See article vol. 23: 922–931
The risk of coronary events is greater in diabetic patients than in non-diabetic patients1), which is partly explained by an increased coronary plaque volume in diabetic patients2). Although statin therapy decreases the coronary plaque volume, diabetes mellitus attenuates the degree of regression of coronary atherosclerosis3). Therefore, decreasing the plaque volume in diabetic patients is a difficult but important therapeutic target.
In this issue, Naito and colleagues investigated the impact of total risk management [low-density lipoprotein cholesterol (LDL-C) < 80 mg/dL, systolic blood pressure (BP) < 130 mmHg, and glycosylated Hb (HbA1c) < 6.5%] on coronary plaque regression in diabetic patients with acute coronary syndrome (ACS)4), which is a sub-analysis of the JAPAN-ACS Study5). From a total study population of 252, they selected 73 diabetic patients and divided them into four groups: group A (N = 8, none of the risk factors achieved the target level), group B (N = 32, one factor achieved the target level), group C (N = 22, two factors achieved the target level), and group D (N = 11, all the factors achieved the target level)4). The percent changes in plaque volume were −1.3 ± 12.1%, −10.5 ± 13.7%, −14.8 ± 13.7%, and −23.0 ± 13.6% in groups A, B, C, and D, respectively (P for trend = 0.00024), suggesting that the number of risk factors that achieved the target level was associated with the extent of coronary plaque volume reduction in a dose-dependent manner4). On the other hand, the incidence of major adverse cardiac events (MACE) was not different between the four groups, probably due to the short follow-up period (10 months).
Although there are several study limitations, which are inherent to subgroup analysis, Naito and colleagues showed the benefit of total risk management for diabetic patients. While each therapeutic target (LDL-C < 80 mg/dL, systolic BP < 130 mmHg, and HbA1c < 6.5%) seems reasonable, we should select appropriate medications. For lipid lowering, statins should be the first-line medication for diabetic patients6). Ezetimibe may be effective for reducing cardiovascular events when added to statin therapy7). For BP lowering, angiotensin-converting enzyme inhibitors (ACE-i) should be the first-line medication for diabetic patients8). For glucose lowering, standard care, including lifestyle modification and metformin, should be applied to reduce the incidence of cardiovascular events9). Furthermore, empagliflozin, an inhibitor of sodium – glucose cotransporter 2, reduced cardiovascular events when added to standard care10). Thus, total risk management (Fig. 1) may be an answer for better prognosis in diabetic patients, but it still needs validation by future prospective studies.
Fig. 1.
Scheme of total risk management for diabetic patients
Abbreviations: ACEi = angiotensin-converting enzyme inhibitors, ARB = angiotensin receptor blockers, BP = blood pressure
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