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Research:
Lauren C. Brown, Jeffrey A. Johnson, Sumit R. Majumdar, Ross T. Tsuyuki, and Finlay A. McAlister
Evidence of suboptimal management of cardiovascular risk in patients with type 2 diabetes mellitus and symptomatic atherosclerosis
CMAJ 2004; 171: 1189-1192 [Abstract] [Full text] [PDF]
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[Read eLetter] CMAJ Article reference 2004:171(10): 1189-92.
Miriam M Shanks   (14 February 2005)
[Read eLetter] Shouldn't this paper be withdrawn?
Lawrence Sanford   (26 November 2004)
[Read eLetter] Evidence made after 2000 can not be applied to data collected before 2000
Malvinder S. Parmar   (12 November 2004)

CMAJ Article reference 2004:171(10): 1189-92. 14 February 2005
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Miriam M Shanks
University of Alberta Hospital

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Re: CMAJ Article reference 2004:171(10): 1189-92.

Mshanks{at}ualberta.ca Miriam M Shanks

Dear editor of CMAJ,

We read with interest the article “Evidence of suboptimal management of Cardiovascular risk in patients with type 2 Diabetes mellitus and symptomatic atherosclerosis” (1).

We have examined the use of agents proven to reduce cardiovascular risk, namely aspirin, statins, angiotensin-converting enzyme (ACE) inhibitors (or equivalent) and beta blockers in a cohort of 407 high risk patients (i.e. those with a history of coronary artery, peripheral vascular or cerebrovascular disease or diabetes) - a significant proportion of whom was referred because of complications of lipid-lowering therapy. Data on patients’ lipid profile and the use of the four medications are being collected at three visits: the initial, the most recent (between November 2003 and July 2004) and the next scheduled this year.

We also examined the differences in medication patterns in a group of 177 diabetic patients: 53 patients with diabetes and proven coronary artery disease (CAD) and in 124 patients with diabetes but without clinical evidence of CAD. While there were no significant differences at “current” visit in the use of aspirin (69% vs. 64%) and statins ( 77% vs. 79 %), both beta blockers ( used only for blood pressure control in patients with diabetes without CAD) and ACE inhibitors were used more frequently in the patients with CAD ( 42% vs. 10%, p < .0005 and 81% vs. 64%, p < .010, respectively).

Overall, the use of medications in the entire cohort of 407 high risk patients (CAD ± DM) increased from the first to the most recent visit (for aspirin, statins, and ACE inhibitors: 47% vs. 75%, 39% vs. 82%, 35% vs. 71%, respectively; all p<.0005).

(1) Brown LC, Johnson JA, Majumdar SR, Tsuyuki RT, McAlister FA. Evidence of suboptimal management of cardiovascular risk in patients with type 2 diabetes mellitus and symptomatic atherosclerosis. CMAJ. 2004;171 (10): 1189-92

1 Miriam Shanks, MD; 2 Dan Holmes, MD; 2 Luba Cermakova; 2 Jiri Frohlich, MD, FRCPC

2 Lipid / Cardiovascular risk reduction clinic,

St.Paul’s Hospital, Vancouver, BC.

1 University of Alberta Hospital

Conflict of Interest:

None declared
Shouldn't this paper be withdrawn? 26 November 2004
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Lawrence Sanford
retired

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Re: Shouldn't this paper be withdrawn?

heart{at}hotmail.com Lawrence Sanford

Unless there is major typographical error in the mthods section of this paper, shouldn't this paper be retracted? As pointed out the preious eLetter, there is major flaw in this paper and I wonder how this paper passed the peer and editorial review. It would be interesting to know the history of this paper - who were the reviewer's of this paper for CMAJ and if this paper was sent to other journals before it made to CMAJ.

Larry Sanford

Conflict of Interest:

None declared
Evidence made after 2000 can not be applied to data collected before 2000 12 November 2004
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Malvinder S. Parmar
Timmins & District Hospital, Timmins, Ontario, Canada

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Re: Evidence made after 2000 can not be applied to data collected before 2000

atbeat{at}ntl.sympatico.ca Malvinder S. Parmar

There is no doubt that today aggressive control of common risk factors is of paramount importance in the management of diabetic patients with atherosclerotic disease to prevent cardiovascular morbidity and mortality. However, the authors in this study[1] applied the evidence gathered after year 2000 to the data collected before 2000 and it was no surprise that the management was found to be sub-optimal based on current recommendations.

In the methods section, the author’s identified this cohort between 1991 and 1996 and followed the cohort until 2000. The evidence regarding the use therapies ‘proven to reduce cardiovascular risk and mortality,’ became available with after 2000, as eluded by the authors, and was not available with that confidence before 2000. The recommendation about anti- platelet agent use to prevent CV events that authors quote was published in 2002[2]. Concerning ACE-inhibitor use in diabetics, the Heart Outcomes Prevention Evaluation [HOPE][3] was in fact published in 2000; since when ace-inhibitors are recommended for CV protection in high-risk patients, including diabetics. Although there was some evidence concerning statin therapy from sub-group analysis of 4S[4] that these agents are effective in diabetics in preventing CV morbidity and mortality but the evidence with confidence became available after the results of Heart Protection Study [HPS] were published in 2003[5]. Then, how can the authors evaluate and conclude that the management of the said cohort was sub-optimal when there were no strong recommendation(s) to use these agents broadly in diabetics.

It would have been best if ‘the 1998 guidelines[6] for the management of diabetes’ were utilized to evaluate the care provided to this cohort. I agree that likely the authors would have found similar findings as it takes few years to implement guidelines in general public and by that time either the guidelines are changed or are in the process of changing and is one of the factors for poor implementation of guidelines. None of the above therapies were strongly recommended for CV protection in 1998 guidelines, as there was no strong evidence to support such recommendations. In fact, UKPDS[7] was published at the same time that highlighted the importance of controlling both blood glucose and blood pressure effectively to improve micro- and macro-vascular complications and did not favor one agent over the other [beta-blocker versus ace- inhibitor].

Since then evidence has accumulated and the recent 2003 guidelines[8] incorporates these therapies and make appropriate recommendation about these therapies. In this study, authors highlights the importance of peripheral arterial disease as an important group of patients that are at increased risk for CV mortality but interestingly the recently published current Canadian guidelines do not even mention even a word about peripheral arterial disease in the 140 pages[8]. How amazing! If guidelines developers are not going to incorporate such information then how one expects for the common practicing physician to apply the accumulating and rapidly changing evidence into their day to day practice.

References:

1. Brown LC, Johnson JA, Mazumdar SR, Tsuyuki RT, McAlister FA: Evidence of suboptimal management of cardiovascular risk in patients with type 2 diabetes mellitus and symptomatic atherosclerosis. CMAJ 2004; 171:1189-92.

2. Antithrombotic Trialists' Collaboration. Collaborative meta- analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients [published erratum in BMJ 2002; 324: 141]. BMJ 2002; 324:71-86.

3. Heart Outcomes Prevention Evaluation (HOPE) Study Investigators. Effects of ramipril on cardiovascular and microvascular outcomes in people with diabetes mellitus: results of the HOPE study and MICRO-HOPE substudy [published erratum in Lancet 2000; 356:860]. Lancet 2000; 355:253-9.

4. Pyorala K, Pederson TR, Kjekshus J, et al. Cholesterol lowering with simvastatin improves prognosis of diabetic patients with coronary heart disease. A subgroup analysis of the Scandinavian Simvaststin Survival Study (4S). Diabetes Care. 1997; 20: 614-20.

5. Heart Protection Study Collaborative Group. MRC/BHF Heart Protection Study of cholesterol lowering with simvastatin in 5963 people with diabetes: a randomized placebo-controlled trial. Lancet 2003; 361:2005-16.

6. Meltzer S, Leiter L, Daneman D, et al: 1998 clinical practice guidelines for the management of diabetes in Canada. CMAJ 1998; 159)8 Suppl):S1-29.

7. UK prospective Diabetes Study Group. Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes. UKPDS 38. BMJ 1998; 317:703-13.

8. Canadian Diabetes Association 2003 Clinical Practice Guidelines for the Prevention and management of Diabetes in Canada. Canadian Journal of Diabetes. 2003; 27(Suppl 2):S1-140.

Conflict of Interest:

None declared