study. Diabetes Care 20: 614–620, 1997.[Abstract]

    3. Goldberg RB, Mellies MJ, Sacks FM, et al.: Cardiovascular events and their reduction with pravastatin in diabetic and glucose-intolerant myocardial infarction survivors with average cholesterol levels: Subgroup analyses in the Cholesterol and Recurrent Events (CARE) trial. Circulation 98:2513–2519, 1998.[Abstract/Free Full Text]

    4. Collins R, Armitage J, Parish S, et al.: MRC/BHF Heart Protection Study of cholesterol-lowering with simvastatin in 5,963 people with diabetes: A randomised placebo-controlled trial.Lancet 361: 2005–2016, 2003.[Medline]

    5. Colhoun HM, Betteridge DJ, Durrington PN, et al.: Primary prevention of cardiovascular disease with atorvastatin in type 2 diabetes in the Collaborative Atorvastatin Diabetes Study (CARDS): Multicentre randomised placebo-controlled trial. Lancet 364: 685–696, 2004.[Medline]

    6. American Diabetes Association: Standards of medical care in diabetes. Diabetes Care 28:S4–S36, 2005.[Free Full Text]

    7. Barnett AH, Bain SC, Bouter P, et al.: Angiotensin-receptor blockade versus converting-enzyme inhibition in type 2 diabetes and nephropathy. N Engl J Med 351:1952–1961, 2004.[Abstract/Free Full Text]

    8. Ruggenenti P, Fassi A, Ilieva AP, et al.: Preventing microalbuminuria in type 2 diabetes. N Engl J Med 351: 1941–1951, 2004.[Abstract/Free Full Text]

    9. Heart Outcomes Prevention Evaluation Study Investigators: Effects of ramipril on cardiovascular and microvascular outcomes in people with diabetes mellitus: Results of the HOPE study and MICRO-HOPE substudy. Lancet 355:253–259, 2000.[Medline]


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