Cardiovascular risk in patients with type 2 diabetes

Lauren Brown and associates1 observed low use of therapies with proven benefit for the prevention of cardiovascular events in patients with type 2 diabetes, both with and without atherosclerotic disease. We are conducting a similar study analyzing use of acetylsalicylic acid (ASA), statins, β-blockers and angiotensin-converting enzyme (ACE) inhibitors (or equivalent) in a cohort of 407 high-risk patients attending the Lipid/Cardiovascular Risk Reduction Clinic at St. Paul's Hospital in Vancouver. These patients have a history of vascular disease (coronary, peripheral or cerebral) with or without diabetes.

Data on the patients' lipid profile and use of the 4 medications at the time of the initial visit to the clinic (between 1984 and 2004) and their most recent visit (between November 2003 and July 2004) have been collected (Table 1). The use of these medications will also be prospectively evaluated at the next scheduled visit.

We are also trying to examine differences in medication use in a subgroup of 178 patients with diabetes from the same cohort: 54 with established coronary artery disease (CAD) and 124 without clinical evidence of CAD. Preliminary data were obtained from the most recent follow-up visits (with an average of 60 months between the first and the most recent visit). We found no significant differences in the use of ASA and statins between the 2 groups; however, the rate of treatment with β-blockers and ACE inhibitors was significantly higher among patients with CAD than among those without CAD. Although the difference in β-blocker use was not unexpected, we were surprised by the low use of ACE inhibitors or equivalent for patients who had diabetes but no clinical evidence of CAD.

These preliminary results indicate that there is room for improvement in implementing treatment guidelines in clinical practice. The overall use of cardioprotective medications was suboptimal at the initial visit, although use had increased significantly by the time of the most recent visit (Table 1). However, the use of ACE inhibitors remained suboptimal among diabetic patients without CAD, a result similar to the data presented by Brown and associates.1 We agree that multidisciplinary cardiovascular risk reduction programs are needed to improve quality of care in high-risk patients.