Cardiovascular prevention in type 2 diabetic patients: review of efficacious treatments

Type 2 diabetes (t2DM) is a chronic and complex metabolic condition requiring continuing medical care in order to reduce the risk of long-term complications. Macrovascular complications cause about 65% of deaths in subjects with t2DM and are responsible for severe co-morbidity. Many studies have addressed cardiovascular (CV) risk reduction in t2DM subjects.

To summarise the evidence concerning the impact of lifestyle and of medical interventions in t2DM patients on CV risk (myocardial infarction, stroke, CV death, or a combination of these).

We successively reviewed the recent guidelines addressing CV prevention in t2DM and searched the Cochrane Controlled Trials Register (CCTR), Medline & Embase to find systematic reviews and original articles on CV events in t2DM patients. We selected original studies which included solely t2DM patients or a large t2DM subgroup (n>100), tested lifestyle habits or drug treatments, and analysed CV endpoints. Their design had to be a randomised controlled trial for drug interventions, and a prospective cohort for lifestyle habits. MAIN STUDIES: We found 4 major guidelines focusing on CV prevention in t2DM patients, all released in 2003, and 10 reviews and meta-analyses: one dealing with dietary intervention, three with blood pressure lowering, one with ACE-inhibitors, one (with update) with platelet-inhibitors , three with cholesterol-inhibitors and one that dealt with both cholesterol-inhibition and blood pressure lowering. We included cohort studies on cigarette smoking (1), physical exercise (3) and weight control (1), as well as randomised trials on treatment of glycaemia (1), lipidaemia (13), blood pressure (12) and platelet aggregation (4). We also included one open randomised trial dealing with a multifactorial treatment.

Global CV risk management in t2DM should aim at changes in lifestyle habits and daily use of multiple drugs. Treatment should be long-term and target-driven with intensified interventions aimed at all validated targets. Lifestyle approach is of primary importance. Five targets are supported by strong clinical evidence (Table 4): reduction of blood pressure and of LDL-Cholesterol to normal values, and the use of three types of drugs which inhibit, respectively, platelet aggregation, angiotensin pathway and cholesterol synthesis.