: You have mentioned that diabetes is very much associated with poor outcomes in CHD patients. Can you address the best methods for choosing agents for these patients with diabetes?

Prof Marso: First thing I will say about diabetes is that it is phenomenally prevalent and increasing in prevalence. There are tens of millions of people newly diagnosed with diabetes every year and diabetes is an important risk factor for developing heart disease. The thing that concerns me most is the change in prevalence both in the United States and quite interestingly， in China. The number of new cases of diabetes in young people in China is increasing at a profound rate， in fact， if it hasn’t already， China will soon surpass the world in the number of people with type 2 diabetes. If that wasn’t bad enough， what bothers me more is the downstream medical effects of this disease for patients， families and the country having to manage this. Diabetes is a profound cardiovascular risk factor. It is associated with a two- to four-fold increase in myocardial infarction， premature mortality and 70% of people with diabetes today die of cardiovascular disease. So cardiologists in China as well as other countries are really going to have to focus on modifying this disease. With respect to therapies， firstly I would say that it is important to diagnose the disease. About a third of people are undiagnosed at any given time. So my initial argument would be that people and health care providers and nurse practitioners really look for the disease and the risk factors for the disease: hypertension， obesity， dyslipidemia. These are all associated with an increased prevalence of diabetes. If one was going to pick two or three strategies to modify the prognosis of people with diabetes， I would have to say it would follow lifestyle risk factor modification， diet and exercise. It can’t be over-emphasized enough. Then you have to manage hypertension and dyslipidemia in people with diabetes and at this ACC meeting， there has been no less than three trials that have addressed those issues.  ACCORD Lipid and ACCORD Hypertension were both presented at this meeting and we learned some really important things. We learned that managing hypertension in people with diabetes doesn’t have to be that strict. People were randomized to <120mmHG compared to 140mmHg and 120mmHg was found to be no better. We just have to be in the ballpark. If we can get the systolic blood pressure down to 130mmHg， then I think we will afford patients a reduction in stroke， death and MI. That being said， we learned some things about lipid management. Statins. Statins. Statins. That is what we need to treat people with diabetes. ACCORD Lipid looked at adding fenofibrate to patients. Once they were on a statin， it turned out it didn’t matter. You don’t need to add a fibrate-type medication to modify risk factors. Treat diabetics to goal - LDL<100. There are many other things but those are probably the summarized highlights.