Reducing cardiovascular risk in type 2 diabetes mellitus

The last decade has seen a paradigm shift in our understanding of the best mechanisms to lower cardiovascular risk in patients with type 2 diabetes. In the past, considerable emphasis was placed on reduction of plasma glucose as a key mechanism to lowering cardiovascular risk and there were misplaced perceptions of benefit from aspirin in all patients. There is now overwhelming evidence that lowering cholesterol with statin therapy and lowering blood pressure with antihypertensive agents, at least to a systolic value of 130 mmHg, are the keys to success in achieving such benefits. Trial and meta-analytical evidence has shown that aspirin therapy for primary prevention of vascular events is probably unwarranted, intensive glucose lowering actually achieves limited reductions in cardiovascular disease, and fibrate therapy has no clear benefit with regard to reducing vascular events in type 2 diabetes despite favourable changes in lipid subfractions. Ongoing studies will help to determine whether other new pharmaceutical agents with different mechanisms of action are capable of achieving further reduction in vascular risk in type 2 diabetes.