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Glucose, blood pressure, and cardiovascular risk.

Diabetes mellitus remains a formidable public health issue, affecting 171 million people worldwide as of 2000, a number estimated to more than double, up to 366 million, by 2030. The majority (>90%) have type 2 diabetes (T2DM), which is linked to westernized diets, obesity, and inactivity. This condition is associated with decreased survival, predominately due to cardiovascular disease (CVD), which appears earlier and more extensively than in nondiabetic persons. A recent large epidemiological study from Denmark found diabetes to be associated with greater mortality from virtually all specific causes. Impressively, at the age of 30 years, a diagnosis of diabetes was associated with a 9-year reduction in life span.1 Although the typical patient with T2DM possesses other CVD risk factors, such as obesity, hypertension, and dyslipidemia, increased mortality and morbidity persist, even after adjustment for these factors. Diabetes is, therefore, widely recognized as an independent CVD risk factor. Indeed, many authorities consider diabetes to be a coronary heart disease (CHD) “risk equivalent,”2,3 although this concept has recently been challenged by others.4

Article see p 153

Perhaps one of the most perplexing aspects of diabetes care, however, is our inability to affect this excess CVD risk through glucose control alone. Addressing the cardinal manifestation of the disease (namely, hyperglycemia) has had either no or minimal impact on the future risk of cardiovascular events. Major clinical trials have conclusively determined that more intensive glycemic control significantly reduces the risk of micro vascular complications (ie, retinopathy and nephropathy).5 In contrast, however, and despite a strong positive epidemiological association between CVD and measures of chronic hyperglycemia, there is little evidence that reducing circulating glucose concentrations translates to a significant improvement in macro vascular outcomes. Specifically, the recent Action to Control Cardiovascular Risk in Diabetes (ACCORD), Action in Diabetes …