Department of Medicine

Case Western Reserve University School of Medicine & UH Case Medical Center

Research on the effects of intensive treatment on hyperglycemia on type 2 diabetes

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Dr. Faramarz Ismail-Beigi M.D., PhD., the previous Division Chief of Endocrinology, and a team of internationally renowned UHCMC diabetes specialists researched the effects of intensive treatment of hyperglycemia (or high blood sugar, a condition in which an excessive amount of glucose circulates in the blood plasma) on microvascular outcomes in type 2 diabetes in analyzing the ACCORD randomized trial.

Hyperglycemia is associated with increased risk of cardiovascular complications in people with type 2 diabetes.

The team set out to find out if reducing the blood glucose concentration to normal levels in people with established type 2 diabetes decreases the rate of microvascular complications. 10,251 patients were randomly assigned, 5,128 to the intensive glycemia control group and 5,123 to standard group. Intensive therapy was stopped before study end because of higher mortality in the glycemia group, and patients were transitioned to standard therapy. After reviewing the results, it was clear that intensive therapy did not reduce the risk of advanced measures of microvascular outcomes (such as kidney failure requiring dialysis, or advanced disease of the retina requiring surgery), but delayed the onset of albuminuria and some measures of eye complications and neuropathy.

The conclusion was made that microvascular benefits of intensive therapy should be weighed against the increase in total and cardiovascular disease-related mortality, increased weight gain, and high risk for severe hypoglycemia.

Dr. Ismail-Beigi suggests that “In elderly people with established type 2 diabetes of many years’ duration and a history of prior cardiovascular disease (such as a heart attack), or risk factors for cardiovascular disease, the benefits and risks associated with intensive blood sugar control needs to be carefully assessed on an individual basis.  The best approach is for patients to have a discussion with their health-care provider to set an appropriate blood sugar goal.”

Much-needed complement to cholesterol testing

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For patients outside the highest and lowest traditional risk factor categories, based on factors like high cholesterol, smoking, diabetes, hypertension and family history of heart disease, MRP-8/14 could become a prominent diagnostic tool. “We are attempting to determine whether the use of MRP-8/14 should sway us toward more aggressive preventive therapies,” says Carl Orringer, MD, the Harrington Heart & Vascular Institute Chair in Preventive Cardiovascular Medicine at the School of Medicine.

Currently, a “high-sensitivity C-reactive protein” (hs-CRP) assay is sometimes used in conjunction with cholesterol tests to assess heart disease risk. Like hs-CRP, MRP-8/14 represents a different biological process than cholesterol and is likely to serve as a complement to, not a substitute for, cholesterol screening. Of cholesterol testing’s shortcomings, Dr. Orringer says, “Relying on cholesterol alone is ignoring the inflammation that lights the fuse that sets off the explosion that is the heart ttack.”

Dr. Orringer, who developed an innovative heart attack risk assessment program that uses CT scans to see whether a person has hardening of the arteries, believes that MRP-8/14 may come to be incorporated to aid in risk estimation.

“A person’s heart attack risk is related to how much calcium is in the arteries—the more calcium, the greater the risk,” Dr. Orringer explains. “Those with calcium in their arteries indicating atherosclerosis might be really good candidates for MRP-8/14 evaluation to see who is at the highest risk.”

CWRUmedicine To Lead Hypertension Study

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Case Western Reserve University School of Medicine is getting nearly 15 million dollars from the National Institutes of health to lead an important new study of hypertension.

Current guidelines recommend lowering hypertensive patients’ systolic blood pressure – that’s the first number in a blood pressure reading – to below 140 – 138 over 90, for example.  But physicians want to know if lowering that recommended systolic blood pressure to below 120 can further reduce the incidence of cardiovascular and kidney disease, or slow the decline of functional cognition.

Dr. Jackson Wright, who heads the Clinical Hypertension Program at University Hospitals Case Medical Center, says the medical school will be one of five U.S. institutions taking a leadership role in what’s called the Systolic Blood Pressure Intervention Trial – dubbed SPRINT.

Wright:  “The fact that Cleveland, Northeast Ohio and Central Ohio has a very diverse population makes this an outstanding location to conduct a study such as SPRINT.”

The study will take place over 9 years, and will involve 75 hundred patients.

Wright says it will measure the benefits of reducing systolic blood pressure against risks posed by increased medication and other factors in treatment of hypertension.

Learn more at CWRUmedicine.org

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