Long-term risk reduction: who needs treatment?

Patients with type 2 diabetes or the metabolic syndrome have an elevated risk of developing cardiovascular disease (CVD). Until recently, strategies to reduce cardiovascular risk in these patients focused mainly on controlling glycemia and blood pressure as a means of preventing disease progression. However, the metabolic abnormalities that cluster both in patients with type 2 diabetes and the metabolic syndrome are all independent risk factors for atherogenesis. There is now substantial evidence that dyslipidemia is an important, modifiable risk factor for CVD in patients with type 2 diabetes or the metabolic syndrome. Recent sub-group analyses of landmark statin trials, such as the Heart Protection Study (HPS), confirm that the benefits of intensive statin therapy on CVD risk extend to patients with type 2 diabetes, irrespective of baseline lipid levels. In addition, the Collaborative AtoRvastatin Diabetes Study (CARDS), the first statin study to focus solely on patients with type 2 diabetes, was stopped early due to the overwhelming benefits of statin therapy on cardiovascular risk in a study population who previously would not have been considered dyslipidemic (mean baseline low-density lipoprotein cholesterol [LDL-C], 3.0 mmol/l [116 mg/dl]). As a result, treatment guidelines are setting increasingly stringent goals for LDL-C levels in an attempt to reduce cardiovascular risk. However, with physicians estimating that approximately 50% of patients with type 2 diabetes do not achieve these goals, initiation of appropriate, effective and rapid-acting statin therapy is paramount in these high-risk patients.