Article Text

This article has a correction. Please see:

Download PDFPDF
To lower or not to lower? Making sense of the latest research on intensive glycaemic control and cardiovascular outcomes
  1. Diana Sherifali1,
  2. Zubin Punthakee2
  1. 1
    School of Nursing, McMaster University, Hamilton, Ontario, Canada
  2. 2
    McMaster University Medical Centre, Hamilton, Ontario, Canada

    Statistics from

    Request Permissions

    If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

    Diabetes is an extremely burdensome and costly chronic disease. It affects an estimated 4–6% of the world’s population, and its prevalence continues to rise.1 2 Diabetes is a major cause of blindness, end stage renal disease, and cardiovascular complications, all of which are preventable.3 4 Clinical practice guidelines for the management of diabetes emphasise the importance of optimal glycaemic control. Specifically, some clinical practice guidelines have suggested targeting a glycated haemoglobin (Hb) A1c concentration ⩽7%, or ⩽6% for those able to safely achieve it.5


    With the recent publication of 3 notable trials, a great deal of debate and confusion has been created about the cardiovascular effects of lowering glucose to near-normal concentrations in people with type 2 diabetes. The Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial, the Action in Diabetes and Vascular Disease: Preterax and Damicron Modified Release Controlled Evaluation (ADVANCE) trial, and the 10-year follow-up of the UK Prospective Diabetes Study (UKPDS) provide complementary information about cardiovascular risk reduction with glucose lowering that can be used to help patients to develop evidence-based goals of therapy individualised to their own circumstances.

    ACCORD, ADVANCE, and the 10-year follow-up of the UKPDS all reported the effects of intensive glucose lowering on vascular outcomes.68 All 3 studies were randomised controlled trials, with an intensive glucose-lowering group and a “standard” control group with less stringent glycaemic targets. The trials differed in many respects (table 1) that may help to reconcile the differences in results (table 2).

    View this table:
    Table 1 Study and patient characteristics*
    View this table:
    Table 2 Summary of study findings*

    Participants and duration of follow-up

    There were important differences in the types of participants recruited and the duration of follow-up. ACCORD enrolled >10 000 patients starting in 2001 and followed them for a median of 3.4 years, at which point the intervention was discontinued (17 mo before the planned completion date) because of unexplained …

    View Full Text

    Linked Articles

    • Correction
      BMJ Publishing Group Ltd