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Primary Prevention of Cardio-Vascular Disease

ASEANZ 2009

Diabetes- New targets for therapy

The early diabetic trials such as UKPDS enrolled relatively younger patients with newly diagnosed diabetes that were treated with oral agents. The newer trials were quite different in enrolling older patients and of these a significant proportion already had macrovascular disease.

The HbA1C target may be appropriately adjusted for the patient. For example:

  • A middle aged patient with mild diabetes should be treated intensively with oral hypoglycaemic agents to lower the HbA1C level below 6%. Hopefully, this will aid in preventing the “legacy effect” and reduce the likelihood of development of macrovascular complications. However, if this same patient requires insulin for good control then the target HbA1c may be reset higher at 7%- by this means one hopefully reduce the likelihood of insulin therapy induced hypoglycaemia and potential for acute cardiovascular complications. It is thought that hypoglycaemia might cause acute cardiovascular events by increasing inflammation and by other mechanisms to promote thrombosis.
  • For the elderly patient, or patient that already has significant macrovascular complications that is treated with insulin, an appropriate HbA1c target may be less than 7% since there is no evidence that more intensive therapy in this group in this group reduces the risk of macrovascular complications and since intensive therapy may be harmful.

The role of antiplatelet therapy for primary prevention is now less clear with publication of small trials that did not find any benefit. However, we need to beware of the errors that can result from placing too much emphasis of the results of underpowered negative trials. In other words, if the patient’s calculated risk is high then it may still be appropriate to consider the use of low dose aspirin for primary prevention.

There is little doubt that lipid modifying therapy should be used to reduce the risk of future cardiovascular events- the best data for benefit remains with statins. The use of Apo-B to guide therapy has been promoted and is likely to be superior to use of LDL cholesterol alone.

The latest recommendations for treatment of hypertension suggest the use of ACE-inhibitors or ARBs first followed by addition of calcium channel blockers. Some calcium channel blockers exacerbate the degree of microalbuminuria but it is not known if this is deleterious.