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Am Fam Physician. 2000;61(4):1178-1180

Coronary heart disease (CHD) is the cause of death in approximately two thirds of patients with type 2 diabetes. Recent evidence suggests that complications associated with CHD can be reduced through intensified treatment of hypertension and dyslipidemia. The Scandinavian Simvastatin Survival Study (4S) has previously shown that treatment with simvastatin, a hydroxymethylglutaryl-CoA reductase inhibitor, reduced mortality from CHD by 42 percent. The 4S study was a double-blind, randomized, prospective, placebo-controlled, multicenter trial of simvastatin therapy in patients with CHD carried out in 94 clinical centers throughout Scandinavia. Herman and associates performed an analysis of the 4S data comparing outcomes in three subgroups: patients with normal fasting glucose levels, patients with impaired fasting glucose tolerance and patients with clinical diabetes.

Over the five years of observation, treatment with simvastatin reduced cardiovascular disease-related hospitalizations by 23 percent in patients with normal fasting glucose levels, by 30 percent in patients with impaired glucose tolerance and by 40 percent in patients with diabetes. Simvastatin therapy reduced the average cost of cardiovascular disease-related hospitalizations by $3,585 in patients with normal fasting glucose levels (this offset 60 percent of the cost of the simvastatin therapy), and by $4,478 in patients with impaired glucose tolerance (this offset 74 percent of the cost of simvastatin therapy). Patients with diabetes had a net cost savings of $1,801 each.

The authors conclude that simvastatin significantly reduced cardiovascular disease-related hospitalizations in all three of these groups. In addition, the benefits of aggressive lipid lowering therapy were greatest in patients with diabetes.

editor's note: This study supports previous research on the value of lipid control in patients with diabetes. Aggressive control of lipids, despite the high up-front costs, is likely to reduce the impact of common macrovascular complications such as ischemic heart disease. Clinicians should work aggressively to achieve the lipid goals set by the American Diabetes Association (i.e., a low-density lipoprotein level of less than 100 mg per dL [2.59 mmol per L]).—j.n.

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