follow-up of glycemic control and.pptx

8/19/2019 Follow-up of Glycemic Control and.pptx

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o ow-up o ycem c ontro an

Cardiovascular Outcomes in Type 2

Diabetes Journal Reading

Dr Doni !aputr


2/17

"ntroduction

#atients wit$ type 2 diabetes $ave a greatlyincreased ris% of cardiovascular events

&ost observational studies $ave s$own an

association between glucose control andcardiovascular disease

T$ere were Four large' randomi(ed' controlled trialsof improved glucose control in patients wit$ type 2diabetes

)*D#!

+CCORD

+D,+C.

,+DT


3/17

"ntroduction

)nited *ingdom #rospective Diabetes !tudy /)*#D!0

T$e most evidence for a reduction in t$e rate ofcardiovascular events wit$ intensive glucose control camefrom t$e )*#D!

Outcomes in t$e )*#D! could be related to interventions ina younger' $ealt$ier group of patients wit$ newly diagnosedtype 2 diabetes or could be related to t$e fact t$at t$e)*#D! used a less intensive glucose treatment protocolt$an t$at used in t$e ot$er trials

+ction to Control Cardiovascular Ris% in Diabetes/+CCORD0

T$e +CCORD trial also recently s$owed a signi1cantreduction in t$e rate of nonfatal cardiovascular events in a

follow-up of its study population' but t$at bene1t was osetby an increase in mortality in t$e original trial


4/17

"ntroduction

+ction in Diabetes and ,ascular Disease3 #retera4 andDiamicron &odi1ed Release Controlled .valuation/+D,+C.0

"n contrast' no reduction in t$e rate of cardiovascular eventsor in mortality was found in a follow- up of t$e +D,+C. trial

,eteran +airs Diabetes Trial /,+DT0

+ report cardiovascular outcomes after an e4tended follow-upperiod of t$e ,+DT a multisite' randomi(ed' controlled trial of

intensive versus standard glucose control in )! militaryveterans wit$ type 2 diabetes' in w$ic$ patients werefollowed for up to 56 years /median' 67 years0

t$e primary outcome of ma8or cardiovascular events wasnonsig- ni1cantly lower in t$e intensive-t$erapy group t$an in

t$e standard-t$erapy group


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&et$ods

!tudy

Design

T$e original study included 95:9 militaryveterans wit$ type 2 diabetes w$o wererandomly assigned to receive eit$er

intensive or standard glucose control

T$e participants w$o were alive andenrolled at t$e conclusion of t$e studyare being followed t$roug$ a national

data registry

T$e coordinating sites in ;ines' "llinois'and +nn +rbor' &ic$igan' collected allt$e data for t$is follow up study


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&et$ods

Data!ourc

es

T$e central ,+ medicalinformation 1les

T$e Centers for &edicare and&edicaid !ervices /C&!0&edicare claims 1les

T$e ,+ deat$ 1les

T$e ational Deat$ "nde4 /D"0


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&et$ods

#rimary

Outcomes

• T$e time to t$e 1rst ma8or cardiovascularevent• T$ere are c$anges in t$e primary outcome

ma%e direct comparisons wit$ t$e original,+DT results di


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&et$ods

Sensitivity Analysis

To assess for potential sample-selection

bias' t$ey soug$t and were granted a;ealt$ "nsurance #ortability and+ccountability +ct waiver to e4amine t$eirprimary and secondary outcomes in t$ecomplete co$ort


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&et$ods

Statistical Analysis

T$e main analysis was performed according to t$eintention-to-treat principle' and *aplan=&eier

survival curves were generated by means of t$eproduct-limit met$od

Dierences in attributes between t$e twotreatment groups were assessed wit$ t$e use oft$e c$i-s>uare test for proportions and !tudent?s t-

test or analysis of variance for continuousvariables

T$ey prespeci1ed t$ree variables to e4amine$eterogeneity of treatment eects' following t$eapproac$ proposed by *ent and colleagues


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Results


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&et$ods


12/17

&et$ods


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Discussion

T$e leading cause of complications anddeat$ in patients wit$ type 2 diabetes is

cardiovascular disease @$en our results are combined wit$

t$ose of t$e t$ree ot$er ma8or clinicaltrials of glycemic control in type 2

diabetes' a clearer picture of t$e eect ofimproved glycemic control seems to beemerging


14/17


15/17

T$e results s$ould not be interpreted assupporting a performance measure for

evaluating t$e >uality of care provided byclinicians and $ealt$ systems t$at usest$e proportion of patients w$o reac$ aglycated $emoglobin level of less t$an5AB

.ven wit$ t$e support of a dedicatedresearc$ team' only appro4imately $alft$e participants $ad a glycated

$emoglobin level of less t$an 5AB


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Discussion


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Conclusion

T$e study found t$at among patients w$o $ad beenrandomly assigned to intensive glucose control orstandard t$erapy for a median of 67 years' t$e

intensive-t$erapy group $ad a signi1cant 95B relativereduction in ma8or cardiovascular events' as comparedwit$ t$e standard-t$erapy group' after almost 9A yearsof total follow-up t$is relative reduction represented 7ma8or cardiovascular events prevented per 9AAAperson-years

+s compared wit$ standard t$erapy' intensive glucosecontrol was not associated wit$ a signi1cant decrease inall-cause mortality after almost 92 years of follow-up

follow-up of glycemic control and.pptx

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