Diabetes has long been considered as one of the most important cardiovascular risk factors. At least 70% of diabetic patients die of cardiovascular complications, so how to effectively prevent and treat cardiovascular complications of diabetes is a topic of concern to endocrinologists and cardiovascular doctors. Recently, holman and others published an article in The Lancet magazine entitled "Cardiovascular Outcome Test of Hypoglycemic Drugs or Strategies for Type 2 Diabetes". The Lancet 2014; 383 (9933): The existing randomized clinical trials based on diabetic patients from October to July, 2008 were systematically reviewed, and some ongoing studies were introduced. Reading this article carefully is very helpful to correctly understand the current situation of prevention and treatment of cardiovascular complications of diabetes.

Clinical research evidence of hypoglycemic and cardiovascular benefits

In the article of holman et al., the clinical trials including UGDP, UKPDS, Digami, Accord, ADVANCE, VADT, Heart 2D, Barry 2D, PROactive, RECORD, TIDE, ORIGIN, EXAMINE, SAVOR-TIMI53, add and Look-ahead * *16 were systematically reviewed. To sum up, no hypoglycemic agent has been proved to be effective in improving the cardiovascular prognosis of patients with type 2 diabetes.

Although the extended follow-up of UKPDS study in 10 years showed that the risk of myocardial infarction in the intensive blood glucose control group decreased statistically, the evidence was obviously insufficient, because this result may be affected by many factors. At present, many clinical studies are still in progress, such as TECOS, CANVAS, EXSCEL, LEADER, CAROLINA, etc. The main drugs used are DPP-4 inhibitor, GLP- 1 and SGLT-2 inhibitor. The publication of these research results will help to further clarify the influence of hypoglycemic therapy on cardiovascular endpoint outcome of diabetic patients.

Enlightenment from existing research

Based on the existing research, we should pay attention to the following aspects when we understand the hypoglycemic and cardiovascular benefits: 1. The relationship between diabetes and cardiovascular diseases is not clear, and whether there is an inevitable causal relationship between them remains to be demonstrated.

2. Although some basic studies or alternative end-point studies have found that many hypoglycemic agents have potential beneficial effects on cardiovascular system, such as protecting vascular endothelial function, resisting oxidative stress, inhibiting inflammatory reaction, having beneficial effects on blood lipid parameters or blood pressure, and losing weight. There is still no conclusive evidence to support that these mechanisms can be transformed into clinical benefits, so they should not be used as evidence of cardiovascular protection;

3. Avoid two extreme understandings. Some scholars fundamentally deny the necessity of hypoglycemic therapy, and this concept should be abandoned. Reasonable hypoglycemic can significantly reduce the death and disability caused by acute hyperglycemia and microvascular complications, so hypoglycemic is not only important but also necessary, and the advantages of hypoglycemic cannot be denied because of the lack of evidence of the benefits of large blood vessels. At the same time, the other extreme should be avoided, that is, exaggerating the cardiovascular protective effect of hypoglycemic therapy and improving the prognosis of great vessels;

4. At present, the blood glucose control target (HbA 1C) suggested by domestic and foreign guidelines is based on microvascular events, and the dose-effect relationship between blood glucose level and macrovascular complications is not clear. However, at present, HbA 1C 7% is used as the hypoglycemic target, which can give consideration to both microvascular benefit and macrovascular safety.

Comprehensive intervention of cardiovascular risk factors is an effective measure.

Based on the existing hypoglycemic drugs and the current treatment mode, it may be difficult to effectively improve the macrovascular prognosis of patients with type 2 diabetes by relying solely on hypoglycemic drugs, so it is necessary to further strengthen the screening and control of other cardiovascular risk factors.

1. antihypertensive therapy: for patients with diabetes complicated with hypertension, the protective effect of lowering blood pressure on cardiovascular system is affirmative. Although previous domestic and foreign guidelines suggested

However, the recently updated Japanese hypertension guidelines believe that due to the high incidence of stroke in Japanese population, strict control of blood pressure is helpful to better prevent stroke, so it is still followed.

2. Blood lipid management: The 20 13 ACC/AHA guidelines for cholesterol-lowering therapy put forward new suggestions for cholesterol-lowering therapy for diabetic patients, suggesting that all 40-75-year-old diabetic patients with LDL-C 1.8-4.9 mmol/L should receive moderate to high-intensity statins, and no cholesterol-lowering target value has been set.

This proposal has caused great controversy at home and abroad. China National Cholesterol Education Program (CCEP) Expert Committee recently organized experts to formulate "China Cholesterol Education Program 20 14 Expert Suggestions on Prevention and Treatment of Dyslipidemia" based on the existing research evidence at home and abroad and combined with China's specific situation.

This proposal puts forward the following suggestions for cholesterol-lowering treatment of patients with type 2 diabetes: 1. In patients with atherosclerotic cardiovascular disease (ASCVD, including coronary heart disease, ischemic stroke and peripheral arterial disease), statins are used to reduce LDL-C to.

3. Application of antiplatelet drugs: For patients with diabetes complicated with coronary heart disease, ischemic stroke and other vascular diseases, if there are no contraindications, aspirin should be taken for secondary prevention. Whether aspirin should be used for primary prevention of diabetic patients without cardiovascular complications is still controversial. European guidelines largely deny the role of aspirin in primary prevention of cardiovascular diseases, while American guidelines tend to be positive.

The current diabetes guidelines in China point out that most of them are men over 50 years old. 60-year-old female 1 risk factors (i.e. family history of cardiovascular disease, hypertension, smoking, dyslipidemia or proteinuria) cardiovascular risk 10 years >: 10%, low dose (75 ~ 150 mg/d) aspirin should be taken as primary prevention; Middle-aged and young patients with moderate cardiovascular risk [1 or above risk factors (male 60 years old), or patients with cardiovascular risk of 5% ~ 10]: low-dose aspirin (75 ~ 150mg/d) can be considered as the primary prevention of this type of diabetes.

In addition, for diabetic patients, active and effective lifestyle intervention is of great value for reducing cardiovascular risk and improving long-term cardiovascular prognosis, and should be an essential part of their treatment strategies.

Li Rui Physical Examination of Beijing Medical University:/