ADVANCE: much higher event rates with AF

Results from the Action in Diabetes and Vascular Disease: preterAx and diamicroN-MR Controlled Evaluation (ADVANCE) study (1) show that, among patients with type 2 diabetes, those who have atrial fibrillation (AF) are at higher risk of death from any cause, cardiovascular death, major cerebrovascular events and heart failure compared to those without AF. The absolute benefit of lowering blood pressure is therefore greater among patients with both diabetes and AF.

The study was designed to quantify the effects of blood pressure lowering and intensive blood glucose control on vascular outcomes. It included 11,140 patients aged 55 years and above, with type 2 diabetes and at least one other risk factor for cardiovascular events. Study participants were randomised to a fixed combination of perindopril and indapamide, or to placebo. Atrial fibrillation was diagnosed by ECG. Patients were seen three, four and six months after randomisation, and every six months thereafter.

pills In total, 847 patients (7.6%) had AF at baseline. Compared to the overall population, they tended to be older and heavier, with higher blood pressure and urinary albumin to creatinine ration (UCR), and a history of macrovascular disease, treated hypertension, left ventricular hypertrophy or pathological Q waves.

Patients were followed up for a mean duration of 4.3 years: 879 patients died during this period. Fifty-three percent of deaths were due to cardiovascular causes, and 15% of deaths took place in patients with AF. AF was associated with greater risks of death due to any cause (hazard ratio [HR] 1.61, p<0.0001), cardiovascular death (HR 1.77, p<0.0001) and heart failure (HR 1.68, p=0.0002). Patients with AF also had a higher risk of major cerebrovascular events (HR 1.68, p=0.0008) but the association with major coronary events was of borderline significance (HR 1.27, p=0.09).

Active treatment to lower blood pressure produced similar relative risk reductions in all-cause death, cardiovascular death and major coronary events in participants with and without AF but, since patients with AF were at higher baseline risk, the absolute benefit of active treatment was greater for this group. Thus, it can be estimated that five years of active treatment would prevent one cardiovascular death among every 42 patients with both DM and AF, compared with one among every 120 patients with diabetes but without AF.

In conclusion, if AF is detected in a patient with diabetes, then more aggressive treatment of all cardiovascular risk factors is indicated.

Reference

Du X, Ninomiya T, de Galan B et al. Risks of cardiovascular events and effects of routine blood pressure lowering among patients with type 2 diabetes and atrial fibrillation : results of the ADVANCE study. Eur Heart J doi:10.1093/eurheartj/ehp055