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76 Cardio Diabetes Medicine 2017

such intervention reduces risk factors for vascular beta blockers for patients with diabetes in the chronic
disease and yields many health benefits (1). ambulatory setting and in the post-ACS population.
With non cardioselective beta blockers that also have
The pharmacological interventions include that of alpha receptor–blocking properties, metabolic mark-
assiduous blood pressure and lipid management for ers may improve, although the clinical relevance of
all patients, and for patients at highest risk, angioten- these differential effects remains unproved. Random-
sin-converting enzyme (ACE) inhibitors independent ized trials of thiazide diuretics that included substan-
of blood pressure and also daily aspirin.
tial numbers of patients with diabetes have consis-
Each component of the diabetic dyslipidemia profile tently demonstrated CVD benefits.
is independently associated with CVD risk, including
increased small, dense LDL particles, increased apo- In a subanalysis of the Antihypertensive and
lipoprotein B concentration, increased triglycerides, Lipid-Lowering Treatment to Prevent
and decreased HDL cholesterol. The most recent
guidelines from the AHA and the American College Heart Attack Trial (ALLHAT), the CVD effects of
of Cardiology (ACC) endorse the prescription of statin chlorthalidone compared with both lisinopril and
drug and intensity predicated on estimated 10-year amlodipine were similar in patients with diabetes or
risk for atherosclerotic vascular disease, indepen- impaired fasting glucose, despite modest but statis-
dent of LDL cholesterol concentrations or specified tically significant increases in incident diabetes as-
LDL cholesterol or non-HDL cholesterol therapeutic sociated with chlorthalidone use. A meta-analysis of
targets. For patients with type 2 diabetes, at least randomized trials further supported the benefits of
moderate-intensity statin therapy is endorsed for thiazide diuretics in the treatment of patients with di-
all patients with diabetes exceeding 7.5% estimated abetes. In the Anglo-Scandinavian Cardiac Outcomes
10-year risk for atherosclerotic cardiovascular com- Trial–Blood Pressure Lowering Arm (ASCOT-BPLA),44
plications. Intensive-dose versus moderate-dose sta- which randomly assigned patients to treatment to
tin therapy reduces cardiovascular risk further, but amlodipine, with perindopril added as needed, or
a large meta-analysis and analyses of data from atenolol with bendroflumethiazide added as needed,
several randomized clinical trials have identified an the amlodipine-perindopril combination yielded a sig-
increased risk of new-onset diabetes associated nificant 13% relative risk reduction in major cardiac
with intensive-dose statin therapies compared with morbidity outcomes in the 923 patients with diabe-
placebo or standard care. Other drugs like fibrates, tes, compared with atenolol-bendroflumethiazide.
omega 3 fatty acids, niacin have controversial ben- The patients with diabetes have aberrations of plate-
efits in reducing the cardiac morbidity and mortality let structure, function, and activity, yielding in aggre-
of the patients. gate a prothrombotic milieu. In addition, absolute or
Hypertension affects approximately 70% of diabetic relative aspirin resistance may occur in up to 40% of
patients (twice the rate observed in nondiabetic sub- patients with diabetes. At present. the ADA and AHA
jects), with a steep graded association between blood recommend daily aspirin (75 to 162 mg/day) for all
pressure and adverse cardiovascular outcomes. Fur- patients with diabetes who have established CVD, or
thermore, blood pressure targets for patients with di- for primary prevention in patients with diabetes older
abetes are more aggressive than for theoverall pop- than 50 years of age for men or 60 years of age for
ulation, with a goal of less than 130/80 mm Hg for women. Two randomized clinical trials currently are
patients with diabetes who can tolerate such aggres- under way to explore further the role of aspirin in
sive management without undue clinical burden, and the setting of primary CVD risk prevention in type 2
a target of below 140/80 for all others. For example, diabetes. A Study of Cardiovascular Events In Diabe-
the Heart Outcomes Prevention Evaluation (HOPE) , tes (ASCEND) &The Aspirin and Simvastatin Combi-
2
which compared ramipril (10 mg daily) with placebo in nation for Cardiovascular Events Prevention Trial in
patients at increased risk for cardiac morbidity, rami- Diabetes (ACCEPT-D).Diabetes is associated with an
pril was superior to placebo in the diabetes subset of increased prevalence of resistance to clopidogrel, a
3577 patients. Early in the course of clinical use, beta prodrug requiring metabolic conversion that tends to
blockers were judged to be relatively contraindicated be impaired in diabetes, resulting in decreased circu-
in the setting of diabetes because of concerns about lating active metabolite.
masking hypoglycemia symptoms and adverse ef- Oral hypoglycemic drugs that are used in diabetes
fects on glucose and lipid metabolism. The results as to have effect on the coronary vasculature as
of cardiovascular disease (CVD)outcomes trials have well as the cardiac musculature. Hence this discus-
allayed these concerns and support the benefit of sion becomes more imperative to discuss these drug

GCDC 2017