Phoenix Veterans Affairs Health Care System, Phoenix, Arizona, USA.
Diabetes. 2009 Nov;58(11):2642-8. doi: 10.2337/db09-0618. Epub 2009 Aug 3.
This study investigated the hypothesis that baseline calcified coronary atherosclerosis may determine cardiovascular disease events in response to intensive glycemic control within the Veterans Affairs Diabetes Trial (VADT).
At baseline, 301 type 2 diabetic participants in the VADT, a randomized trial comparing the effects of intensive versus standard glucose lowering on cardiovascular events, had baseline coronary atherosclerosis assessed by coronary artery calcium (CAC) measured by computed tomography. Participants were followed over the 7.5-year study for development of cardiovascular end points.
During a median follow-up duration of 5.2 years, 89 cardiovascular events occurred. Although intensive glucose-lowering therapy did not significantly reduce cardiovascular events in the substudy cohort as a whole, there was evidence that the response was modified by baseline CAC, as indicated by significant P values for treatment by log(CAC + 1) interaction terms in unadjusted and multivariable-adjusted models (0.01 and 0.03, respectively). Multivariable-adjusted hazard ratios (HRs) for the effect of treatment indicated a progressive diminution of benefit with increasing CAC. Subgroup analyses were also conducted for clinically relevant CAC categories: those above and below an Agatston score of 100. Among those randomized to intensive treatment, for the subgroup with CAC >100, 11 of 62 individuals had events, while only 1 of 52 individuals with CAC < or = 100 had an event. The multivariable HR for intensive treatment for those with CAC >100 was 0.74 (95% CI 0.46-1.20; P = 0.21), while for the subgroup with CAC < or = 100, the corresponding HR was 0.08 (0.008-0.77; P = 0.03), with event rates of 39 and 4 per 1,000 person-years, respectively.
These data indicate that intensive glucose lowering reduces cardiovascular events in those with less extensive calcified coronary atherosclerosis.
本研究旨在验证基线钙化性冠状动脉粥样硬化是否可预测退伍军人事务糖尿病试验（VADT）中强化血糖控制对心血管疾病事件的影响。
在 VADT 中，301 例 2 型糖尿病患者随机接受强化与标准降糖治疗，以比较两种治疗方案对心血管事件的影响。基线时通过 CT 测量冠状动脉钙（CAC）评估冠状动脉粥样硬化程度。在 7.5 年的研究期间，观察心血管终点事件的发生情况。
中位随访时间为 5.2 年，共发生 89 例心血管事件。尽管强化降糖治疗并未显著降低整个亚组患者的心血管事件发生率，但根据未经校正和多变量校正模型中治疗与 log（CAC+1）交互项的 P 值（分别为 0.01 和 0.03），基线 CAC 可改变治疗反应，这表明存在证据支持该假说。多变量校正后的危险比（HR）表明，随着 CAC 的增加，治疗效果逐渐减弱。还对 CAC 有临床意义的亚组进行了亚组分析：CAC 高于和低于 100 分者。在接受强化治疗的亚组中，CAC>100 者 62 人中发生了 11 例事件，而 CAC≤100 者 52 人中仅发生了 1 例事件。CAC>100 者接受强化治疗的多变量 HR 为 0.74（95%CI，0.46-1.20；P=0.21），而 CAC≤100 者的相应 HR 为 0.08（0.008-0.77；P=0.03），事件发生率分别为每 1000 人年 39 例和 4 例。
这些数据表明，在钙化性冠状动脉粥样硬化程度较轻的患者中，强化血糖控制可降低心血管事件的发生风险。
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