Should the occurrence of a first coronary event change the management of diabetes?

The coronary morbi-mortality is particularly high in type 2 diabetes, which represents the vast majority of all diabetes. Hyperglycemia is an independ ent vascular risk factor in the short and long-term. The relationship betwe en the degree of hyperglycemia and vascular risk is linear with no threshol d effect. The occurrence of a first coronary event is an occasion, though l ate, to review the management of all risk factors in diabetic patients. In these patients, intensive insulin therapy administred in the acute phase of infarction reduces cardiovascular mortality by 30% at 1 and 3 years, Th ere are no specific studies of secondary prevention by optimal therapy of d iabetes, but, in the UKPDS, the treatment of hyperglycemia with sulfonylure a or insulin only marginally reduced the number of cardiovascular events. O n the other hand, treatment of obese patients with metformin significantly reduced the incidence of myocardial infarction and of mortality diabetes re lated. These results, though observed with the same level of glycemic contr ol as in the other treatment groups, suggest a cardio-protective effect of metformin itself. These beneficial effects should be weighed up against the potential risk of lactic acidosis which still limits the widespread use of metformin in with coronary heart disease patients. Follow-up studies show that diabetic with coronary heart disease patients d o not receive ail effective therapeutic inventions in secondary prevention and that the treatment of hyperglycemia is often neglected. Close collabora tion between cardiologists and diabetologists is necessary to improve the m anagement of type 2 diabetes.