Glycemic control may improve CV outcomes in diabetes, statin therapy
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CV outcomes in high-risk patients with diabetes receiving statin therapy were strongly associated with baseline HbA1c levels, according to findings published in the Journal of the American Heart Association.
In the ACCELERATE trial cohort, researchers found that higher baseline HbA1c in patients with diabetes on statin therapy was independently associated with incidence for major adverse CV events, defined as CV death, nonfatal MI, cerebrovascular accident, hospitalization for unstable angina and revascularization (Kaplan-Meier event rate estimate = 12.6-18.2; P < .001).
Elevated baseline HbA1c level was also linked to higher risk for the triple endpoint of death, nonfatal MI and stroke (Kaplan-Meier event rate estimate, 7.8-11.3; P = .003) and for the individual endpoints of nonfatal MI (Kaplan-Meier event rate estimate, 3.1-7; P < .001), hospitalization for unstable angina (Kaplan-Meier event rate estimate, 1.8-5; P = .003) and revascularization (Kaplan-Meier event rate estimate, 7.3-11.1; P = .001), but not for nonfatal stroke (Kaplan-Meier event rate estimate, 1.4-2.4; P = .45).
“The current analysis from a rigorously performed randomized clinical trial identifies glycemic control, as measured by HbA1c levels, in patients with diabetes at high cardiovascular risk to remain an independent predictor for the future development of cardiovascular events in contemporary clinical practice, despite statin use and near optimal LDL-C levels at baseline,” Venu Menon, MD, director of the coronary care unit at the Heart and Vascular Institute at Cleveland Clinic, and colleagues wrote. “Moreover, our results suggest that although improved glycemic control may have diminishing returns in reduction of hard clinical endpoints, such as mortality and nonfatal stroke, among those with HbA1c < 8%, as demonstrated in the ACCORD (Patel A, et al. N Engl J Med. 2008;doi:10.1056/NEJMoa0802987) and ADVANCE trials (Gerstein HC, et al. N Engl J Med. 2008;doi:10.1056/NEJMoa0802743), it remains strongly predictive of softer but clinically important endpoints, such as coronary revascularization and hospitalization for unstable angina.”
In other findings, incidence of CV mortality (Kaplan-Meier estimate, 2.6-4.3; P = .21) and all-cause mortality (Kaplan-Meier estimate, 4.8-5.9; P = .21) were similar regardless of baseline HbA1c.
After adjusting for baseline characteristics, researchers found that baseline HbA1c was an independent predictor for major adverse CV events (HR = 1.06; 95% CI, 1.02-1.11).
Researchers assessed 8,145 patients enrolled in the ACCELERATE trial with established diabetes and baseline HbA1c measurements (mean age, 66 years; 76% men; 78% white). Using Kaplan-Meier event rates, stratified by baseline HbA1c levels at 30 months, investigators aimed to determine the effect of glycemic control on CV outcomes in patients with diabetes receiving statin therapy.
“HbA1c levels remain strongly predictive of future cardiovascular events in patients with diabetes, despite optimal lipid, blood pressure and preventive strategies and despite recent outcomes data that may shift the focus away from glycemic control,” the researchers wrote. “Awareness of the HbA1c levels will enable clinicians to recognize residual risk and initiate or substitute proven medications that improve downstream cardiovascular outcomes in this vulnerable population.” – by Scott Buzby
Disclosures: The authors report no relevant financial disclosures.
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