Author + information
- Hussam Abuissa, MD and
- James H. O’Keefe Jr., MD⁎ ()
- ↵⁎Mid-America Heart Institute, Cardiovascular Consultants, 4330 Wornall Road, Suite 2000, Kansas City, Missouri 64111
We appreciate the interest by Dr. Rassi in our recent study on the role of angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) in diabetes prevention (1). We agree that lifestyle modifications that increase physical activity and minimize abdominal obesity are the most rational and cost-effective strategies for preventing type 2 diabetes. Despite this knowledge, compliance with a prescription for daily exercise and lasting weight loss proves difficult for many people; the epidemic of diabetes continues to escalate. Thus, safe pharmacologic approaches for preventing this disease will probably be relevant and important for many individuals.
Screening for new-onset diabetes using the American Diabetes Association criteria of a fasting plasma glucose of ≥126 mg/dl at two different visits in patients with no diabetes at the time of enrollment is a valid initial test to identify this disease at its early stages and prevent its chronic sequelae. However, the use of data from relatively short-term studies to calculate a number-needed-to-treat (NNT) can be misleading, as the risk of diabetes accrues over decades or, indeed, a lifetime.
Insulin resistance is a common pathophysiologic disturbance that plays a causal role in both hypertension and type 2 diabetes. It also results in overactivity of the rennin-angiotensin-aldosterone system leading to hypertrophy and stiffening of smooth muscles in the arterial wall and left ventricle. Angiotensin-converting enzyme inhibitors and ARBs have a proven efficacy for improving outcomes in insulin-resistant conditions, such as hypertension, coronary heart disease (CHD), and congestive heart failure, and they are the most effective antihypertensive agents for regressing smooth muscle hypertrophy commonly seen in these conditions (2). The fact that they also reduce the risk of new-onset diabetes is just one more reason to choose them for these established indications over other antihypertensive agents that worsen insulin sensitivity, such as traditional beta-blockers and diuretics (3).
Metabolic syndrome is a more robust marker for risk of type 2 diabetes and CHD events (4). If the NNT with an ACE inhibitor or ARB to prevent the development of new-onset diabetes in these patients is to be calculated, it will be substantially lower than that found in populations from our study, who were obviously at a lower risk. Therefore, as we have advocated, targeting high-risk prediabetic individuals for use of an ACE inhibitor or ARB therapy will increase the cost-effectiveness of these medications.
- American College of Cardiology Foundation
- Dahlof B.,
- Sever P.S.,
- Poulter N.R.,
- et al.
- Sattar N.,
- Gaw A.,
- Scherbakova O.,
- et al.