Diabetes Study Sparks Treatment Debate

April 8, 2008 -- Diabetes patients who used medicine to lower their cholesterol and blood pressure to below target levels displayed improvements in several important markers of heart and vascular disease, a study shows. But the patients were just as likely as less aggressively treated patients to have heart attacks and strokes.

The study appears in the April 9 edition of The Journal of the American Medical Association.

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Heart disease is the leading cause of death in adults with diabetes. There has been much debate about how much to reduce systolic blood pressure (SBP) and LDL "bad" cholesterol readings in these high-risk patients.

In one of the first controlled trials to address the issue, researchers randomly assigned 499 middle-aged American Indians with type 2 diabetes to treatment aimed at reaching either standard blood pressure and lipid targets (LDL of no more than 100mg/DL and SBP of no more than 130 mm Hg) or more aggressive lowering of these levels (LDL of no more than 70 mg/dL and SBP of no more than115 mm Hg).

The patients were all obese (BMI range of 32-34, normal <25); two-thirds were women.

Aggressive Treatment vs. Standard Treatment

Over the course of the trial, the more aggressively treated patients experienced regression of plaque buildup in neck arteries (not seen in the standard treatment group), and greater improvement in heart muscle thickening, researcher Barbara V. Howard, PhD, tells WebMD.

Both treatment groups also had far fewer heart attacks and strokes than would have been expected without treatment.

But no advantage was seen for aggressive lowering of LDL and SBP in terms of heart attack and stroke incidence.  And patients treated to lower SBP targets experienced more side effects related to their blood pressure medications.

Howard tells WebMD that the study's relatively small sample size and short duration of follow-up may explain the failure to demonstrate a difference in outcomes among the two groups.

"My educated guess is that we will see a difference when we continue to follow these patients," she says. "Our study suggests that these lower targets could bring benefits, but we need more research to really understand the risks vs. benefits of this strategy."

How Low Should You Go?

These findings appear certain to add to the debate within preventive cardiology about how low to go in reducing cardiovascular risk factors like high blood pressure, LDL cholesterol, and high blood sugar in diabetic and other high-risk populations.

The debate hit the front pages of the nation's newspapers early in February when findings from the 10,000-person ACCORD study suggested that rather than reducing heart attack and stroke deaths, intensive blood sugar lowering may increase such risks among people with type 2 diabetes.

"We have basically taken as gospel that if we change risk factors [like LDL, blood pressure, and blood sugar] good things will happen," Duke University Medical Center cardiologist Eric D. Peterson, MD, tells WebMD. "Studies like ACCORD and this one suggest that modifying risk factors alone may not ensure better outcomes."