Secondary Prevention of Cardiovascular Disease in Patients With Type 2 Diabetes Mellitus: International Insights From the TECOS Trial (Trial Evaluating Cardiovascular Outcomes With Sitagliptin)

Abstract

Background: Intensive risk factor modification significantly improves outcomes for patients with diabetes mellitus and cardiovascular disease. However, the degree to which secondary prevention treatment goals are achieved in international clinical practice is unknown.

Methods: Attainment of 5 secondary prevention parameters-aspirin use, lipid control (low-density lipoprotein cholesterol <70 mg/dL or statin therapy), blood pressure control (<140 mm Hg systolic, <90 mm Hg diastolic), angiotensin-converting enzyme inhibitor or angiotensin receptor blocker use, and nonsmoking status-was evaluated among 13 616 patients from 38 countries with diabetes mellitus and known cardiovascular disease at entry into TECOS (Trial Evaluating Cardiovascular Outcomes With Sitagliptin). Logistic regression was used to evaluate the association between individual and regional factors and secondary prevention achievement at baseline. Cox proportional hazards regression analysis was used to determine the association between baseline secondary prevention achievement and cardiovascular death, myocardial infarction, or stroke.

Results: Overall, 29.9% of patients with diabetes mellitus and cardiovascular disease achieved all 5 secondary prevention parameters at baseline, although 71.8% achieved at least 4 parameters. North America had the highest proportion (41.2%), whereas Western Europe, Eastern Europe, and Latin America had proportions of ≈25%. Individually, blood pressure control (57.9%) had the lowest overall attainment, whereas nonsmoking status had the highest (89%). Over a median 3.0 years of follow-up, a higher baseline secondary prevention score was associated with improved outcomes in a step-wise graded relationship (adjusted hazard ratio, 0.60; 95% confidence interval, 0.47-0.77 for those patients achieving all 5 measures versus those achieving ≤2).

Conclusions: In an international trial population, significant opportunities exist to improve the quality of cardiovascular secondary prevention care among patients with diabetes mellitus and cardiovascular disease, which in turn could lead to reduced risk of downstream cardiovascular events.

Clinical trial registration: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00790205.

Keywords: cardiovascular diseases; diabetes mellitus; secondary prevention.

© 2017 American Heart Association, Inc.

Figures

Figure 1. Forest plot with adjusted associations between region and each secondary prevention component

Individuals with complete data for the variable of interest were included in the analyses for each secondary prevention component. Percent represents proportion of the total study population for whom that secondary prevention measure was at goal. ACE indicates angiotensin-converting enzyme inhibitor; and ARB, angiotensin receptor blocker. Adjustment factors included sex, age, history of coronary artery disease, history of cerebrovascular disease, history of peripheral arterial disease, history of heart failure, heart rate, body mass index, race, ethnicity, estimated glomerular filtration rate, glycated hemoglobin level, and high-density lipoprotein cholesterol. Countries and sample size included in each world region: North America: United States (n=2045), Canada (n=549). Asia Pacific and Other: Australia (n=427), China (n=31), Hong Kong (n=360), India (n=1817), Israel (n=362), Korea (n=330), Malaysia (n=257), New Zealand (n=274), Singapore (n=91), Taiwan (n=210), South Africa (n=406). Western Europe: Belgium (n=94), Germany (n=503), Spain (n=202), Finland (n=50), France (n=86), United Kingdom (n=516), Italy (n=192), Netherlands (n=309), Norway (n=43), Sweden (n=81). Eastern Europe: Bulgaria (n=504), Czech Republic (n=462), Estonia (n=88), Hungary (n=565), Lithuania (n=320), Latvia (n=401), Poland (n=605), Romania (n=345), Russia (n=465), Slovakia (n=110), Turkey (n=100). Latin America: Argentina (n=542), Brazil (n=406), Chile (n=293), Colombia (n=230).

Figure 2. Prevalence of secondary prevention measures

Each black circle represents the proportion of individuals with the secondary prevention measure within a given country. The red bars represent the mean proportion of individuals with the secondary prevention measures across all countries. Individuals with complete data for the variable of interest were included in the analyses for each secondary prevention component. ACE indicates angiotensin-converting enzyme inhibitor; and ARB, angiotensin receptor blocker.

Figure 3. Kaplan–Meier curves of secondary prevention scores for the primary outcome of cardiovascular death, myocardial infarction, or stroke

Secondary prevention score is the sum of any of the following 5 parameters which are present: aspirin use, lipid control (low-density lipoprotein cholesterol