Heart disease in diabetic patients is undertreated
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《英国医生杂志》
Patients with type 2 diabetes and symptoms of atherosclerotic disease were systematically undertreated with drugs known to be effective in reducing the risk of cardiovascular disease and mortality, "perhaps because of a 慻lucocentric?view of diabetes," according to a study published in the journal of the Canadian Medical Association (CMAJ 2004;171:1189-92).
Most deaths among diabetic patients are caused by cardiovascular disease, yet the study, of data on 12 106 patients in Canada with type 2 diabetes (mean age 64 years, 55% men, mean follow up period of five years), showed that less than 25% received an antiplatelet drug or a statin and less than 50% received an angiotensin converting enzyme (ACE) inhibitor.
Although the diabetic patients with coronary artery disease were more likely to receive antiplatelet drugs, statins, or ACE inhibitors than the patients without the disease (p<0.001 for all drugs), overall use of these drugs was suboptimal (37%, 29%, and 60% respectively for each group of drugs among patients with symptomatic coronary artery disease). Similar patterns of practice were found among patients with symptomatic cerebrovascular disease and peripheral arterial disease.
"All three proven efficacious therapies were prescribed for only 11% of patients with coronary artery disease, 22% with cerebrovascular disease and 12% with peripheral artery disease. Patients with peripheral artery disease who had undergone lower limb amputation were no more likely to subsequently receive anti-platelet agents or statins than those without an amputation," said the study.
The researchers identified considerable undertreatment among patients with type 2 diabetes despite the fact that recent epidemiological studies have indicated that peripheral artery disease may be present in one quarter to one half of all adults with type 2 diabetes and that the survival rate for the disease (85% at five years) is worse than that for patients with breast cancer (72% at five years).
The study data came from administrative records from the Saskatchewan health department between 1991 and 1996. But Jeffrey Johnson, a professor of public health sciences at the University of Saskatchewan and one of the authors, says similar gaps in treatment have been seen in Ontario and Alberta.
"Our figures probably underestimate the prevalence of symptomatic conditions, as patients with mild conditions, who are unlikely to seek treatment or be admitted to hospital, would not be captured in the databases. This would result in an underestimation of care gaps," says the study.
Also, aboriginal people are excluded from the database, because they are covered under federal health insurance, and some evidence shows that management of cardiovascular risk among aboriginal people with diabetes may be worse than among other people.
The study shows "an alarming care gap that needs to be addressed" and implies a "glucocentric view" in overall management of diabetes, in which "an overemphasis on glycaemic control ?deflects attention away from cardiovascular risk management."
The authors join the members of the Prevention of Atherothrombotic Disease Network in advocating screening for cardiovascular symptoms among patients with type 2 diabetes and that they be prescribed antiplatelet drugs, statins, and ACE inhibitors unless they have specific contraindications.(Quebec David Spurgeon)
Most deaths among diabetic patients are caused by cardiovascular disease, yet the study, of data on 12 106 patients in Canada with type 2 diabetes (mean age 64 years, 55% men, mean follow up period of five years), showed that less than 25% received an antiplatelet drug or a statin and less than 50% received an angiotensin converting enzyme (ACE) inhibitor.
Although the diabetic patients with coronary artery disease were more likely to receive antiplatelet drugs, statins, or ACE inhibitors than the patients without the disease (p<0.001 for all drugs), overall use of these drugs was suboptimal (37%, 29%, and 60% respectively for each group of drugs among patients with symptomatic coronary artery disease). Similar patterns of practice were found among patients with symptomatic cerebrovascular disease and peripheral arterial disease.
"All three proven efficacious therapies were prescribed for only 11% of patients with coronary artery disease, 22% with cerebrovascular disease and 12% with peripheral artery disease. Patients with peripheral artery disease who had undergone lower limb amputation were no more likely to subsequently receive anti-platelet agents or statins than those without an amputation," said the study.
The researchers identified considerable undertreatment among patients with type 2 diabetes despite the fact that recent epidemiological studies have indicated that peripheral artery disease may be present in one quarter to one half of all adults with type 2 diabetes and that the survival rate for the disease (85% at five years) is worse than that for patients with breast cancer (72% at five years).
The study data came from administrative records from the Saskatchewan health department between 1991 and 1996. But Jeffrey Johnson, a professor of public health sciences at the University of Saskatchewan and one of the authors, says similar gaps in treatment have been seen in Ontario and Alberta.
"Our figures probably underestimate the prevalence of symptomatic conditions, as patients with mild conditions, who are unlikely to seek treatment or be admitted to hospital, would not be captured in the databases. This would result in an underestimation of care gaps," says the study.
Also, aboriginal people are excluded from the database, because they are covered under federal health insurance, and some evidence shows that management of cardiovascular risk among aboriginal people with diabetes may be worse than among other people.
The study shows "an alarming care gap that needs to be addressed" and implies a "glucocentric view" in overall management of diabetes, in which "an overemphasis on glycaemic control ?deflects attention away from cardiovascular risk management."
The authors join the members of the Prevention of Atherothrombotic Disease Network in advocating screening for cardiovascular symptoms among patients with type 2 diabetes and that they be prescribed antiplatelet drugs, statins, and ACE inhibitors unless they have specific contraindications.(Quebec David Spurgeon)