Pioglitazone for a middle-aged man with type 2 diabetes and a previous myocardial infarction

A 55-year-old Caucasian man who had a myocardial infarction 9 months earlier was referred to our cardiology clinic. He had an 8-year history of diabetes, had long-standing hypertension, and had smoked for more than 20 years until 2 years earlier. His existing medical management strategy included 100 mg of aspirin, 40 mg of simvastatin (Zocor), 50 mg of losartan (Cozaar), and 1000 mg of metformin (Fortamet, Glucophage, Riomet) daily.

At presentation, the patient's blood pressure was 145/85 mm Hg, his body mass index was 30 kg/m², and his waist circumference was 106 cm. His glycosylated hemoglobin level (A1C) was 8.0%, and his fasting plasma glucose concentration was 8.9 mmol/L. Although his low-density lipoprotein cholesterol level was normal, his high-density lipoprotein (HDL) cholesterol level was low (1.07 mmol/L), and his triglyceride level was high (2.78 mmol/L). Liver function tests were normal.

On clinical examination, there were no signs of heart failure, especially no ankle edema or rales. An electrocardiogram (ECG) showed normal sinus rhythm at 84 beats/minute and left bundle branch block. Echocardiography revealed good pump function (ejection fraction, approximately 50% with left anterior hypokinesia) and slight septal hypertrophy.

The patient was started on a regimen of 5 mg of bisoprolol (Zebeta) and 30 mg of pioglitazone (Actos) to address his hypertension and abnormal glucose and lipid levels, respectively. All other therapies were continued without further dose changes.

After 3 months, the patient returned to the clinic for evaluation. His glucose and lipid levels had improved: A1C, 7.5%; HDL cholesterol level, 1.26 mmol/L (+18%); triglyceride level, 2.34 mmol/L (-16%). A safety evaluation showed that the patient's liver function tests remained normal. His blood pressure was 125/80 mm Hg, and no signs or symptoms of heart failure were found. The ECG results had not changed, except for the resting heart rate (64 beats/minute). Echocardiographically, ventricular contraction parameters remained constant.

The patient was advised to lose weight and to continue taking all drugs. He was monitored every 6 months. After 3 years, he had not experienced any additional cardiovascular events.

Patients with diabetes and a previous MI have a particularly unfavorable prognosis in terms of recurrent MI and other cardiovascular events. A multifactorial strategy, such as the regimen used for this patient, is necessary to target the numerous underlying causes of both conditions in an attempt to prevent further macrovascular diseases. The addition of the glucose-lowering drug pioglitazone to the patient's existing strategy of antiaggregation, lipid-altering, antihypertensive, and glucose-lowering drugs further improved glucose and lipid levels. This positive effect of pioglitazone on atherogenic dyslipidemia (combined with its other antiarteriosclerotic effects) appears to be beneficial for the prevention of cardiovascular events in very high-risk patients.