This document summarizes key findings from major clinical trials on intensive glycemic control and cardiovascular outcomes in patients with type 2 diabetes (T2D). The trials showed that intensive control reduced microvascular complications but had mixed effects on macrovascular outcomes. Intensive lifestyle intervention focused on weight loss improved cardiovascular risk factors in the short term but did not reduce cardiovascular events in the long term. Hypoglycemia from intensive control may increase cardiovascular risk, though its relationship is unclear.
State of art cardiovascular prevention in diabetes - helsinki april 2018SoM
Intensive glucose control reduces microvascular complications in patients with type 2 diabetes but does not significantly reduce macrovascular events or mortality. Lipid and blood pressure lowering are effective at reducing cardiovascular outcomes, with lipid lowering reducing events by 20-40% and blood pressure lowering reducing mortality by 10-20% and stroke by 25-30%. Target blood pressures of below 130/80 mmHg and LDL cholesterol levels below 1 mmol/L are recommended for diabetes patients to reduce cardiovascular risk.
This document summarizes lessons from studies on type 2 diabetes (DM2), including the UK Prospective Diabetes Study (UKPDS). The UKPDS found that intensive glucose control reduced long-term risk of microvascular complications and myocardial infarction compared to conventional treatment. These benefits persisted for over a decade after the trial. The study also found metformin treatment reduced cardiovascular events compared to sulfonylurea/insulin. Overall, the UKPDS provides evidence that earlier and tighter glucose control has long-term benefits in preventing diabetes complications.
Simposio ALAD Avances en la prevención y el tratamiento de la diabetes tipo 2...rdaragnez
This document summarizes research on diabetes treatment and outcomes from several long-term clinical trials. It finds that intensive glucose control early in type 2 diabetes can significantly reduce cardiovascular and renal complications long-term. However, rapidly lowering glucose in those with existing cardiovascular disease may increase mortality risk. Multifactorial treatment including blood pressure and glucose control provides substantial benefits and is recommended for all type 2 diabetes patients.
This document provides an overview of Galvus (vildagliptin) and discusses pancreatic islet dysfunction in type 2 diabetes. It notes that both insufficient insulin production and excessive glucagon secretion from alpha cells contribute to hyperglycemia in type 2 diabetes. The document reviews evidence that beta cell function deteriorates over time in type 2 diabetes despite stable insulin sensitivity, and that early glycemic control can reduce complications and have long-term legacy effects on cardiovascular outcomes compared to late control.
This document summarizes key information from a presentation on optimal prevention of cardiovascular outcomes in type 2 diabetes:
1) Type 2 diabetes significantly increases the risk of cardiovascular disease and other chronic complications. Both intensive lipid and blood pressure lowering through medications like statins and ACE inhibitors have been shown to reduce cardiovascular events.
2) While glucose lowering also aims to reduce cardiovascular risk, trials yielded mixed results. Intensive control increased mortality in ACCORD but showed long-term benefits after the UKPDS trial. Current guidelines target HbA1c under 7%.
3) The choice of glucose-lowering medications is also important. Rosiglitazone increased cardiovascular risk and was withdrawn. Ongoing monitoring of
The document discusses diabetes care and management strategies. It covers several key points:
1. The Alphabet Strategy outlines evidence-based targets for diabetes care including advice, blood pressure, cholesterol, diabetes control, eye exams, foot exams, and medications.
2. Studies show tight control of blood pressure and cholesterol significantly reduces cardiovascular risks for those with diabetes.
3. The UKPDS trial demonstrated that intensive glucose control can reduce microvascular complications, though the effects on macrovascular disease are less certain. Maintaining an A1c below 7% is a recommended target.
The document discusses hypertension (high blood pressure) and its role in cardiovascular disease risk. It summarizes several studies showing that controlling hypertension, through lifestyle changes and medication such as diuretics, ACE inhibitors, and ARBs, can significantly reduce the risks of heart attack, stroke, heart failure, and death. The use of combination drug therapy to control blood pressure is often more effective than single drug therapy alone.
State of art cardiovascular prevention in diabetes - helsinki april 2018SoM
Intensive glucose control reduces microvascular complications in patients with type 2 diabetes but does not significantly reduce macrovascular events or mortality. Lipid and blood pressure lowering are effective at reducing cardiovascular outcomes, with lipid lowering reducing events by 20-40% and blood pressure lowering reducing mortality by 10-20% and stroke by 25-30%. Target blood pressures of below 130/80 mmHg and LDL cholesterol levels below 1 mmol/L are recommended for diabetes patients to reduce cardiovascular risk.
This document summarizes lessons from studies on type 2 diabetes (DM2), including the UK Prospective Diabetes Study (UKPDS). The UKPDS found that intensive glucose control reduced long-term risk of microvascular complications and myocardial infarction compared to conventional treatment. These benefits persisted for over a decade after the trial. The study also found metformin treatment reduced cardiovascular events compared to sulfonylurea/insulin. Overall, the UKPDS provides evidence that earlier and tighter glucose control has long-term benefits in preventing diabetes complications.
Simposio ALAD Avances en la prevención y el tratamiento de la diabetes tipo 2...rdaragnez
This document summarizes research on diabetes treatment and outcomes from several long-term clinical trials. It finds that intensive glucose control early in type 2 diabetes can significantly reduce cardiovascular and renal complications long-term. However, rapidly lowering glucose in those with existing cardiovascular disease may increase mortality risk. Multifactorial treatment including blood pressure and glucose control provides substantial benefits and is recommended for all type 2 diabetes patients.
This document provides an overview of Galvus (vildagliptin) and discusses pancreatic islet dysfunction in type 2 diabetes. It notes that both insufficient insulin production and excessive glucagon secretion from alpha cells contribute to hyperglycemia in type 2 diabetes. The document reviews evidence that beta cell function deteriorates over time in type 2 diabetes despite stable insulin sensitivity, and that early glycemic control can reduce complications and have long-term legacy effects on cardiovascular outcomes compared to late control.
This document summarizes key information from a presentation on optimal prevention of cardiovascular outcomes in type 2 diabetes:
1) Type 2 diabetes significantly increases the risk of cardiovascular disease and other chronic complications. Both intensive lipid and blood pressure lowering through medications like statins and ACE inhibitors have been shown to reduce cardiovascular events.
2) While glucose lowering also aims to reduce cardiovascular risk, trials yielded mixed results. Intensive control increased mortality in ACCORD but showed long-term benefits after the UKPDS trial. Current guidelines target HbA1c under 7%.
3) The choice of glucose-lowering medications is also important. Rosiglitazone increased cardiovascular risk and was withdrawn. Ongoing monitoring of
The document discusses diabetes care and management strategies. It covers several key points:
1. The Alphabet Strategy outlines evidence-based targets for diabetes care including advice, blood pressure, cholesterol, diabetes control, eye exams, foot exams, and medications.
2. Studies show tight control of blood pressure and cholesterol significantly reduces cardiovascular risks for those with diabetes.
3. The UKPDS trial demonstrated that intensive glucose control can reduce microvascular complications, though the effects on macrovascular disease are less certain. Maintaining an A1c below 7% is a recommended target.
The document discusses hypertension (high blood pressure) and its role in cardiovascular disease risk. It summarizes several studies showing that controlling hypertension, through lifestyle changes and medication such as diuretics, ACE inhibitors, and ARBs, can significantly reduce the risks of heart attack, stroke, heart failure, and death. The use of combination drug therapy to control blood pressure is often more effective than single drug therapy alone.
This document discusses antiplatelet treatment strategies in diabetic patients with acute coronary syndrome (ACS). It summarizes several clinical trials comparing different P2Y12 inhibitors in this population. The key points are:
1. Diabetic patients with ACS have higher mortality and morbidity than non-diabetic patients. Clopidogrel response is more variable in diabetics, with higher rates of non-response.
2. A head-to-head trial found ticagrelor reduced platelet reactivity more than prasugrel in diabetic ACS patients after loading doses, with fewer patients having high on-treatment platelet reactivity.
3. Clinical trials showed ticagrelor and prasug
The document summarizes findings from the ACCORD clinical trial which compared an intensive glucose lowering strategy targeting an A1C less than 6.0% to a standard strategy targeting an A1C of 7.0-7.9% in adults with type 2 diabetes at high risk for cardiovascular disease. The intensive strategy resulted in lower A1C levels but also increased mortality, did not reduce the risk of major cardiovascular events, and was associated with more hypoglycemia, weight gain, and other side effects. Certain subgroups such as those with an A1C under 8% at baseline or receiving primary prevention may have experienced reduced cardiovascular risk with intensive control.
The document discusses the concept of "metabolic memory" where the risks of diabetic complications can persist even after glucose levels have returned to normal. It provides evidence from animal and human studies in the 1980s and 2000s supporting this concept. It then summarizes findings from several major clinical trials that compared intensive glucose control to standard control and found reductions in microvascular and macrovascular outcomes with intensive control, though the benefits took years to emerge after trial completion.
This document discusses the relationship between diabetes, cardiovascular risk, and glycemic control. It summarizes evidence from several major clinical trials on whether intensively lowering A1c reduces cardiovascular risk and whether the specific treatment used matters. The trials show mixed results, with some finding reduced risk of cardiovascular events but others finding no benefit or even potential harm from intensive control. The appropriate A1c target and best treatment approach remains unclear from the evidence.
1) The LEADER trial investigated the cardiovascular outcomes of treatment with liraglutide vs placebo in patients with type 2 diabetes at high risk of cardiovascular events. 2) The primary outcome was a composite of cardiovascular death, non-fatal myocardial infarction, and non-fatal stroke. Liraglutide was found to be non-inferior and superior to placebo for reducing the primary outcome. 3) When outcomes were analyzed according to history of prior myocardial infarction or stroke, liraglutide was found to reduce the primary outcome and cardiovascular death compared to placebo regardless of prior history.
This document discusses the management of hypertension in patients with type 2 diabetes. It provides an overview of clinical trials that have evaluated blood pressure targets for reducing cardiovascular risk in this population. The trials have shown that intensive control of blood pressure below 140/80 mmHg reduces microvascular complications, but trials targeting levels under 120/80 mmHg have found no additional cardiovascular benefit and an increased risk of side effects. Current guidelines recommend a systolic blood pressure goal of 130-140 mmHg for most patients with diabetes.
Ueda2015 diabetes control dr.lobna el-toonyueda2015
This document discusses diabetes control and treatment challenges. It summarizes:
1) Traditional oral antidiabetic medications can cause hypoglycemia, weight gain, beta-cell exhaustion, and uncertainties around cardiovascular safety which challenge achieving optimal diabetes control and treatment goals.
2) Clinical trials studying the effects of intensive glycemic control on cardiovascular outcomes have had mixed results, with some trials showing benefits and others showing potential harms, highlighting the need for safer antidiabetic therapies.
3) Newer antidiabetic drug classes like DPP-4 inhibitors have shown comparable or improved efficacy and safety profiles over traditional medications in clinical trials, though long-term outcomes data is still emerging.
Ueda2015 diabetes control dr.lobna el-toonyueda2015
This document discusses diabetes control and treatment challenges. It summarizes:
1) Traditional oral antidiabetic medications can cause hypoglycemia, weight gain, beta-cell exhaustion, and uncertainties around cardiovascular safety which challenge achieving optimal diabetes control and treatment goals.
2) Clinical trials studying the effects of intensive glycemic control on cardiovascular outcomes have had mixed results, with some trials showing benefits and others showing potential harms, highlighting the need for safer antidiabetic therapies.
3) Newer antidiabetic drug classes like DPP-4 inhibitors have shown comparable or improved efficacy and safety profiles over traditional medications in clinical trials, though long-term outcomes data is still emerging.
The Importance of CV Outcomes in Patients T2 Diabetes Mellitus Sara Temkit
Empa-reg outcome and Leader trials have substantiated the use of Liraglutide and Empagliflozin (as add-ons to Metformin in patients at high CV risk). This has led to changes in Canadian Diabetes Association (CDA) guidelines.
The SPRINT trial examined the effects of more intensive vs standard blood pressure treatment in 9,361 participants aged 50 and older with high blood pressure. It found that intensively lowering systolic blood pressure below 120 mm Hg significantly reduced cardiovascular events like heart attack, stroke, and heart failure by 25% and lowered mortality by 27% compared to standard treatment below 140 mm Hg. However, intensively treated participants experienced more side effects like hypotension, syncope, and acute kidney injury. Overall the benefits of intensive treatment outweighed the risks. The results suggest blood pressure goals may need to be lowered from 140/90 mm Hg, but more evidence is still needed before changing clinical practice guidelines.
Management of CAD in Diabetes the cardiovascular equivalent is challenging.The slides take you from the epidemiology,ADD,and CV benefit and how to manage CAD
This document summarizes guidelines for managing type 2 diabetes, including treatment options and their associated risks of hypoglycemia. It presents a case study of a 47-year-old man with diabetes and discusses guideline-recommended treatment approaches. Various oral medications are compared in terms of their efficacy in lowering A1C and risk of hypoglycemia when used as add-ons to metformin. Studies show DPP-4 inhibitors like sitagliptin have similar glycemic control as sulphonylureas with a lower risk of hypoglycemia.
1) Multiple lines of evidence from meta-analyses, prospective cohort studies, and randomized controlled trials establish that LDL causes atherosclerotic cardiovascular disease (ASCVD).
2) The risk of atherosclerosis and need for treatment depends on LDL levels and increases with age from childhood through older age. Lowering LDL, including to very low levels, reduces ASCVD risk and can regress atherosclerotic plaques.
3) Intensive LDL lowering through combination therapy such as statins plus ezetimibe or PCSK9 inhibitors provides additional cardiovascular benefit beyond statin therapy alone, including in those already at very low LDL levels. The greatest risk reduction occurs in high-risk groups.
Cardiovascular disease is a major risk for those with diabetes.
1) Studies like the Framingham Heart Study and UKPDS found diabetes to be a significant risk factor for cardiovascular mortality and events like heart attacks.
2) Having diabetes poses similar risks as having a heart attack, with endothelial dysfunction, dyslipidemia, and other factors increasing cardiovascular risks.
3) Lifestyle changes like diet, exercise, weight loss and optimal control of blood pressure, cholesterol and blood sugars can help prevent premature cardiovascular events for those with diabetes.
CVD related mortality increases in patients with type 2 diabetes. People with type 2 diabetes have a higher risk of heart attack, stroke, and lower limb amputation compared to those without diabetes. They also die 5-10 years earlier on average. Intensive control of blood sugar, blood pressure, and lipids can help reduce cardiovascular risk in this population, but tight glycemic control has risks as evidenced by the ACCORD trial results. Multiple factors contribute to higher cardiovascular risk in diabetes including dyslipidemia, hypertension, hyperglycemia, and insulin resistance. Lifestyle changes and medication are important for managing these modifiable risk factors.
This document provides information on an academic detailing session for health care professionals on medications for type 2 diabetes, specifically SGLT2 inhibitors and GLP1 agonists. It summarizes clinical trial evidence on empagliflozin, semaglutide, and canagliflozin that shows reductions in cardiovascular outcomes and death. It also reviews dosage, costs, ongoing trials, and clinical considerations for safe use of SGLT2 inhibitors.
The SPRINT trial examined the effects of more intensive vs standard blood pressure treatment in over 9,000 adults age 50 or older with high blood pressure. Participants were randomized to a systolic blood pressure goal of less than 120 mm Hg (intensive) or less than 140 mm Hg (standard). The trial found that the primary composite cardiovascular outcome occurred at a 25% lower rate in the intensive treatment group compared to standard treatment. All-cause mortality was also 27% lower with intensive treatment. Intensive treatment resulted in more frequent adverse events like hypotension but overall benefits were found to exceed potential harms.
ueda2012 do we still need high doses-d.mohammedueda2015
This document discusses hypertension and the need for high doses of antihypertensive medications. It provides data showing that over half of adults with hypertension still have uncontrolled blood pressure despite improvements. It also summarizes trials showing residual cardiovascular risk even when blood pressure is controlled. The document advocates for early use of combination antihypertensive therapy, especially those targeting the renin-angiotensin-aldosterone system, to improve control and reduce organ damage. It highlights valsartan specifically as a well-studied angiotensin receptor blocker with strong evidence from numerous trials across cardiovascular conditions.
This document discusses hypertension guidelines and management. It covers the epidemiology of hypertension, guidelines for classification and treatment targets, detection of white coat and masked hypertension, and management of hypertension in patients with comorbidities like chronic kidney disease. Proper control of hypertension is important for reducing cardiovascular and renal risks. Treatment involves lifestyle changes and antihypertensive medications, with certain drugs offering additional organ protective effects. Management is more complex in patients on dialysis or after kidney transplantation.
- The document discusses the evidence for lipid lowering therapy in patients with chronic kidney disease (CKD). It summarizes data from major trials showing proportional reductions in major vascular events with reductions in LDL cholesterol.
- For patients at high risk of atherosclerotic events like those with diabetes or known heart disease, statin therapy may provide similar benefits regardless of kidney function, though the evidence is less clear for patients on dialysis or with mild CKD.
- Ongoing trials like SHARP and AURORA aim to provide more evidence on the risks and benefits of statin therapy in patients with CKD or on dialysis.
How to Manage Your Lost Opportunities in Odoo 17 CRMCeline George
Odoo 17 CRM allows us to track why we lose sales opportunities with "Lost Reasons." This helps analyze our sales process and identify areas for improvement. Here's how to configure lost reasons in Odoo 17 CRM
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Similar to Approaches to managing CV risk in patients with T2D.pptx
This document discusses antiplatelet treatment strategies in diabetic patients with acute coronary syndrome (ACS). It summarizes several clinical trials comparing different P2Y12 inhibitors in this population. The key points are:
1. Diabetic patients with ACS have higher mortality and morbidity than non-diabetic patients. Clopidogrel response is more variable in diabetics, with higher rates of non-response.
2. A head-to-head trial found ticagrelor reduced platelet reactivity more than prasugrel in diabetic ACS patients after loading doses, with fewer patients having high on-treatment platelet reactivity.
3. Clinical trials showed ticagrelor and prasug
The document summarizes findings from the ACCORD clinical trial which compared an intensive glucose lowering strategy targeting an A1C less than 6.0% to a standard strategy targeting an A1C of 7.0-7.9% in adults with type 2 diabetes at high risk for cardiovascular disease. The intensive strategy resulted in lower A1C levels but also increased mortality, did not reduce the risk of major cardiovascular events, and was associated with more hypoglycemia, weight gain, and other side effects. Certain subgroups such as those with an A1C under 8% at baseline or receiving primary prevention may have experienced reduced cardiovascular risk with intensive control.
The document discusses the concept of "metabolic memory" where the risks of diabetic complications can persist even after glucose levels have returned to normal. It provides evidence from animal and human studies in the 1980s and 2000s supporting this concept. It then summarizes findings from several major clinical trials that compared intensive glucose control to standard control and found reductions in microvascular and macrovascular outcomes with intensive control, though the benefits took years to emerge after trial completion.
This document discusses the relationship between diabetes, cardiovascular risk, and glycemic control. It summarizes evidence from several major clinical trials on whether intensively lowering A1c reduces cardiovascular risk and whether the specific treatment used matters. The trials show mixed results, with some finding reduced risk of cardiovascular events but others finding no benefit or even potential harm from intensive control. The appropriate A1c target and best treatment approach remains unclear from the evidence.
1) The LEADER trial investigated the cardiovascular outcomes of treatment with liraglutide vs placebo in patients with type 2 diabetes at high risk of cardiovascular events. 2) The primary outcome was a composite of cardiovascular death, non-fatal myocardial infarction, and non-fatal stroke. Liraglutide was found to be non-inferior and superior to placebo for reducing the primary outcome. 3) When outcomes were analyzed according to history of prior myocardial infarction or stroke, liraglutide was found to reduce the primary outcome and cardiovascular death compared to placebo regardless of prior history.
This document discusses the management of hypertension in patients with type 2 diabetes. It provides an overview of clinical trials that have evaluated blood pressure targets for reducing cardiovascular risk in this population. The trials have shown that intensive control of blood pressure below 140/80 mmHg reduces microvascular complications, but trials targeting levels under 120/80 mmHg have found no additional cardiovascular benefit and an increased risk of side effects. Current guidelines recommend a systolic blood pressure goal of 130-140 mmHg for most patients with diabetes.
Ueda2015 diabetes control dr.lobna el-toonyueda2015
This document discusses diabetes control and treatment challenges. It summarizes:
1) Traditional oral antidiabetic medications can cause hypoglycemia, weight gain, beta-cell exhaustion, and uncertainties around cardiovascular safety which challenge achieving optimal diabetes control and treatment goals.
2) Clinical trials studying the effects of intensive glycemic control on cardiovascular outcomes have had mixed results, with some trials showing benefits and others showing potential harms, highlighting the need for safer antidiabetic therapies.
3) Newer antidiabetic drug classes like DPP-4 inhibitors have shown comparable or improved efficacy and safety profiles over traditional medications in clinical trials, though long-term outcomes data is still emerging.
Ueda2015 diabetes control dr.lobna el-toonyueda2015
This document discusses diabetes control and treatment challenges. It summarizes:
1) Traditional oral antidiabetic medications can cause hypoglycemia, weight gain, beta-cell exhaustion, and uncertainties around cardiovascular safety which challenge achieving optimal diabetes control and treatment goals.
2) Clinical trials studying the effects of intensive glycemic control on cardiovascular outcomes have had mixed results, with some trials showing benefits and others showing potential harms, highlighting the need for safer antidiabetic therapies.
3) Newer antidiabetic drug classes like DPP-4 inhibitors have shown comparable or improved efficacy and safety profiles over traditional medications in clinical trials, though long-term outcomes data is still emerging.
The Importance of CV Outcomes in Patients T2 Diabetes Mellitus Sara Temkit
Empa-reg outcome and Leader trials have substantiated the use of Liraglutide and Empagliflozin (as add-ons to Metformin in patients at high CV risk). This has led to changes in Canadian Diabetes Association (CDA) guidelines.
The SPRINT trial examined the effects of more intensive vs standard blood pressure treatment in 9,361 participants aged 50 and older with high blood pressure. It found that intensively lowering systolic blood pressure below 120 mm Hg significantly reduced cardiovascular events like heart attack, stroke, and heart failure by 25% and lowered mortality by 27% compared to standard treatment below 140 mm Hg. However, intensively treated participants experienced more side effects like hypotension, syncope, and acute kidney injury. Overall the benefits of intensive treatment outweighed the risks. The results suggest blood pressure goals may need to be lowered from 140/90 mm Hg, but more evidence is still needed before changing clinical practice guidelines.
Management of CAD in Diabetes the cardiovascular equivalent is challenging.The slides take you from the epidemiology,ADD,and CV benefit and how to manage CAD
This document summarizes guidelines for managing type 2 diabetes, including treatment options and their associated risks of hypoglycemia. It presents a case study of a 47-year-old man with diabetes and discusses guideline-recommended treatment approaches. Various oral medications are compared in terms of their efficacy in lowering A1C and risk of hypoglycemia when used as add-ons to metformin. Studies show DPP-4 inhibitors like sitagliptin have similar glycemic control as sulphonylureas with a lower risk of hypoglycemia.
1) Multiple lines of evidence from meta-analyses, prospective cohort studies, and randomized controlled trials establish that LDL causes atherosclerotic cardiovascular disease (ASCVD).
2) The risk of atherosclerosis and need for treatment depends on LDL levels and increases with age from childhood through older age. Lowering LDL, including to very low levels, reduces ASCVD risk and can regress atherosclerotic plaques.
3) Intensive LDL lowering through combination therapy such as statins plus ezetimibe or PCSK9 inhibitors provides additional cardiovascular benefit beyond statin therapy alone, including in those already at very low LDL levels. The greatest risk reduction occurs in high-risk groups.
Cardiovascular disease is a major risk for those with diabetes.
1) Studies like the Framingham Heart Study and UKPDS found diabetes to be a significant risk factor for cardiovascular mortality and events like heart attacks.
2) Having diabetes poses similar risks as having a heart attack, with endothelial dysfunction, dyslipidemia, and other factors increasing cardiovascular risks.
3) Lifestyle changes like diet, exercise, weight loss and optimal control of blood pressure, cholesterol and blood sugars can help prevent premature cardiovascular events for those with diabetes.
CVD related mortality increases in patients with type 2 diabetes. People with type 2 diabetes have a higher risk of heart attack, stroke, and lower limb amputation compared to those without diabetes. They also die 5-10 years earlier on average. Intensive control of blood sugar, blood pressure, and lipids can help reduce cardiovascular risk in this population, but tight glycemic control has risks as evidenced by the ACCORD trial results. Multiple factors contribute to higher cardiovascular risk in diabetes including dyslipidemia, hypertension, hyperglycemia, and insulin resistance. Lifestyle changes and medication are important for managing these modifiable risk factors.
This document provides information on an academic detailing session for health care professionals on medications for type 2 diabetes, specifically SGLT2 inhibitors and GLP1 agonists. It summarizes clinical trial evidence on empagliflozin, semaglutide, and canagliflozin that shows reductions in cardiovascular outcomes and death. It also reviews dosage, costs, ongoing trials, and clinical considerations for safe use of SGLT2 inhibitors.
The SPRINT trial examined the effects of more intensive vs standard blood pressure treatment in over 9,000 adults age 50 or older with high blood pressure. Participants were randomized to a systolic blood pressure goal of less than 120 mm Hg (intensive) or less than 140 mm Hg (standard). The trial found that the primary composite cardiovascular outcome occurred at a 25% lower rate in the intensive treatment group compared to standard treatment. All-cause mortality was also 27% lower with intensive treatment. Intensive treatment resulted in more frequent adverse events like hypotension but overall benefits were found to exceed potential harms.
ueda2012 do we still need high doses-d.mohammedueda2015
This document discusses hypertension and the need for high doses of antihypertensive medications. It provides data showing that over half of adults with hypertension still have uncontrolled blood pressure despite improvements. It also summarizes trials showing residual cardiovascular risk even when blood pressure is controlled. The document advocates for early use of combination antihypertensive therapy, especially those targeting the renin-angiotensin-aldosterone system, to improve control and reduce organ damage. It highlights valsartan specifically as a well-studied angiotensin receptor blocker with strong evidence from numerous trials across cardiovascular conditions.
This document discusses hypertension guidelines and management. It covers the epidemiology of hypertension, guidelines for classification and treatment targets, detection of white coat and masked hypertension, and management of hypertension in patients with comorbidities like chronic kidney disease. Proper control of hypertension is important for reducing cardiovascular and renal risks. Treatment involves lifestyle changes and antihypertensive medications, with certain drugs offering additional organ protective effects. Management is more complex in patients on dialysis or after kidney transplantation.
- The document discusses the evidence for lipid lowering therapy in patients with chronic kidney disease (CKD). It summarizes data from major trials showing proportional reductions in major vascular events with reductions in LDL cholesterol.
- For patients at high risk of atherosclerotic events like those with diabetes or known heart disease, statin therapy may provide similar benefits regardless of kidney function, though the evidence is less clear for patients on dialysis or with mild CKD.
- Ongoing trials like SHARP and AURORA aim to provide more evidence on the risks and benefits of statin therapy in patients with CKD or on dialysis.
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LAND USE LAND COVER AND NDVI OF MIRZAPUR DISTRICT, UPRAHUL
This Dissertation explores the particular circumstances of Mirzapur, a region located in the
core of India. Mirzapur, with its varied terrains and abundant biodiversity, offers an optimal
environment for investigating the changes in vegetation cover dynamics. Our study utilizes
advanced technologies such as GIS (Geographic Information Systems) and Remote sensing to
analyze the transformations that have taken place over the course of a decade.
The complex relationship between human activities and the environment has been the focus
of extensive research and worry. As the global community grapples with swift urbanization,
population expansion, and economic progress, the effects on natural ecosystems are becoming
more evident. A crucial element of this impact is the alteration of vegetation cover, which plays a
significant role in maintaining the ecological equilibrium of our planet.Land serves as the foundation for all human activities and provides the necessary materials for
these activities. As the most crucial natural resource, its utilization by humans results in different
'Land uses,' which are determined by both human activities and the physical characteristics of the
land.
The utilization of land is impacted by human needs and environmental factors. In countries
like India, rapid population growth and the emphasis on extensive resource exploitation can lead
to significant land degradation, adversely affecting the region's land cover.
Therefore, human intervention has significantly influenced land use patterns over many
centuries, evolving its structure over time and space. In the present era, these changes have
accelerated due to factors such as agriculture and urbanization. Information regarding land use and
cover is essential for various planning and management tasks related to the Earth's surface,
providing crucial environmental data for scientific, resource management, policy purposes, and
diverse human activities.
Accurate understanding of land use and cover is imperative for the development planning
of any area. Consequently, a wide range of professionals, including earth system scientists, land
and water managers, and urban planners, are interested in obtaining data on land use and cover
changes, conversion trends, and other related patterns. The spatial dimensions of land use and
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9
Changes in vegetation cover refer to variations in the distribution, composition, and overall
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How to Setup Warehouse & Location in Odoo 17 Inventory
Approaches to managing CV risk in patients with T2D.pptx
1. Approaches to managing CV risk in patients with T2D
EDUCATIONAL SLIDE MODULES
Date of preparation: November 2015
Version 1.0
Date goes here
2. *Includes smoking cessation
Rydén L et al. Eur Heart J 2013;34:3035
Management of CV risk factors
Antihypertensive
therapy
Effects on
macrovascular risk
uncertain or not
fully established
Effects on macrovascular
risk established
3. Module content
Management of CV risk factors
Multifactorial approach to reducing CV events in T2D
Antiplatelet therapy
Control of LDL-cholesterol
Antihypertensive therapy
Weight loss and lifestyle intervention*
Glycaemic control
*Includes smoking cessation
4. Module content
Management of CV risk factors
Multifactorial approach to reducing CV events in T2D
Antiplatelet therapy
Control of LDL-cholesterol
Antihypertensive therapy
Weight loss and lifestyle intervention*
Glycaemic control
*Includes smoking cessation
5. VADT3
UKPDS2
ADVANCE5
ACCORD4
1. Meinert CL et al. Diabetes 1970;19(suppl):789; 2. UKPDS 33. Lancet 1998;352:837; 3. Duckworth W et al. N Engl J Med 2009;360:129;
4. Gerstein HC et al. N Engl J Med 2008;358:2545; 5. Patel A et al. N Engl J Med 2008;358:2560
Major historic T2D CV outcomes trials focused on
intensive vs conventional glycaemic control
5
1950 1960 1970 1980 1990 2000 2010
UGDP1
Date of first patient enrolment
6. Trial N
Duration
of follow-
up (years)
Glycaemic target
Main inclusion criteria
Intensive
treatment
Standard
treatment
UKPDS1 3867 10.0* FPG
<6 mmol/l
FPG
<15 mmol/l
T2D newly diagnosed
ADVANCE2 11,140 4.3* HbA1c
≤6.5%
per local
guidelines
T2D and macrovascular or
microvascular disease, or
1 CV risk factor
ACCORD3 10,251 3.5† HbA1c
<6.0%
HbA1c
7.0–7.9%
T2D and CVD or 2 CV
risk factors
VADT4 1791 5.6* HbA1c
≤6%
HbA1c
8–9%
Long-standing, poorly
controlled T2D
*Median; †Mean
1. UKPDS 33. Lancet 1998;352:837; 2. Patel A et al. N Engl J Med 2008;358:2560; 3. Gerstein HC et al. N Engl J Med 2008;358:2545;
4. Duckworth W et al. N Engl J Med 2009;360:129
Major historic T2D CV outcomes trials had
different durations and baseline CV risk
6
7. 0 10 20 30 40
Any diabetes-related endpoint* p=0.029
12%
Microvascular complications* p=0.0099
25%
Retinopathy progression† p=0.015
21%
Microalbuminuria† p=0.000054
33%
Risk reduction (%)
*Median follow-up, 10 years
†Assessed as surrogate endpoints; follow-up, 12 years
UKPDS 33. Lancet 1998;352:837
UKPDS: intensive glycaemic control reduced
microvascular but not macrovascular outcomes
7
Myocardial infarction* p=0.052
16%
Diabetes-related death* p=0.34
10%
All-cause mortality* p=0.44
6%
8. Holman RR et al. N Engl J Med 2008;359:1577
Fatal or non-fatal MI: Intensive treatment
UKPDS: long-term follow-up revealed significant reduction
in MI associated with previous intensive glycaemic control
8
Overall values at the end of the study in 1997
Annual values during the 10-year post-trial monitoring period
HR
(95%
CI)
RR 0.84
p=0.052
RR 0.85
p=0.01
1.4
1.2
1.0
0.8
0.4
0.6
1997 2001 2003 2005 2007
1999
186
387
212
450
239
513
271
573
296
636
319
678
No. of events
Conventional therapy
Sulphonylurea–insulin
9. Patel A et al. N Engl J Med 2008;358:2560
ADVANCE: intensive glycaemic control reduced
microvascular but not macrovascular events
9
Standard control Intensive control
Major macrovascular events
66
25
6
20
15
10
5
0
18 24 30 36 42 48
12 54 60
0
p=0.32
Cumulative
incidence
(%)
Follow-up (months)
Major microvascular events
25
6
20
15
10
5
0
18 24 30 36 42 48 66
12 54 60
0
Follow-up (months)
p=0.01
14% risk
reduction
10. HR, 0.54 (95% CI 0.34,0.85)
p=0.007
2
Patients
with
event
(%)
1
0
4 6 10
Follow-up (years)
2 8
0
Zoungas S et al. N Engl J Med 2014;371:1392
End-stage renal disease
ADVANCE-ON: intensive glycaemic control had
significant benefit for end-stage renal disease
10
Standard control
Intensive control
No. at risk
Intensive 5571 5402 5186 4124 3764 2811
Standard 5569 5400 5173 4041 3681 2683
11. *First occurrence of non-fatal MI or non-fatal stroke or death from CV causes
Gerstein HC et al. N Engl J Med 2008;358:2545
ACCORD: intensive glucose-lowering arm terminated
early (after 3.5 years) because of higher overall mortality
11
Intensive therapy
(n=5128)
Standard therapy
(n=5123)
Outcome
No. of patients
(annual event rate, %)
No. of patients
(annual event rate, %)
Primary outcome* 352 (2.11) 371 (2.29)
Secondary outcome
Death
Any cause 257 (1.41) 203 (1.14)
CV cause 135 (0.79) 94 (0.56)
Non-fatal stroke 67 (0.39) 61 (0.37)
Fatal or non-fatal
CHF
152 (0.90) 124 (0.75)
Non-fatal MI 186 (1.11) 235 (1.45)
0.5 1.0 2.0
Hazard ratio (95% CI)
Favours intensive
therapy
Favours standard
therapy
12. *Composite of MI, stroke, CV death, CHF, surgery for vascular disease, inoperable coronary disease, and amputation for ischaemic gangrene
Duckworth W et al. N Engl J Med 2009;360:129
Primary outcome*
VADT: no difference in primary endpoint between intensive
and standard glucose-lowering therapy after 5.6 years
12
Probability
of
no
event
0 4 8
Years
6
2
Intensive therapy
Standard therapy
HR 0.88 (95% CI 0.74, 1.05)
p=0.14
10
0.20
0.40
0.60
0.80
0.00
1.00
13. *Composite of heart attack, stroke, new or worsening congestive heart failure, amputation for ischaemic gangrene, or death from cardiovascular causes
Hayward RA et al. N Engl J Med 2015;372:2197
Primary outcome*
VADT: significant benefit of intensive vs standard glucose-lowering
therapy in primary endpoint at 10-year follow up
13
Probability
of
no
event
0 4 8 12
Years
0.00
0.25
0.50
0.75
1.00
10
6
2
Intensive therapy
Standard therapy
HR 0.83 (95% CI 0.70, 0.99)
p=0.04
14. Turnbull FM et al. Diabetologia 2009;52:2288
Meta-analysis including 27,049 participants and 2370 major vascular events
No evidence from prospective trials that more
intensive glycaemic control reduces mortality
14
Hazard ratio
(95% CI)
ACCORD 257 (1.41) 203 (1.14) -1.01
ADVANCE 498 (1.86) 533 (1.99) -0.72
UKPDS 123 (0.13) 53 (0.25) -0.66
VADT 102 (2.22) 95 (2.06) -1.16
Overall 980 884 -0.88
ACCORD 137 (0.79) 94 (0.56) -1.01
ADVANCE 253 (0.95) 289 (1.08) -0.72
UKPDS 71 (0.53) 29 (0.52) -0.66
VADT 38 (0.83) 29 (0.63) -1.16
Overall 497 441 -0.88
All-cause mortality
Cardiovascular death
Trials
Number of events
(annual event rate, %)
More intensive Less intensive
∆HbA1c (%)
Favours more
intensive
Favours less
intensive
Overall HR (95% CI)
1.04 (0.90, 1.20)
1.10 (0.84, 1.42)
0.5 2.0
1.0
15. Trials
Number of events
(annual event rate, %) ΔHbA1c (%) Hazard ratio (95% CI) Overall HR (95% CI)
More intensive Less intensive
Major cardiovascular events*
ACCORD 352 (2.11) 371 (2.29) -1.01
ADVANCE 557 (2.15) 590 (2.28) -0.72
UKPDS 169 (1.30) 87 (1.60) -0.66
VADT 116 (2.68) 128 (2.98) -1.16
Overall 1194 1176 -0.88 0.91 (0.84, 0.99)
Stroke
Overall 378 370 -0.88 0.96 (0.83, 1.10)
Myocardial infarction
Overall 730 745 -0.88 0.85 (0.76, 0.94)
Hospitalised/fatal heart failure
Overall 459 446 -0.88 1.00 (0.86, 1.16)
*Major CV events = CV death or non-fatal stroke or non-fatal MI
†Diamonds incorporate point estimate (vertical dashed line) and
encompass 95% CI of overall effect for each outcome
Turnbull FM et al. Diabetologia 2009;52:2288
Meta-analysis including 27,049 participants and 2370 major vascular events
Meta-analysis shows modest benefit of intensive
glycaemic control on macrovascular risk
15
1.0
0.5 2.0
†
Favours more
intensive
Favours less
intensive
16. Study1 Baseline HbA1c
Control vs intensive
Mean duration of
diabetes at
baseline (years)
Microvascular CVD Mortality
UKPDS 9% 7.9% vs 7% Newly diagnosed ↓ ↔ ↔
ACCORD1–3 8.3% 7.5% vs 6.4% 10.0 ↓* ↔ ↑
ADVANCE 7.5 % 7.3% vs 6.5% 8.0 ↓ ↔ ↔
VADT 9.4 % 8.4% vs 6.9% 11.5 ↓ ↔ ↔
*No change in primary microvascular composite but significant decreases in micro/macroalbuminuria2,3
**No change in major clinical microvascular events but significant reduction in ESRD (p=0.007)5
1. Table adapted from Bergenstal RM et al. Am J Med 2010;123:374.e9; 2. Genuth S & Ismail Beigi F. Clin Endocrinol Metab 2012;97:41;
3. Ismail-Beigi F et al. Lancet 2010;376:419; 4. Hayward RA et al. N Engl J Med 2015;372:2197; 5. Zoungas S et al. N Engl J Med 2014;371:1392
Glucose-lowering studies confirmed benefit on microvascular
complications but mixed results on macrovascular outcomes
16
Long-term follow-up1,4,5
↓ ↓ ↔ ↓ ↔ ↓
↓* ↔ ↑
↓ ↔** ↔ ↔ ↔ ↔
↓ ? ↔ ↓ ↔ ↔
17. • Hypoglycaemia may be associated with co-morbidities that impact CVD
• A UK cohort study showed hypoglycaemia was associated with
increased CV risk and mortality1
• In ACCORD, severe hypoglycaemia was more frequent in the intensive
glucose-lowering than in the standard arm2
– Severe hypoglycaemia associated with increased risk of death in both arms
but in patients who experienced hypoglycaemia, risk of death was lower in
the intensive than in the standard arm3
• Meta-analysis of major glycaemic control trials associated intensive glucose
control with increased risk of severe hypoglycaemia, but with
no increase in CV events4
• Systematic review of prospective and retrospective datasets suggested severe
hypoglycaemia associated with 2-fold increase in CVD5
– Co-morbidities alone could not account for this association
1. Khunti K et al. Diabetes Care 2015;38:316; 2. Gerstein HC et al. N Engl J Med 2008;358:2545; 3. Bonds DE et al. BMJ 2010;340:b4909;
4. Turnbull FM et al. Diabetologia 2009;52:2288; 5. Goto A et al. BMJ 2013;347:f4533
Does hypoglycaemia impact CV risk?
17
18. Module content
Management of CV risk factors
Multifactorial approach to reducing CV events in T2D
Antiplatelet therapy
Control of LDL-cholesterol
Antihypertensive therapy
Weight loss and lifestyle intervention*
Glycaemic control
*Includes smoking cessation
19. *p<0.001 vs diabetes support and education
Look AHEAD Research Group. Diabetes Care 2007;30:1374
Intensive lifestyle intervention, focused on weight loss,
improved CV risk factors in T2D in the short term
19
Follow-up: 1 year
All 3 goals
HbA1c
<7%
BP
<130/80
mmHg
LDL-C
<100 mg/dl
(2.6 mmol/l)
73
69
44
24
51
57
45
16
0
20
40
60
80
100
Patients
achieving
ADA
goal
(%)
*
*
*
8.6
0.7
0
2
4
6
8
10
Weight
reduction
(%
body
weight)
*
Intensive lifestyle
intervention
Diabetes support and
education
20. No. at risk
Control 2575 2425 2296 2156 2019 688
Intervention 2570 2447 2326 2192 2049 505
Endpoint: Composite of CV death, non-fatal MI, non-fatal stroke and hospitalisation for angina
Look AHEAD Research Group. N Engl J Med 2013;369:145
Intensive lifestyle intervention, focused on weight loss,
did not improve CV risk in T2D in the long term
20
Years
2 4 6 10
8
Patients
with
primary
endpoint
(%)
HR, 0.95;
95% CI 0.80, 1.09
20
16
12
8
4
0
0
100
98
96
94
92
0
0 2 4 6 10
8
90
102
Estimated
mean
(kg)
Years
Weight loss
* *
* * *
* *
*
*
*
Main effect: -4 (95% CI -5, -3)
*p˂0.001
Intervention Control
21. Module content
Management of CV risk factors
Multifactorial approach to reducing CV events in T2D
Antiplatelet therapy
Control of LDL-cholesterol
Antihypertensive therapy
Weight loss and lifestyle intervention*
Glycaemic control
*Includes smoking cessation
22. Meta-analysis of 40 large scale, randomised, controlled trials of BP-lowering treatment including patients with diabetes (n=100,354 participants)
Emdin CA et al. JAMA 2015;313:603
10 mmHg reduction in SBP reduces all-cause mortality,
macrovascular and microvascular outcomes in T2D
22
Outcome
All-cause mortality
Macrovascular disease
CV disease
CHD
Stroke
Heart failure
Microvascular disease
Renal failure
Retinopathy
Albuminuria
0.5 1.0 2.0
Favours BP lowering Favours control
Relative risk (95% CI)
23. • Intensive BP lowering did not reduce 3P-MACE, CV death or MI but showed an
effect on stroke (p=0.01) and non-fatal stroke (p=0.03) over a mean follow-up of
4.7 years
3P-MACE, 3-point major adverse cardiovascular events; BP, blood pressure; CV, cardiovascular; MI, myocardial infarction
ACCORD Study Group. N Engl J Med 2010;362:1575
ACCORD BP: impact of intensive vs standard BP
lowering on 3P-MACE, CV death, MI and stroke
23
No. at risk
Intensive 2362 2291 2223 2174 1841 1128 313 186 88
Standard 2371 2287 2235 2186 1879 1196 382 215 114
Years since randomisation
0 3 4
1 2 5 6 7 8
Systolic
BP
(mmHg)
0
140
130
110
120
Intensive
Standard
BP lowering
0
0.2
1.0
0.8
0.4
0.6
0 3 4
1 2 5 6 7 8
0.0
0.1
0.2
0 3 4
1 2 5 6 7 8
Intensive
Standard
p=0.03
Proportion
with
event
Years
Stroke
24. • Reduction in risk of CV death (12%) and mortality (9%), but no differences in,
MI or stroke after long-term follow up
*In post-trial follow-up subgroup of patients
BP, blood pressure; CV, cardiovascular; HR, hazard ratio; MI, myocardial infarction
Zoungas S et al. N Engl J Med 2014;371:1392
ADVANCE ON: impact of lowering BP on CV outcomes
24
No. at risk
Active 5569 5425 5229 4109 3784 2826
Placebo 5571 5401 5158 4066 3681 2693
No. at risk
Active 5569 5337 5065 3946 3562 2586
Placebo 5571 5303 5008 3914 3486 2466
Stroke
HR 0.94 (95% CI 0.83, 1.07)
p=0.35
Follow-up (year)
Patients
with
event
(%)
0
60
100
90
70
80
10
50
40
20
30
0 4
2 6 8 10
CV death
HR 0.88 (95% CI 0.77, 0.99)
p=0.04
Follow-up (year)
Patients
with
event
(%)
0
60
100
90
70
80
10
50
40
20
30
0 4
2 6 8 10
0
5
25
20
10
15
0 4
2 6 8 10
Intensive
Standard
26. Meta-analysis of 40 trials of BP-lowering treatment including patients with diabetes (n=100,354 participants)
Emdin CA et al. JAMA 2015;313:603
Effect of 10 mmHg reduction in SBP on CV
outcomes by baseline ≥140 or <140 mmHg
26
0.5 1.0 2.0
Favours BP
lowering
Favours
control
Overall
Baseline SBP <140 mmHg
Baseline SBP 140 mmHg
Outcome
Mortality
CVD
CHD
Stroke
Relative risk (95% CI)
27. Meta-analysis of 40 trials of BP-lowering treatment including patients with diabetes (n=100,354 participants)
Emdin CA et al. JAMA 2015;313:603
CV outcomes based on mean
SBP achieved (≥130 or <130 mmHg)
27
Overall
Achieved SBP <130 mmHg
Achieved SBP 130 mmHg
0.5 1.0 2.0
Favours BP
lowering
Favours
control
Outcome
Mortality
CVD
CHD
Stroke
Relative risk (95% CI)
28. Guidelines
Goal BP (mmHg)
General Diabetes Elderly (≥80 years)
ESC/EASD 20131 <140/85†
ESH/ESC 20132 <140/90 <140/85 <150/90
NICE 20113,4 <140/90 <140/80* <150/90
ASH/ISH 20135 <140/90 <140/90* <150/90
JNC 8 20146 <140/90 <140/90* <150/90
(Aged ≥60 years)
ADA 20157 <140/90
CHEP8 <140/90 <130/80 <150/90
*<130/80 mmHg in chronic kidney disease and albuminuria; †SBP <130 mmHg in nephropathy
1. Rydén L et al. Eur Heart J 2013;34:3035; 2. Mancia G et al. J Hypertens 2013;31:1281; 3. http://guidance.nice.org.uk/CG127;
4. http://www.nice.org.uk/guidance/cg87; 5. Weber MA et al. J Hypertens 2014;32:3; 6. James PA et al. JAMA 2014;5;311:507;
7. American Diabetes Association. Diabetes Care 2015;38(suppl. 1):S1; 8. Daskalopoulou SS et al. Can J Cardiol 2015;31:549
Recent updates to blood pressure goals reflect
limited evidence of benefit <140/90 mmHg
28
29. Module content
Management of CV risk factors
Multifactorial approach to reducing CV events in T2D
Antiplatelet therapy
Control of LDL-cholesterol
Antihypertensive therapy
Weight loss and lifestyle intervention*
Glycaemic control
*Includes smoking cessation
30. -32
-24 -23 -22
-24
-31
-25
-44
-37
-8
-42
-19
-25
-18
-11
-60
-50
-40
-30
-20
-10
0
RR
reduction
or
hazard
ratio
(%)
Combined
1. Rydén L et al. Eur Heart J 2007;28:88; 2. Libby P. J Am Coll Cardiol 2005;46:1225; 3. LaRosa JC et al. N Engl J Med 2005;352:1425;
4. Shepherd J et al. N Engl J Med 1995;333:1301; 5. Downs JR et al. JAMA 1998;279:1615; 6. Ridker PM et al. N Engl J Med 2008;359:2195;
7. Colhoun HM et al. Lancet 2004;364:685; 8. ALLHAT-LLT. JAMA 2002;288:2998
Statin therapy has a pivotal role in reducing CV risk
30
6605
6595
20,536
4159
9014
4444
N 10,001 17,802
Non-diabetes Diabetes
AFCAPS/
TexCAPS5
4S1,2 LIPID1,2 CARE1,2 WOSCOPS4
Trial HPS1,2
TNT3 JUPITER6
Secondary prevention Primary prevention
High risk
CARDS7 ALLHAT-LLT8
2838 10,355
31. Cholesterol Treatment Trialists’ (CTT) Collaboration. Lancet 2012;380:581
CV risk reduction with statins is
proportional to LDL cholesterol decrease
31
0
40
80
120
160
2.5
2
1.5
1
12
10
8
6
31
27
21
15
68
57
45
31
100
84
66
45
142
119
93
61
Major
vascular
events
avoided
per
1000
<5
5 to 10
20 to 30
10 to 20
30
32. Module content
Management of CV risk factors
Multifactorial approach to reducing CV events in T2D
Antiplatelet therapy
Control of LDL-cholesterol
Antihypertensive therapy
Weight loss and lifestyle intervention*
Glycaemic control
*Includes smoking cessation
33. *10-year CV risk >10%
American Diabetes Association. Diabetes Care 2015;38(suppl. 1):S1
ASA reduces CV risk in patients post-primary event
33
Absolute decrease in CV risk depends on underlying risk
Main AE is increased
risk of GI bleeding
Recommended for:
Excess risk 1–5 per
1000 per year
If CVD risk >1% per year, CVD events prevented
may exceed bleeding events induced
Primary prevention in
patients at high risk*
Secondary prevention
34. Module content
Management of CV risk factors
Multifactorial approach to reducing CV events in T2D
Antiplatelet therapy
Control of LDL-cholesterol
Antihypertensive therapy
Weight loss and lifestyle intervention*
Glycaemic control
*Includes smoking cessation
35. *Includes smoking cessation
Rydén L et al. Eur Heart J 2013;34:3035
Antihypertensive
therapy
Reducing CV risk in T2D requires a multifactorial approach
36. *Non-fatal MI, CHD, stroke and all-cause mortality
1. Sattar N. Diabetologia 2013;56:686; 2. Ray KK et al. Lancet 2009;373:1765
CV risk reduction in T2D may require multiple
interventions including BP and lipid management
36
-12.5
-8.2
-2.9
-14
-12
-10
-8
-6
-4
-2
0
No
of
CV
events*
prevented
per
200
patients
for
5
years
Per 4 mmHg
lower SBP1
Per 1 mmol/l lower LDL-
C1
Per 0.9%
lower HbA1c1,2
37. Composite endpoint: CV death, non-fatal MI, non-fatal stroke revascularisation and amputation.
Gaede P et al. N Engl J Med 2003;348:383
Steno-2: Intensive multifactorial control of CV risk factors
reduces CV risk in patients with T2D and microalbuminuria
37
Unadjusted HR 0.47
(95% CI 0.24, 0.73); p=0.008
Primary
composite
endpoint
(%)
60
0
10
20
40
50
30
Conventional
(85 events)
Intensive
(33 events)
12 24 36 48 60 72 84 96
0
Months of follow-up
38. Gaede P et al. N Engl J Med 2008;358:580
Steno-2: intensive multifactorial control of CV risk factors
continues to reduce CV risk over long-term follow-up
38
0 1 2 3 4 5 6 7 8 9 10 11 13
12
0
10
20
30
40
50
60
70
80
p<0.001
Years of follow-up
Cumulative
incidence
of
any
cardiovascular
event
(%)
Conventional therapy
Intensive therapy
39. Approaches to managing CV risk in patients with T2D
EDUCATIONAL SLIDE MODULES
Date of preparation: November 2015
Version 1.0
Date goes here
40. *p<0.01; †p<0.05, each vs 2007–2010
NHANES 1988–2010. Stark Casagrande S et al. Diabetes Care 2013;36:2271
Despite improvement over 2 decades, many patients
with diabetes are still not reaching CV goals
40
1988–1994 1999–2002 2003–2006 2007–2010
Patients
reaching
goal
(%)
90
70
40
20
0
30
50
60
80
10
HbA1c <7.0%
(<53 mmol/mol)
*
†
BP
<130/80 mmHg
*
*
†
BP
<140/90 mmHg
*
*
LDL
<100 mg/dl
(2.6 mmol/l)
†
*
*
On statin
*
*
*
HbA1c <7.0%,
BP <130/80 mmHg
and LDL <100 mg/dl
(2.6 mmol/l)
*
*
From 2007–2010, 81.2% of
patients did not achieve the
composite ABC goal1
41. • Beneficial effect of glycaemic control on macrovascular risk has not been
established in prospective, long-term CV outcome trials
• Beneficial effects of LDL-cholesterol lowering,1 antihypertensive2 and
antiplatelet3 therapy on CV risk are well established
• Multifactorial approach recommended for control of CV and microvascular
risk1,4
– Pursue recommended treatment goals with regard to glucose, blood
pressure and lipids
– Pursue lifestyle interventions
– Provide antiplatelet therapy if indicated
– However, many patients fail to achieve CV risk factor goals5
1. Cholesterol Treatment Trialists’ (CTT) Collaboration. Lancet 2012;380:581; 2. Emdin CA et al. JAMA 2015;313:603;
3. American Diabetes Association. Diabetes Care 2015;38(suppl. 1):S1; 4. Rydén L et al. Eur Heart J 2013;34:3035;
5. NHANES 1988–2010. Stark Casagrande S et al. Diabetes Care 2013;36:2271
Summary
41
43. Orchard for DCCT/EDIC. JAMA 2015;313:45
Reduced all-cause mortality in intensive treatment
group after 27 years reveals legacy effect in T1D
• Mortality between groups did not differ until after the first 15 years of follow-up
Treatment Follow-up to 27 years
No. at risk
Conventional
Intensive
730
711
726
706
721
697
712
694
693
685
476
501
HR 0.67 (95% CI 0.46, 0.99); p=0.045
Cumulative
mortality,
proportion
Conventional treatment
Intensive treatment
Time since DCCT randomisation, years
0.12
0.10
0.08
0.06
0.04
0.02
0
0 5 10 25
15 20 30
43
44. Outcome
No. of events
intensive/standard
therapy
Intensive
therapy better
Standard
therapy better Odds ratios (95% Cl)
Total CHD 756/877 0.86 (0.78, 0.95)
Non-fatal Ml 522/613 0.85 (0.75, 0.96)
CHD death 234/264 0.88 (0.73, 1.06)
Heart failure 657/590 1.12 (0.91, 1.38)
Stroke 428/461 0.93 (0.81, 1.06)
CVD death 555/552 1.07 (0.83, 1.38)
Non-CHD-related
CV death
321/288 1.13 (0.89, 1.44)
Non-CV mortality 479/465 1.03 (0.90, 1.18)
All-cause mortality 1034/1017 1.05 (0.89, 1.23)
CHD, coronary heart disease; CV, cardiovascular; CVD, cardiovascular disease; MI, myocardial infarction
Ray KK et al. Lancet 2009;373:1765; Supplementary appendix
Impact of glucose lowering on CV outcomes
44
1.0 1.5
0.5 2.0
45. Ray KK et al. Lancet 2009; 373:1765; Supplementary appendix
Impact of glucose lowering on heart failure
45
Standard therapy better
Heterogeneity between groups: p=0.002
Overall (I-squared=62.9%, p=0.029)
Subgroup 1
ADVANCE
Subtotal (I-squared=0.0%, p=0.401)
UKPDS
VADT
Subtotal (I-squared=0.0%, p=0.948)
Subgroup 2
PROactive
ACCORD
100.00
24.61
44.05
14.99
16.34
55.95
22.80
21.25
1.08 (0.90, 1.31)
0.95 (0.79, 1.15)
1.33 (1.13, 1.56)
0.89 (0.62, 1.27)
0.93 (0.67, 1.29)
0.93 (0.81, 1.08)
1.41 (1.14, 1.76)
1.23 (0.97, 1.57)
Odds Ratio
Intensive therapy better
Study
Odds Ratio
(95% CI) Weight (%)
1
0.5 1.5 2