Do Lipid-Lowering Agents Provide a Greater Reduction in Cardiovascular Events among Patients with Diabetes?
First published as a Letter to the Editor in Annals of Internal Medicine 149(11):841, December 2, 2008.
Comment / Response
TO THE EDITOR: The U.S. Preventive Services Task Force
(USPSTF) no longer recommends routine screening for type 2 diabetes
mellitus in adults with hyperlipidemia (1). This recommendation
seems to have been based, at least in part, on an analysis of the
secondary prevention trials, which showed that lipid treatment reduced
the incidence of coronary heart disease (CHD) events by
about the same relative percentage among those with type 2 diabetes
mellitus and those without.
Because the incidence of major CHD events is higher in adults
with type 2 diabetes mellitus than in those without, one would
expect that patients with diabetes would benefit more by having
greater absolute reductions in CHD events than patients without
diabetes despite similar reductions in relative percentage. Therefore,
reductions in absolute percentage (and not relative percentage) of
CHD events with lipid treatment in these groups should have been
considered.
Anil K. Gollapudi, MD
W.G. "Bill" Hefner Veterans Affairs Medical Center
Salisbury, NC 28144
References
1. U. S. Preventive Services Task Force. Screening for type 2 diabetes mellitus in adults:
U.S. Preventive Services Task Force recommendation statement. Ann Intern Med
2008;148:846-54. [PMID: 18519930]
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IN RESPONSE: In making its recommendation on screening for type
2 diabetes, the USPSTF considered interventions, including lipid-lowering
agents, for effects on such health outcomes as cardiovascular
events. In reviewing the evidence on lipid-lowering agents, the
USPSTF found that persons with diabetes do not seem to benefit to
a greater extent than those without for the primary prevention of
cardiovascular events, whether considering absolute or relative risk
reduction. For example, in the Heart Protection Study, the absolute
reduction in coronary events for participants receiving simvastatin
versus placebo was similar in those with and without diabetes: 3.2%
and 3.0%, respectively (calculated from data in the Heart Protection
Study) (1). Therefore, the evidence does not support screening for
type 2 diabetes on the basis of lipid status.
However, the USPSTF
encourages clinicians to perform a global cardiovascular disease risk
assessment to determine a person's 10-year cardiovascular disease risk
(2) and to screen for type 2 diabetes if knowledge of diabetes status
would change management, including the management of hypertension
or the use of lipid-lowering agents and aspirin.
Ned Calonge, MD, MPH
Colorado Department of Public Health and Environment
Denver, CO 80246
Diana B. Petitti, MD, MPH
Keck School of Medicine, University of Southern California
Los Angeles, CA 90089
References
1. Collins R, Armitage J, Parish S, Sleigh P, Peto R. Heart Protection Study Collaborative
Group. MRC/BHF Heart Protection Study of cholesterol-lowering with simvastatin
in 5963 people with diabetes: a randomised placebo-controlled trial. Lancet
2003;361:2005-16. [PMID: 12814710]
2. Health Link, Medical College of Wisconsin. Calculate Your Risk of Coronary Heart
Disease. Accessed at http://hp2010.nhlbihin.net/atpiii/calculator.asp.
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Current as of November 2008
Internet Citation:
Do Lipid-Lowering Agents Provide a Greater Reduction in Cardiovascular Events among Patients with Diabetes? Published Comment and Response: Letter to the Editor and Response. First published in Annals of Internal Medicine 149(11):841. Agency for Healthcare Research and Quality, Rockville,
MD. http://www.ahrq.gov/clinic/tfcomments/tfdiabcom.htm