nhlbi/nei national institutes of health
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1
NHLBI/NEI
National Institutes of Health
NHLBI/NEI
National Institutes of Health
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Diabetes & CVD
• Patients with type 2 diabetes
• 2 to 4 X increased risk of CVD
• Question: What is value of intensive control of CVD risk factors in reducing CVD rates?
• Glycemia• Lipids (HDL-C/TG)• Systolic Blood Pressure
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Overall Goal for ACCORD
To test three complementary medical
treatment strategies for type 2
diabetes to enhance options for
reducing the very high rate of major
CVD morbidity and mortality
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The Three Medical Strategies(Three Trials in One)
• Intensive glycemic control• A1C < 6% versus 7.0%-7.9%
• Treatment to increase HDL-C and lower TG (in context of good LDL-C and glycemia control)
• Fenofibrate + Simvastatin versus Simvastatin
• Intensive blood pressure control (in context of good glycemia control)
• SBP < 120 mmHg versus SBP < 140 mmHg
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Double 2 x 2
IntensiveGlycemicControl
5000
StandardGlycemicControl
5000
Lipid BP
Fibrate Placebo Intensive Std
210021002900 2900
1450 1450
14501450
1050
10501050
1050
10,000
42005800
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Primary Outcome Measure
First occurrence of a major cardiovascular disease event:
• Nonfatal MI
• Nonfatal Stroke
• Cardiovascular Death
MI’s, Strokes, and Deaths adjudicated by a committee masked to treatment assignment
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Other ACCORD Outcomes
• Other cardiovascular outcomes
• Total mortality
• Microvascular outcomes
• Health-related Quality of Life (subset)
• Cost-effectiveness (subset)
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ACCORD Eye Study
National Eye Institute
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• important primary endpoint• common cause of vision loss• medical management crucial• standard of care: yearly
dilated eye exams
Diabetic Retinopathy
ACCORD Eye Study Rationale
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• important primary endpoint• DCCT – Primary outcome• UKPDS – Composite primary
outcome
Diabetic Retinopathy
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Diabetes Control and ComplicationsTrial (DCCT)
Randomized Clinical Trial
Intensive Blood Glucose Controlvs.
Conventional Blood Glucose Control
Type 1 Diabetes
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0
10
20
30
40
50
60
0 2 4 6 8 10
Primary Intervention - 3 Step Change
Years
PercentWith Event
DCCT Results
ConventionalIntensive
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0
10
20
30
40
50
60
0 2 4 6 8 10
Secondary Intervention - 3 Step Change
Years
PercentWith Event
DCCT Results
ConventionalIntensive
14
0
0.5
1
1.5
2
2.5
0 1 2
Secondary Intervention - 3 Step Change
Years
PercentWith Event
DCCT Results
P < 0.02
ConventionalIntensive
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Results of Intensive Therapy:
• Clinically Important Retinopathy (34-76%)
• Photocoagulation (34%)
• First Appearance of Retinopathy (27%)
DCCT Summary
Reduction in Retinopathy
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Further Retinopathy Progression from the Level at DCCT Closeout
Adjusted For DCCT Closeout Level
02
46
810
1214
1618
20
1 2 3 4
Per
cen
tage
Years of follow-up in EDIC
Conventional RxConventional Rx
Tight Control RxTight Control Rx
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Randomized Clinical Trial
Intensive Blood Glucose Controlvs.
Conventional Blood Glucose Control
U K Prospective Diabetes Study
Type 2 Diabetes
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U K Prospective Diabetes StudyMicrovascular Endpoints
10%
30%
20%
6 930 1512
Years
Conventional
Intensive
0%
Event Rate
Photocoagulation/VHRenal Failure/DeathMyocardial Infarction
p=0.0099
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U K Prospective Diabetes StudyRetinopathy - 2 Step Progression
10%
30%
40%
20%
6 930 12Years
Conventional
Intensive
50%
0%
Event Rate
p=0.78 p=0.02 p=0.01 p=0.01
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Randomized Clinical Trial
Intensive Blood Pressure Controlvs.
Conventional Blood Pressure Control
U K Prospective Diabetes Study
Type 2 Diabetes
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U K Prospective Diabetes StudyBlood Pressure by Treatment Group
mm Hg
100
80
120
140
160
3 6 90
Years1 2 4 5 87
Less Tight - Systolic
More Tight - Systolic
Less Tight - Diastolic
More Tight - Diastolic
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Retinopathy - 2 Step Progression
10%
30%
40%
20%
6 930 12
Years
Less Tight BP Control
More Tight BP Control
50%
0%
Event Rate
UKPDS Blood Pressure Trial
P=0.38 P=0.02 P=0.004
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Serum Cholesterol
Diabetic Retinopathy
and
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Early Treatment Diabetic
Retinopathy Study (ETDRS)
Wisconsin Epidemiologic Study of
Diabetic Retinopathy (WESDR)
Serum cholesterol
Observational Data
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Doubled the risk of retinal hard
50% increased risk of moderate vision
50% increased risk of developing hard exudate at baseline
Serum cholesterol-ETDRS Results
Elevated levels:
exudate during follow-up
loss at 5 years
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to assess the rates of progression of
medical treatment on diabetic retinopathy
To evaluate the effects of these 3
diabetic retinopathy
ACCORD Eye Study
Objectives
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Baseline (within 4 months of enrollment)
Sample size: n=4,065
4 years for all enrolled at baseline
ACCORD Eye Study
Eye Exam and Fundus Photos
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Clinical coordinator from the diabetes
Coordinating Center (Wake Forest U.) and
Eye exam form, fundus photographs sent to
clinic will schedule patient
ACCORD Eye Study
Study flow
Reading Center (U. of Wisconsin)
29Alexandria meeting
Feb 18-20, 2004
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