Risk Factor Control Can Mitigate Danger from Type 2 Diabetes

People with diabetes and optimal values for five health variables had risks similar to those in people without diabetes.

Diabetes has been considered as dangerous as cardiovascular disease in its association with death and cardiovascular events, but to what extent can modifying patients' risk factors mitigate this association? Investigators made use of a Swedish national registry enrolling people with type 2 diabetes to determine whether the excess risk for death and cardiovascular events (stroke, acute myocardial infarction, and hospitalization for heart failure) could be reduced or eliminated with control of five risk factors — glycated hemoglobin, LDL cholesterol, albuminuria, smoking, and blood pressure.

During a median follow-up of 5.7 years, the investigators compared 271,174 people with diabetes to 1,355,870 controls without diabetes and matched by age, sex, and county. The excess diabetes-associated risk decreased with each variable that fell within the target range. People with diabetes and optimal values for all five risk factors had a similar risk for death as controls — and a significantly lower risk for acute myocardial infarction. However, their risk for hospitalization for heart failure remained consistently higher. The effect of having risk factors within target ranges seemed most prominent in younger individuals. Smoking was the strongest predictor of death.

Comment:This study heralds great news: The risk associated with type 2 diabetes can be eliminated with risk factor control. A remaining question is which treatment strategies, if any, can produce what was found in this observational study, particularly with regard to glucose, LDL cholesterol, and blood pressure control. Although we cannot answer that question today, the findings are promising that type 2 diabetes need not be considered a risk that cannot be eliminated.

— Harlan M. Krumholz, MD, SM reviewing Rawshani A et al. N Engl J Med 2018 Aug 16