Byron J. Hoogwerf, MD

Modulation of the renin-angiotensin-aldosterone (RAA) system using angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) has been shown to have beneficial effects on blood pressure, diabetic nephropathy, coronary heart disease, and heart failure.

In their post hoc analysis of the DIGAMI 2 (Diabetes Mellitus Insulin-Glucose Infusion in Acute Myocardial Infarction 2) study, Mellbin and colleagues suggest that insulin therapy after myocardial infarction (MI) may be associated with increased clinical events (not mortality), whereas metformin therapy may be associated with reduced events and sulfonylurea therapy with neutral effects.

The relationship of glucose levels to cardiovascular disease (CVD) risk, especially coronary heart disease (CHD), in observational data sets has been the subject of several studies. These studies have shown that the relationship between fasting (and postprandial glucose) and CHD risk is continuous and graded, and that this relationship extends below the currently defined threshold for diagnosing diabetes mellitus. The assumption has been that glycemic control in patients with diabetes mellitus should favorably affect CVD outcomes in randomized clinical trials; however, the results of several large trials have not consistently confirmed this hypothesis. In fact, ACCORD (Action to Control Cardiovascular Risk in Diabetes) data suggest a small increased risk in mortality for patients at high risk for CHD events.