Soma S. Nag

Macrovascular risk factors in patients with diabetes: physician treatment strategies and extent of control.

OBJECTIVE To describe current approaches used by physicians to address macrovascular risk factors among patients with diabetes and their effect on glycosylated hemoglobin (HbA1c), blood pressure, and cholesterol (low-density lipoprotein cholesterol [LDL-C]) goal attainment. METHODS Newly referred or diagnosed patients with diabetes (N = 1,808) under the care of 133 community physicians were enrolled in a 12-month prospective multi-center observational study. The invited physicians treat a large number of patients with diabetes and included endocrinologists, internists, and primary care physicians. Patient and physician characteristics, physician ranking of treatment strategy priority, and patient ranking of diabetes-related complications of greatest concern were recorded at enrollment. Follow-up treatment rates and goal attainment rates for glucose (HbA1c <7%), cholesterol (LDL-C <100 mg/dL), and blood pressure (less than 130/80 mm Hg) were examined, both overall and for the most frequently occurring treatment strategies. RESULTS After evaluating the metabolic profiles of patients enrolled in the study, physicians assigned the highest treatment priority to glucose control for 67.6% of patients. Treatment rates during the 12-month follow-up were highest for glycemic control (87.2%), followed by blood pressure management (77.9%), and lipid control (63.9%). Among treated patients, goal attainment for HbA1c, LDL-C, and blood pressure was 57.6%, 47.7%, and 22.8%, respectively. Regardless of treatment strategy, follow-up goal attainment was the highest for HbA1c (54.8% to 72.3%), followed by LDL-C (41.7% to 48.4%), and lowest for blood pressure (12.0% to 37.1%). CONCLUSION These findings suggest the need for strategies that emphasize combined glucose, blood pressure, and cholesterol treatment in order to achieve more effective control of microvascular and macrovascular risk factors among patients with diabetes.

Trends in lipid management among patients with diabetes

OBJECTIVE To examine trends in lipid management (cholesterol testing, treatment, and goal attainment) among patients with diabetes and to analyze the factors associated with initiation of lipid-lowering therapy. METHODS We conducted a longitudinal, retrospective study of patients with diabetes identified during a 24-month baseline period (January 1, 1995, to December 31, 1996) and for whom follow-up was continued for 5 years (1997 to 2001). Generalized estimating equations were used to test for time trend effects in lipid management. We modeled the days from baseline to the first lipid-lowering prescription fill date with a multivariate Cox proportional hazards regression model. RESULTS Rates of lipid testing, treatment, and goal attainment significantly improved (P<0.001) during the 5-year study period: from 37% to 67% for lipid testing; from 19% to 41% for treatment with a lipid-lowering agent; from 22% to 37% for achievement of low-density lipoprotein cholesterol (LDL-C) levels < 100 mg/dL; and from 54% to 75% for achievement of LDL-C levels < 130 mg/dL. The relative likelihood (hazard rate) of treatment with lipid-lowering agents was greater for patients with LDL-C levels > or = 100 mg/dL relative to patients with LDL-C concentrations < 100 mg/dL. Treatment with lipid-lowering agents of patients with a cardiovascular event during follow-up was approximately 3 times more likely relative to those without such an event. CONCLUSION We found that rates of lipid testing, treatment, and goal attainment improved significantly between 1997 and 2001. Nevertheless, ample room for improvement of these rates continues to exist. Particular attention may be warranted to ensure that patients with diabetes receive lipid-lowering agents not only after a cardiovascular event but also before such an event occurs.

CHD Prevalence in Americans Age 50 Years and Older Using NCEP and WHO Definitions of Metabolic Syndrome

The World Health Organization (WHO) criteria for metabolic syndrome were originally published in 1998 and subsequently revised in 1999. The National Cholesterol Education Program (NCEP) proposed somewhat different criteria for the metabolic syndrome in 2001. This study compares the NCEP and WHO criteria for metabolic syndrome with respect to prevalence of coronary heart disease (CHD) in those 50 years and older. The Third National Health and Nutrition Examination Survey (NHANES III) was used to classify adults (> 50 years) by metabolic syndrome using NCEP and 1999 WHO definitions. Risk factor information for components of the metabolic syndrome, traditional cardiovascular risk factors and the prevalence of CHD were determined for each group. Individuals 50 years and older meeting only NCEP criteria had more traditional cardiovascular risk factors than those only meeting WHO criteria and less insulin resistance, per se. Consequently, the NCEP‐only group had a greater prevalence of CHD (18.8%) compared to the WHO‐only group (12.6%, p < 0.001). As a whole (including all individuals who met either NCEP or WHO criteria), prevalence of CHD was significantly higher in those meeting the NCEP definition (15.5%) compared to those meeting the WHO definition of metabolic syndrome (14.1%, p < 0.001). In conclusion, many individuals 50 years and older meet both NCEP and WHO criteria for metabolic syndrome (i.e., there is substantial concordance between the two criteria) and both criteria identify individuals with insulin resistance. NCEP criteria identified individuals with significantly higher CHD prevalence compared to the WHO criteria. In spite of the fact that individuals who met only the WHO criteria were more insulin resistant than the NCEP‐only individuals, those who met only the NCEP clinical criteria for metabolic syndrome had a much worse cardiovascular risk profile and were more likely to have prevalent CHD than those who met only the WHO criteria.

Diyabette kardiyovasküler riskin yeniden değerlendirilmesi

This review covers significant work on drugs working on the intestine for the year up to June 1990. Developments in bile acid sequestrants and related drugs are discussed. Some novel properties of β-hydroxy-β-methylglutaryl coenzyme A reductase inhibitors are considered. Finally, the role of acyl coenzyme A: cholesterol acyltransferase, cholesteryl ester hydrolase and compounds affecting these enzymes in intestinal cholesterol absorption are assessed.