Diabetes and the impact of treating cardiovascular risk factors

Earlier in his career, Dr Rutter spent two years as a Research Fellow in Cardiology and Endocrinology at the Lahey Clinic, Massachusetts, USA. While in the US he worked on the BARI 2D trial and further developed his interest in cardiovascular disease while working with the Framingham Heart Study team. With colleagues in the US and using data from the BARI 2D trial, he has investigated whether comprehensive cardiovascular risk factor control improves survival in patients with Type 2 diabetes and coronary heart disease.

Below, Dr Rutter explains the importance of this recently published research and how it could change clinical practice.

It is estimated that around 3.9 million people are living with diabetes in UK, with Type 2 diabetes making up 90% of this number. Type 2 diabetes develops when the insulin-producing cells in the body are unable to produce enough insulin, or when the insulin that is produced does not work properly.

There are a number of medical complications associated with Type 2 diabetes, which often develop even before patients receive a clinical diagnosis of their condition. One of these complications is cardiovascular disease (CVD), which includes heart disease and stroke. People with diabetes have about twice the risk of developing a range of CVD, compared to those without, with 52% of Type 2 diabetes deaths being linked to CVD complications.

With around 10% of the NHS budget spent on diabetes treatment, it is vital as medical professionals that we look for new ways to manage and treat Type 2 diabetes to reduce fatalities and improve the health of our patients.

Our recently published paper ‘Comprehensive Cardiovascular Risk Factor Control Improves Survival’ in the Journal of the American College of Cardiology, explores whether achieving six risk factor goals (no smoking, low cholesterol, weight loss, blood pressure and blood glucose levels) through protocol-guided intensive medical therapy improves outcomes in patients with type 2 diabetes and coronary heart disease.

A holistic approach was used to achieve these risk factor goals, involving advice for patients about smoking cessation, diet and exercise combined with doctors following prescribing protocols designed to help physicians effectively manage their patients’ cholesterol, blood pressure and blood glucose levels.

This approach was followed for 5 years from the time of the baseline assessment in 2,265 patients, with regular clinical follow-ups. The study assessed how the change in risk factor control brought about by the trial intervention was related to important outcomes such as death and heart attacks. We found that patients achieving 6 risk factor goals during the trial had approximately half the risk of death and heart attack when compared to those achieving 0 to 2 risk factor goals. These are remarkable findings in a trial that that found no survival benefit from costly and potentially risky surgical intervention for coronary heart disease.

What does this mean for the NHS and the wider medical community?

As highlighted in an associated editorial by Maron and Boden, these data are compelling and argue persuasively that all patients with stable heart disease should receive optimal medical therapy. Sadly, current use of optimal medical therapy for patients with diabetes and heart disease is disappointingly low in most settings. The research has shown that serious outcomes can be prevented using simple interventions such as blood pressure and cholesterol lowering that can be made available to the vast majority of these patients in the NHS and in other healthcare settings around the world. The focus should be on simultaneous control of multiple risk factors rather than dealing with individual risk factors in isolation. Optimal medical therapy needs to be more widely embraced and used by clinicians so that it becomes a universal standard of care.

What is new and what does this mean for patients?

For people with Type 2 diabetes and heart disease, this is excellent news because we now have stronger evidence that we can dramatically change the natural history of the condition which, so often in the past, has ended in death due to a heart attack. Optimal medical care involves patients through lifestyle interventions (diet and physical activity), concordance with prescribed medical therapy and in the monitoring of risk factor levels such as glucose.

The full paper and an audio commentary is available online here