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Primary prevention of cardiovascular disease with atorvastatin in type 2 diabetes in the Collaborative Atorvastatin Diabetes Study (CARDS): Multicentre randomised placebo-controlled trial
Preventive Cardiology
rate. Essentially all patients should be considered for statins “regardless of baseline lipid values.” The CARDS investigators suggest (perhaps in jest) the next goal is to define the population of diabetics at such a low risk as to justify withholding statins. Good luck! MR
Abstracts Primary Prevention of Cardiovascular Disease With Atorvastatin in Type 2 Diabetes in the Collaborative Atorvastatin Diabetes Study (CARDS): Multicentre Randomised Placebo-Controlled Trial
Sugar-Sweetened Beverages, Weight Gain, and Incidence of Type 2 Diabetes in Young and MiddleAged Women
Colhoun HM, Betteridge DJ, Durrington PN, et al. on behalf of the CARDS investigators. Lancet 2004;364:685–96. Study Question: Does atorvastatin reduce cardiovascular disease (CVD) outcomes in patients with diabetes without high levels of LDL cholesterol (LDL-C)? Methods: A total of 2838 diabetics aged 40 –75 years in 132 centers in the UK and Ireland were randomized to either placebo (n ⫽ 1410) or atorvastatin 10 mg daily (n ⫽ 1428). Participants had no history of CVD, an LDL-C ⱕ160 mg/ dL, a fasting triglyceride of ⱕ600 mg/dL, and at least one of the following: retinopathy, albuminuria, current smoking, or hypertension. The primary end point was time to first occurrence of the following: acute coronary heart disease events, coronary revascularization, or stroke. Analysis was by intention to treat. Results: There was no difference between groups regarding mean age of 61.5 years, 68% male, average duration of diabetes of 7.8 years, mean LDL-C 116 mg/dL, HDL-C 54 mg/dL, and diabetic treatment of oral agents only in 65%, insulin in 15%, combination in 4%, and diet only in 15%. The trial was terminated 2 years earlier than expected because the prespecified early stopping rule for efficacy had been met. Median duration of follow-up was 3.9 years. A total of 127 patients allocated placebo (2.46 per 100 person-years at risk) and 83 allocated atorvastatin (1.54 per 100 person-years at risk) had at least one major CV event (rate reduction 37% [95% CI ⫺52 to ⫺17]; p ⫽ 0.001). Treatment would be expected to prevent at least 37 major vascular events per 1000 such people treated for 4 years. Assessed separately, acute coronary events were reduced by 36% (⫺55 to ⫺9), coronary revascularization by 31% (⫺59 to 16), and rate of stroke by 48% (⫺69 to ⫺11). Atorvastatin reduced the death rate by 27% (⫺48 to 1; p ⫽ 0.059). No excess of adverse events was noted in the atorvastatin group. Conclusions: Atorvastatin 10 mg daily is safe and efficacious in reducing the risk of first CVD events, including stroke, in patients with type 2 diabetes without a high LDL-C. No justification is available for having a particular threshold level of LDL-C as the sole arbiter of which patients with type 2 diabetes should receive statins. Perspective: The results of CARDS affirm the British Heart Protection Study and provide clear evidence for the recent guidelines recommending treating diabetics with statins as CHD risk equivalents by assuming a 2% annual CV event
Schulze MB, Manson JE, Ludwig DS, et al. JAMA 2004;292: 927–34 Study Question: Is there a relationship between consumption of sugar-sweetened beverages (cola and juices) and weight change and risk of type 2 diabetes in women? Methods: A prospective cohort analysis was conducted from 1991 to 1999 among women in the Nurses’ Health Study II. The diabetes analysis included 91,249 women free of diabetes and other major chronic diseases at baseline in 1991. The weight change analysis included 51,603 women for whom complete dietary information and body weight were ascertained at intervals. Primary outcomes were weight gain and incidence of type 2 diabetes. Results: Mean age was 35 years, BMI 25 kg/m2, and 16% had a family history of diabetes. There were 741 incident cases of confirmed type-2 diabetes during 716,300 personyears of follow-up. Those with stable consumption patterns had no difference in weight gain, but weight gain over a 4-year period was highest among women who increased their sugar-sweetened soft drink consumption from 1 or fewer per week to 1 or more per day (multivariate-adjusted means, 4.69 kg for 1991 to 1995 and 4.20 kg for 1995 to 1999) and was smallest among women who decreased their intake (1.34 and 0.15 kg for the two periods, respectively) after adjusting for lifestyle and dietary confounders. After adjustment for potential confounders, women consuming 1 or more sugar-sweetened soft drinks per day had a relative risk (RR) of type 2 diabetes of 1.83 (95% CI, 1.42–2.36; p ⬍ 0.001 for trend) compared with those who consumed less than 1 of these beverages per month. Similarly, consumption of fruit punch was associated with increased diabetes risk (RR for ⱖ1 drink per day compared with ⬍1 drink per month, 2.00; 95% CI, 1.33–3.03; p ⫽ 0.001). Conclusions: Higher consumption of sugar-sweetened beverages is associated with a greater magnitude of weight gain and an increased risk for development of type-2 diabetes in women, possibly by providing excessive calories and large amounts of rapidly absorbable sugars. Perspective: Food with a high glycemic index, defined as rapidly digested and absorbed into the bloodstream, such as simple sugars, processed flours, corn, breads, and white potatoes, increase levels of insulin, body fat, BMI, the metabolic syndrome, and diabetes. Sugar-sweetened beverages
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rate. Essentially all patients should be considered for statins “regardless of baseline lipid values.” The CARDS investigators suggest (perhaps in jest) the next goal is to define the population of diabetics at such a low risk as to justify withholding statins. Good luck! MR
Abstracts Primary Prevention of Cardiovascular Disease With Atorvastatin in Type 2 Diabetes in the Collaborative Atorvastatin Diabetes Study (CARDS): Multicentre Randomised Placebo-Controlled Trial
Sugar-Sweetened Beverages, Weight Gain, and Incidence of Type 2 Diabetes in Young and MiddleAged Women
Colhoun HM, Betteridge DJ, Durrington PN, et al. on behalf of the CARDS investigators. Lancet 2004;364:685–96. Study Question: Does atorvastatin reduce cardiovascular disease (CVD) outcomes in patients with diabetes without high levels of LDL cholesterol (LDL-C)? Methods: A total of 2838 diabetics aged 40 –75 years in 132 centers in the UK and Ireland were randomized to either placebo (n ⫽ 1410) or atorvastatin 10 mg daily (n ⫽ 1428). Participants had no history of CVD, an LDL-C ⱕ160 mg/ dL, a fasting triglyceride of ⱕ600 mg/dL, and at least one of the following: retinopathy, albuminuria, current smoking, or hypertension. The primary end point was time to first occurrence of the following: acute coronary heart disease events, coronary revascularization, or stroke. Analysis was by intention to treat. Results: There was no difference between groups regarding mean age of 61.5 years, 68% male, average duration of diabetes of 7.8 years, mean LDL-C 116 mg/dL, HDL-C 54 mg/dL, and diabetic treatment of oral agents only in 65%, insulin in 15%, combination in 4%, and diet only in 15%. The trial was terminated 2 years earlier than expected because the prespecified early stopping rule for efficacy had been met. Median duration of follow-up was 3.9 years. A total of 127 patients allocated placebo (2.46 per 100 person-years at risk) and 83 allocated atorvastatin (1.54 per 100 person-years at risk) had at least one major CV event (rate reduction 37% [95% CI ⫺52 to ⫺17]; p ⫽ 0.001). Treatment would be expected to prevent at least 37 major vascular events per 1000 such people treated for 4 years. Assessed separately, acute coronary events were reduced by 36% (⫺55 to ⫺9), coronary revascularization by 31% (⫺59 to 16), and rate of stroke by 48% (⫺69 to ⫺11). Atorvastatin reduced the death rate by 27% (⫺48 to 1; p ⫽ 0.059). No excess of adverse events was noted in the atorvastatin group. Conclusions: Atorvastatin 10 mg daily is safe and efficacious in reducing the risk of first CVD events, including stroke, in patients with type 2 diabetes without a high LDL-C. No justification is available for having a particular threshold level of LDL-C as the sole arbiter of which patients with type 2 diabetes should receive statins. Perspective: The results of CARDS affirm the British Heart Protection Study and provide clear evidence for the recent guidelines recommending treating diabetics with statins as CHD risk equivalents by assuming a 2% annual CV event
Schulze MB, Manson JE, Ludwig DS, et al. JAMA 2004;292: 927–34 Study Question: Is there a relationship between consumption of sugar-sweetened beverages (cola and juices) and weight change and risk of type 2 diabetes in women? Methods: A prospective cohort analysis was conducted from 1991 to 1999 among women in the Nurses’ Health Study II. The diabetes analysis included 91,249 women free of diabetes and other major chronic diseases at baseline in 1991. The weight change analysis included 51,603 women for whom complete dietary information and body weight were ascertained at intervals. Primary outcomes were weight gain and incidence of type 2 diabetes. Results: Mean age was 35 years, BMI 25 kg/m2, and 16% had a family history of diabetes. There were 741 incident cases of confirmed type-2 diabetes during 716,300 personyears of follow-up. Those with stable consumption patterns had no difference in weight gain, but weight gain over a 4-year period was highest among women who increased their sugar-sweetened soft drink consumption from 1 or fewer per week to 1 or more per day (multivariate-adjusted means, 4.69 kg for 1991 to 1995 and 4.20 kg for 1995 to 1999) and was smallest among women who decreased their intake (1.34 and 0.15 kg for the two periods, respectively) after adjusting for lifestyle and dietary confounders. After adjustment for potential confounders, women consuming 1 or more sugar-sweetened soft drinks per day had a relative risk (RR) of type 2 diabetes of 1.83 (95% CI, 1.42–2.36; p ⬍ 0.001 for trend) compared with those who consumed less than 1 of these beverages per month. Similarly, consumption of fruit punch was associated with increased diabetes risk (RR for ⱖ1 drink per day compared with ⬍1 drink per month, 2.00; 95% CI, 1.33–3.03; p ⫽ 0.001). Conclusions: Higher consumption of sugar-sweetened beverages is associated with a greater magnitude of weight gain and an increased risk for development of type-2 diabetes in women, possibly by providing excessive calories and large amounts of rapidly absorbable sugars. Perspective: Food with a high glycemic index, defined as rapidly digested and absorbed into the bloodstream, such as simple sugars, processed flours, corn, breads, and white potatoes, increase levels of insulin, body fat, BMI, the metabolic syndrome, and diabetes. Sugar-sweetened beverages
ACC CURRENT JOURNAL REVIEW Nov 2004
34