Author
Bastiaan E. de Galan
Other affiliations: Radboud University Nijmegen Medical Centre, Royal Prince Alfred Hospital, Maastricht University Medical Centre ...read more
Bio: Bastiaan E. de Galan is an academic researcher from Maastricht University. The author has contributed to research in topics: Diabetes mellitus & Medicine. The author has an hindex of 20, co-authored 67 publications receiving 7942 citations. Previous affiliations of Bastiaan E. de Galan include Radboud University Nijmegen Medical Centre & Royal Prince Alfred Hospital.
Papers published on a yearly basis
Papers
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TL;DR: The SUGAR-DIP trial aims to assess the clinical effectiveness, cost-effectiveness and patient experience of a stepwise combined OGLD treatment protocol, compared with conventional insulin-based therapy for GDM.
Abstract: Introduction In women with gestational diabetes mellitus (GDM) requiring pharmacotherapy, insulin was the established first-line treatment. More recently, oral glucose lowering drugs (OGLDs) have gained popularity as a patient-friendly, less expensive and safe alternative. Monotherapy with metformin or glibenclamide (glyburide) is incorporated in several international guidelines. In women who do not reach sufficient glucose control with OGLD monotherapy, usually insulin is added, either with or without continuation of OGLDs. No reliable data from clinical trials, however, are available on the effectiveness of a treatment strategy using all three agents, metformin, glibenclamide and insulin, in a stepwise approach, compared with insulin-only therapy for improving pregnancy outcomes. In this trial, we aim to assess the clinical effectiveness, cost-effectiveness and patient experience of a stepwise combined OGLD treatment protocol, compared with conventional insulin-based therapy for GDM. Methods The SUGAR-DIP trial is an open-label, multicentre randomised controlled non-inferiority trial. Participants are women with GDM who do not reach target glycaemic control with modification of diet, between 16 and 34 weeks of gestation. Participants will be randomised to either treatment with OGLDs, starting with metformin and supplemented as needed with glibenclamide, or randomised to treatment with insulin. In women who do not reach target glycaemic control with combined metformin and glibenclamide, glibenclamide will be substituted with insulin, while continuing metformin. The primary outcome will be the incidence of large-for-gestational-age infants (birth weight >90th percentile). Secondary outcome measures are maternal diabetes-related endpoints, obstetric complications, neonatal complications and cost-effectiveness analysis. Outcomes will be analysed according to the intention-to-treat principle. Ethics and dissemination The study protocol was approved by the Ethics Committee of the Utrecht University Medical Centre. Approval by the boards of management for all participating hospitals will be obtained. Trial results will be submitted for publication in peer-reviewed journals.
6 citations
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TL;DR: A case of artifactual hypoglycaemia in a patient with SSc and a quick method for its diagnosis, which has potential clinical consequences for patients with S Sc and RP at risk for or having been diagnosed with diabetes.
Abstract: SIR, The term artifactual hypoglycaemia has been proposed for the discrepancy between low capillary and normal plasma glucose levels, and has been described in various conditions, including RP [1]. Early recognition is challenging, but is important to prevent anxiety and unnecessary treatment and diagnostic tests. We present a case of artifactual hypoglycaemia in a patient with SSc and propose a quick method for its diagnosis. A 57-year-old man was referred from another hospital because of recurrent, asymptomatic hypoglycaemia. His medical history included SSc and RP, treated with lowdose prednisolone, and aortic valve stenosis with intestinal angiodysplasia for which somatostatin had been recently started. Subsequent monitoring of capillary glucose by finger-stick measurements revealed glucose levels ranging between 2.3 and 7.7 mmol/l, with 15% of these below 3.5 mmol/l. Screening diagnostic analysis for insulinoma, performed before the patient was referred, was reportedly negative. Somatostatin, which was thought to have caused the low glucose levels, had been discontinued, the dose of prednisolone was increased (from 5 to 10 mg daily) and continuous feeding over a nasogastric tube had been initiated. However, none of these interventions had led to a clear, sustainable glucose-increasing effect (Fig. 1), although his body weight had increased by 4 kg. The patient had become increasingly anxious about the apparent treatment resistance of his hypoglycaemia. The patient occasionally reported non-specific symptoms like blurred vision and tremor that were unrelated to the capillary glucose level and did not respond to ingestion of dextrose. We concluded that the criteria of Whipple’s triad for hypoglycaemia were not met [2] and suspected a measurement artefact. Because his sclerosis-affected skin hindered venous access, we performed simultaneous measurements on the patient’s earlobe when finger-stick measurement suggested hypoglycaemia. These measurements revealed glucose levels to be 2.8 mmol/l higher in earlobe capillary blood, with none of them being in the hypoglycaemic range. Screening for diabetes in people at elevated risk is routine practice at all levels of clinical care across medical specialties. Hypoglycaemia in such a patient not treated with glucose-lowering agents should raise the health care provider’s suspicion of artifactual hypoglycaemia, especially when the event is based on capillary blood glucose, measured by finger-stick. Unawareness of this phenomenon may lead to unnecessary diagnostic and therapeutic interventions, as exemplified in our patient. Artifactual hypoglycaemia, previously referred to as pseudo-hypoglycaemia, has been described in patients with RP, circulatory shock, peripheral arterial disease, Eisenmenger syndrome, acrocyanosis or hypothermia [1]. It has been ascribed to reduced perfusion of the peripheral microcirculation with decelerated glucose transit and increased glucose uptake into the surrounding tissue [3]. Additionally, the term has also been used to describe falsely low plasma glucose values resulting from increased glycolysis by leukocytes, e.g. in chronic myeloid leukaemia [1, 3]. Diagnosis of artifactual hypoglycaemia relies on simultaneous glucose measurements in capillary blood and a venous specimen [1]. Because venous access can be difficult in patients with SSc because of their fibrotized skin and stiffened veins, we chose the earlobe as alternative site for glucose measurement. Earlobe measurements reflect also capillary blood glucose; however, the earlobe remains unaffected by SSc, because it lacks connective tissue [4, 5]. In addition, it allows for diagnosis at the bedside with the same glucose metre, thus circumventing any differences in accuracy with laboratory methods. Our case has potential clinical consequences for patients with SSc and RP at risk for or having been diagnosed with diabetes. Indeed, artifactual normal or lower than expected finger-stick glucose values in these patients may give false assumptions of the level of glucose control in people with (coexistent) diabetes or even refute its diagnosis, potentially withholding patients from appropriate treatment. This phenomenon must be particularly considered if there is a discrepancy between the haemoglobin A1c level and glucose values measured by fingerstick. Whenever frequent glucose monitoring is required, e.g. with insulin treatment, switching from finger-stick to earlobe capillary glucose measurement may be considered. This case illustrates the importance of awareness of artifactual hypoglycaemia, not only to avoid unnecessary work-up and therapy, but also to prevent anxiety associated with the belief of having a medical condition that appears unsolvable. We suggest performing simultaneous glucose measurements on the patient’s earlobe and finger-stick whenever this phenomenon is likely to occur, not only in patients with supposedly hypoglycaemia, but also in case of lower than expected glucose levels in patients with (poorly controlled) diabetes mellitus.
6 citations
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TL;DR: It remains unknownwhich specific immune cell subsets are recruited in response to hypoglycaemia, and to identify these subsets, blood samples collected during clamped euglycaemia from seven people with type 1 diabetes were analysed.
Abstract: To the Editor: We recently reported enhanced ex vivo cytokine production of immune cells during hypoglycaemia in humans [1]. Chronic inflammation contributes to cardiovascular disease and atherosclerosis and may link hypoglycaemia to increased cardiovascular risk and mortality observed in individuals with diabetes [2]. Hypoglycaemia induces leucocytosis, possibly mediated by marked increases in plasma adrenaline (epinephrine) and cortisol levels. Adrenaline recruits immune cells from themarginal pool (vascular endothelium), likely by interfering with CD11aand CX3CR1-dependent adhesion of leucocytes to the vessel wall [3]. Indeed, gene expression levels of CD11a and CX3CR1were increased in peripheral bloodmononuclear cells (PBMCs) isolated during hypoglycaemia [1]. It remains unknownwhich specific immune cell subsets are recruited in response to hypoglycaemia. To identify these subsets, we analysed blood samples collected during clamped euglycaemia or hypoglycaemia from seven people with type 1 diabetes (three men, age 27.1 ± 9.7 years, HbA1c 55.9 ± 8.9 mmol/mol [7.2 ± 0.8%] and diabetes duration 11.4 ± 5.4 years; mean ± SD) by flow cytometry. This was a substudy of a larger study (ClinicalTrials.gov registration no. NCT03286816), for which we analysed data obtained within the control arm (for study design and endpoints, see [4]). The study was approved by the local institutional review board of Radboud University Medical Center and all study participants gave written informed consent before participation. All participants had normal awareness of hypoglycaemia (assessed by the Dutch version of the Cox questionnaire and normal counter-regulatory responses to the hypoglycaemic clamp). Participants underwent a two-step euglycaemic (5.0mmol/l)– hypoglycaemic (2.8 mmol/l) glucose clamp. At the end of each glycaemic phase, blood was drawn for flow cytometry and to determine catecholamine levels. Undiluted blood (50 μl, BD Vacutainer K2E [EDTA], BD, Plymouth, UK) was incubated for 15 min at room temperature in the dark with the following antibodies (all mouse): CD16-FITC (dilution 1:5), CD56-PE (1:10) (BD Biosciences, Vianen, the Netherlands); CD14-ECD (1:10), CD3-ECD (1:10), CD3-PE (1:5), CD45-PECy7 (1:50), CD8-ECD (1:10), HLA-DRPECy5 (1:10) (Beckman Coul te r, Woerden , the Netherlands); CD4-PECy7 (1:20) (ITK Diagnostics BV, Uithoorn, the Netherlands). After the addition of 1 ml lysis buffer (BD Pharm Lyse, BD Biosciences), samples were mixed, incubated for another 10 min and finally measured on a Beckman Coulter FC500 flow cytometer. Single staining and fluorescence-minus-one control stains were used to determine the position of analysis gates. Flow cytometry data were analysed using Kaluza software (Beckman Coulter). Immune cell subset numbers were calculated based on percentages measured with flow cytometry and cell numbers from blood differentials measured on a Sysmex XN-450 (Sysmex, EttenLeur, the Netherlands). A Spearman’s rank sum test was used for correlation analysis. Wilcoxon signed rank test was used to test differences between two related samples. All data are expressed as mean ± SD. A p value of <0.05 was considered * Jacqueline M. Ratter Jacqueline.Ratter@radboudumc.nl
6 citations
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TL;DR: It is concluded that hypoglycemia induces a pro-inflammatory response at the cellular and protein level that is sustained for one week in people with type 2 diabetes and controls.
Abstract: Iatrogenic hypoglycaemia activates the immune system and is associated with an increased risk for atherosclerotic disease. We determined acute and long-term effects of insulin-induced hypoglycemia on inflammatory markers in humans with or without type 2 diabetes. Fifteen adults with type 2 diabetes and 16 matched controls (M/F 17/14, age 59.6±7.1 years, BMI 28.5±4.3 kg/m2) underwent a hyperinsulinemic-euglycemic (5.31±0.32 mmol/L) hypoglycemic (2.80±0.12 mmol/L) glucose clamp. Blood was drawn during euglycemia and hypoglycemia and 1, 3 and 7 days later, to determine circulating immune cell composition, function, and inflammatory proteins. In response to hypoglycemia, absolute numbers of circulating lymphocytes and monocytes significantly increased and remained elevated for one week. The proportion of CD16+ -monocytes increased, and the proportion of CD14+ -monocytes decreased, which sustained for a week in people without diabetes. During hypoglycemia, ex vivo stimulated, monocytes released more TNF-α and IL-1β, and less IL-10, particularly in people with diabetes. Hs-CRP and 25 circulating inflammatory proteins increased, remaining significantly elevated one week after hypoglycemia. While levels at euglycemia differed, responses to hypoglycemia were broadly similar in people with or without type 2 diabetes. We conclude that hypoglycemia induces a pro-inflammatory response at the cellular and protein level that is sustained for one week in people with type 2 diabetes and controls.
5 citations
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TL;DR: In this article, the authors assess cross-sectional associations between dietary advanced glycation end products (AGEs) intake and generalized microvascular function in a population-based cohort.
5 citations
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TL;DR: In this article, a randomized controlled trial of Aliskiren in the Prevention of Major Cardiovascular Events in Elderly people was presented. But the authors did not discuss the effect of the combination therapy in patients living with systolic hypertension.
Abstract: ABCD
: Appropriate Blood pressure Control in Diabetes
ABI
: ankle–brachial index
ABPM
: ambulatory blood pressure monitoring
ACCESS
: Acute Candesartan Cilexetil Therapy in Stroke Survival
ACCOMPLISH
: Avoiding Cardiovascular Events in Combination Therapy in Patients Living with Systolic Hypertension
ACCORD
: Action to Control Cardiovascular Risk in Diabetes
ACE
: angiotensin-converting enzyme
ACTIVE I
: Atrial Fibrillation Clopidogrel Trial with Irbesartan for Prevention of Vascular Events
ADVANCE
: Action in Diabetes and Vascular Disease: Preterax and Diamicron-MR Controlled Evaluation
AHEAD
: Action for HEAlth in Diabetes
ALLHAT
: Antihypertensive and Lipid-Lowering Treatment to Prevent Heart ATtack
ALTITUDE
: ALiskiren Trial In Type 2 Diabetes Using Cardio-renal Endpoints
ANTIPAF
: ANgioTensin II Antagonist In Paroxysmal Atrial Fibrillation
APOLLO
: A Randomized Controlled Trial of Aliskiren in the Prevention of Major Cardiovascular Events in Elderly People
ARB
: angiotensin receptor blocker
ARIC
: Atherosclerosis Risk In Communities
ARR
: aldosterone renin ratio
ASCOT
: Anglo-Scandinavian Cardiac Outcomes Trial
ASCOT-LLA
: Anglo-Scandinavian Cardiac Outcomes Trial—Lipid Lowering Arm
ASTRAL
: Angioplasty and STenting for Renal Artery Lesions
A-V
: atrioventricular
BB
: beta-blocker
BMI
: body mass index
BP
: blood pressure
BSA
: body surface area
CA
: calcium antagonist
CABG
: coronary artery bypass graft
CAPPP
: CAPtopril Prevention Project
CAPRAF
: CAndesartan in the Prevention of Relapsing Atrial Fibrillation
CHD
: coronary heart disease
CHHIPS
: Controlling Hypertension and Hypertension Immediately Post-Stroke
CKD
: chronic kidney disease
CKD-EPI
: Chronic Kidney Disease—EPIdemiology collaboration
CONVINCE
: Controlled ONset Verapamil INvestigation of CV Endpoints
CT
: computed tomography
CV
: cardiovascular
CVD
: cardiovascular disease
D
: diuretic
DASH
: Dietary Approaches to Stop Hypertension
DBP
: diastolic blood pressure
DCCT
: Diabetes Control and Complications Study
DIRECT
: DIabetic REtinopathy Candesartan Trials
DM
: diabetes mellitus
DPP-4
: dipeptidyl peptidase 4
EAS
: European Atherosclerosis Society
EASD
: European Association for the Study of Diabetes
ECG
: electrocardiogram
EF
: ejection fraction
eGFR
: estimated glomerular filtration rate
ELSA
: European Lacidipine Study on Atherosclerosis
ESC
: European Society of Cardiology
ESH
: European Society of Hypertension
ESRD
: end-stage renal disease
EXPLOR
: Amlodipine–Valsartan Combination Decreases Central Systolic Blood Pressure more Effectively than the Amlodipine–Atenolol Combination
FDA
: U.S. Food and Drug Administration
FEVER
: Felodipine EVent Reduction study
GISSI-AF
: Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto Miocardico-Atrial Fibrillation
HbA1c
: glycated haemoglobin
HBPM
: home blood pressure monitoring
HOPE
: Heart Outcomes Prevention Evaluation
HOT
: Hypertension Optimal Treatment
HRT
: hormone replacement therapy
HT
: hypertension
HYVET
: HYpertension in the Very Elderly Trial
IMT
: intima-media thickness
I-PRESERVE
: Irbesartan in Heart Failure with Preserved Systolic Function
INTERHEART
: Effect of Potentially Modifiable Risk Factors associated with Myocardial Infarction in 52 Countries
INVEST
: INternational VErapamil SR/T Trandolapril
ISH
: Isolated systolic hypertension
JNC
: Joint National Committee
JUPITER
: Justification for the Use of Statins in Primary Prevention: an Intervention Trial Evaluating Rosuvastatin
LAVi
: left atrial volume index
LIFE
: Losartan Intervention For Endpoint Reduction in Hypertensives
LV
: left ventricle/left ventricular
LVH
: left ventricular hypertrophy
LVM
: left ventricular mass
MDRD
: Modification of Diet in Renal Disease
MRFIT
: Multiple Risk Factor Intervention Trial
MRI
: magnetic resonance imaging
NORDIL
: The Nordic Diltiazem Intervention study
OC
: oral contraceptive
OD
: organ damage
ONTARGET
: ONgoing Telmisartan Alone and in Combination with Ramipril Global Endpoint Trial
PAD
: peripheral artery disease
PATHS
: Prevention And Treatment of Hypertension Study
PCI
: percutaneous coronary intervention
PPAR
: peroxisome proliferator-activated receptor
PREVEND
: Prevention of REnal and Vascular ENdstage Disease
PROFESS
: Prevention Regimen for Effectively Avoiding Secondary Strokes
PROGRESS
: Perindopril Protection Against Recurrent Stroke Study
PWV
: pulse wave velocity
QALY
: Quality adjusted life years
RAA
: renin-angiotensin-aldosterone
RAS
: renin-angiotensin system
RCT
: randomized controlled trials
RF
: risk factor
ROADMAP
: Randomized Olmesartan And Diabetes MicroAlbuminuria Prevention
SBP
: systolic blood pressure
SCAST
: Angiotensin-Receptor Blocker Candesartan for Treatment of Acute STroke
SCOPE
: Study on COgnition and Prognosis in the Elderly
SCORE
: Systematic COronary Risk Evaluation
SHEP
: Systolic Hypertension in the Elderly Program
STOP
: Swedish Trials in Old Patients with Hypertension
STOP-2
: The second Swedish Trial in Old Patients with Hypertension
SYSTCHINA
: SYSTolic Hypertension in the Elderly: Chinese trial
SYSTEUR
: SYSTolic Hypertension in Europe
TIA
: transient ischaemic attack
TOHP
: Trials Of Hypertension Prevention
TRANSCEND
: Telmisartan Randomised AssessmeNt Study in ACE iNtolerant subjects with cardiovascular Disease
UKPDS
: United Kingdom Prospective Diabetes Study
VADT
: Veterans' Affairs Diabetes Trial
VALUE
: Valsartan Antihypertensive Long-term Use Evaluation
WHO
: World Health Organization
### 1.1 Principles
The 2013 guidelines on hypertension of the European Society of Hypertension (ESH) and the European Society of Cardiology …
14,173 citations
01 Jan 2014
TL;DR: These standards of care are intended to provide clinicians, patients, researchers, payors, and other interested individuals with the components of diabetes care, treatment goals, and tools to evaluate the quality of care.
Abstract: XI. STRATEGIES FOR IMPROVING DIABETES CARE D iabetes is a chronic illness that requires continuing medical care and patient self-management education to prevent acute complications and to reduce the risk of long-term complications. Diabetes care is complex and requires that many issues, beyond glycemic control, be addressed. A large body of evidence exists that supports a range of interventions to improve diabetes outcomes. These standards of care are intended to provide clinicians, patients, researchers, payors, and other interested individuals with the components of diabetes care, treatment goals, and tools to evaluate the quality of care. While individual preferences, comorbidities, and other patient factors may require modification of goals, targets that are desirable for most patients with diabetes are provided. These standards are not intended to preclude more extensive evaluation and management of the patient by other specialists as needed. For more detailed information, refer to Bode (Ed.): Medical Management of Type 1 Diabetes (1), Burant (Ed): Medical Management of Type 2 Diabetes (2), and Klingensmith (Ed): Intensive Diabetes Management (3). The recommendations included are diagnostic and therapeutic actions that are known or believed to favorably affect health outcomes of patients with diabetes. A grading system (Table 1), developed by the American Diabetes Association (ADA) and modeled after existing methods, was utilized to clarify and codify the evidence that forms the basis for the recommendations. The level of evidence that supports each recommendation is listed after each recommendation using the letters A, B, C, or E.
9,618 citations
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TL;DR: In this paper, a randomized clinical trial was conducted to evaluate the effect of preterax and Diamicron Modified Release Controlled Evaluation (MDE) on the risk of stroke.
Abstract: ABI
: ankle–brachial index
ACCORD
: Action to Control Cardiovascular Risk in Diabetes
ADVANCE
: Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified Release Controlled Evaluation
AGREE
: Appraisal of Guidelines Research and Evaluation
AHA
: American Heart Association
apoA1
: apolipoprotein A1
apoB
: apolipoprotein B
CABG
: coronary artery bypass graft surgery
CARDS
: Collaborative AtoRvastatin Diabetes Study
CCNAP
: Council on Cardiovascular Nursing and Allied Professions
CHARISMA
: Clopidogrel for High Athero-thrombotic Risk and Ischemic Stabilisation, Management, and Avoidance
CHD
: coronary heart disease
CKD
: chronic kidney disease
COMMIT
: Clopidogrel and Metoprolol in Myocardial Infarction Trial
CRP
: C-reactive protein
CURE
: Clopidogrel in Unstable Angina to Prevent Recurrent Events
CVD
: cardiovascular disease
DALYs
: disability-adjusted life years
DBP
: diastolic blood pressure
DCCT
: Diabetes Control and Complications Trial
ED
: erectile dysfunction
eGFR
: estimated glomerular filtration rate
EHN
: European Heart Network
EPIC
: European Prospective Investigation into Cancer and Nutrition
EUROASPIRE
: European Action on Secondary and Primary Prevention through Intervention to Reduce Events
GFR
: glomerular filtration rate
GOSPEL
: Global Secondary Prevention Strategies to Limit Event Recurrence After MI
GRADE
: Grading of Recommendations Assessment, Development and Evaluation
HbA1c
: glycated haemoglobin
HDL
: high-density lipoprotein
HF-ACTION
: Heart Failure and A Controlled Trial Investigating Outcomes of Exercise TraiNing
HOT
: Hypertension Optimal Treatment Study
HPS
: Heart Protection Study
HR
: hazard ratio
hsCRP
: high-sensitivity C-reactive protein
HYVET
: Hypertension in the Very Elderly Trial
ICD
: International Classification of Diseases
IMT
: intima-media thickness
INVEST
: International Verapamil SR/Trandolapril
JTF
: Joint Task Force
LDL
: low-density lipoprotein
Lp(a)
: lipoprotein(a)
LpPLA2
: lipoprotein-associated phospholipase 2
LVH
: left ventricular hypertrophy
MATCH
: Management of Atherothrombosis with Clopidogrel in High-risk Patients with Recent Transient Ischaemic Attack or Ischaemic Stroke
MDRD
: Modification of Diet in Renal Disease
MET
: metabolic equivalent
MONICA
: Multinational MONItoring of trends and determinants in CArdiovascular disease
NICE
: National Institute of Health and Clinical Excellence
NRT
: nicotine replacement therapy
NSTEMI
: non-ST elevation myocardial infarction
ONTARGET
: Ongoing Telmisartan Alone and in combination with Ramipril Global Endpoint Trial
OSA
: obstructive sleep apnoea
PAD
: peripheral artery disease
PCI
: percutaneous coronary intervention
PROactive
: Prospective Pioglitazone Clinical Trial in Macrovascular Events
PWV
: pulse wave velocity
QOF
: Quality and Outcomes Framework
RCT
: randomized clinical trial
RR
: relative risk
SBP
: systolic blood pressure
SCORE
: Systematic Coronary Risk Evaluation Project
SEARCH
: Study of the Effectiveness of Additional Reductions in Cholesterol and
SHEP
: Systolic Hypertension in the Elderly Program
STEMI
: ST-elevation myocardial infarction
SU.FOL.OM3
: SUpplementation with FOlate, vitamin B6 and B12 and/or OMega-3 fatty acids
Syst-Eur
: Systolic Hypertension in Europe
TNT
: Treating to New Targets
UKPDS
: United Kingdom Prospective Diabetes Study
VADT
: Veterans Affairs Diabetes Trial
VALUE
: Valsartan Antihypertensive Long-term Use
VITATOPS
: VITAmins TO Prevent Stroke
VLDL
: very low-density lipoprotein
WHO
: World Health Organization
### 1.1 Introduction
Atherosclerotic cardiovascular disease (CVD) is a chronic disorder developing insidiously throughout life and usually progressing to an advanced stage by the time symptoms occur. It remains the major cause of premature death in Europe, even though CVD mortality has …
7,482 citations
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Katholieke Universiteit Leuven1, Gdańsk Medical University2, University of Valencia3, Zamorano4, Ghent University5, Charles University in Prague6, University of Glasgow7, University of Naples Federico II8, University Medical Center Utrecht9, Linköping University10, University of Birmingham11, University of Oslo12, Lund University13, Complutense University of Madrid14, University of Erlangen-Nuremberg15, John Radcliffe Hospital16, Tallinn University of Technology17, University of Lausanne18
TL;DR: 2007 Guidelines for the Management of Arterial Hypertension : The Task Force for the management of Arterspertension of the European Society ofhypertension (ESH) and of theEuropean Society of Cardiology (ESC).
Abstract: Because of new evidence on several diagnostic and therapeutic aspects of hypertension, the present guidelines differ in many respects from the previous ones. Some of the most important differences are listed below:
1. Epidemiological data on hypertension and BP control in Europe.
2. Strengthening of the prognostic value of home blood pressure monitoring (HBPM) and of its role for diagnosis and management of hypertension, next to ambulatory blood pressure monitoring (ABPM).
3. Update of the prognostic significance of night-time BP, white-coat hypertension and masked hypertension.
4. Re-emphasis on integration of BP, cardiovascular (CV) risk factors, asymptomatic organ damage (OD) and clinical complications for total CV risk assessment.
5. Update of the prognostic significance of asymptomatic OD, including heart, blood vessels, kidney, eye and brain.
6. Reconsideration of the risk of overweight and target body mass index (BMI) in hypertension.
7. Hypertension in young people.
8. Initiation of antihypertensive treatment. More evidence-based criteria and no drug treatment of high normal BP.
9. Target BP for treatment. More evidence-based criteria and unified target systolic blood pressure (SBP) (<140 mmHg) in both higher and lower CV risk patients.
10. Liberal approach to initial monotherapy, without any all-ranking purpose.
11. Revised schema for priorital two-drug combinations.
12. New therapeutic algorithms for achieving target BP.
13. Extended section on therapeutic strategies in special conditions.
14. Revised recommendations on treatment of hypertension in the elderly.
15. Drug treatment of octogenarians.
16. Special attention to resistant hypertension and new treatment approaches.
17. Increased attention to OD-guided therapy.
18. New approaches to chronic management of hypertensive disease
7,018 citations
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TL;DR: Despite an early loss of glycemic differences, a continued reduction in microvascular risk and emergent risk reductions for myocardial infarction and death from any cause were observed during 10 years of post-trial follow-up.
Abstract: From the Diabetes Trials Unit (R.R.H., S.K.P., M.A.B.), the Division of Public Health and Primary Health Care (H.A.W.N.), and the National Institute of Health Re- search (NIHR) School for Primary Care Research (H.A.W.N.), Oxford Centre for Diabetes, Endocrinology, and Metabo- lism (R.R.H., S.K.P., M.A.B., D.R.M., H.A.W.N.); and the NIHR Oxford Bio- medical Research Centre (R.R.H., D.R.M., H.A.W.N.) — both in Oxford, United Kingdom. Address reprint requests to Dr. Holman at the Diabetes Trials Unit, Ox- ford Centre for Diabetes, Endocrinology, and Metabolism, Churchill Hospital, Head- ington, Oxford OX3 7LJ, United Kingdom, or at rury.holman@dtu.ox.ac.uk. Background During the United Kingdom Prospective Diabetes Study (UKPDS), patients with type 2 diabetes mellitus who received intensive glucose therapy had a lower risk of microvascular complications than did those receiving conventional dietary therapy. We conducted post-trial monitoring to determine whether this improved glucose con- trol persisted and whether such therapy had a long-term effect on macrovascular outcomes. Methods Of 5102 patients with newly diagnosed type 2 diabetes, 4209 were randomly assigned to receive either conventional therapy (dietary restriction) or intensive therapy (either sulfonylurea or insulin or, in overweight patients, metformin) for glucose control. In post-trial monitoring, 3277 patients were asked to attend annual UKPDS clinics for 5 years, but no attempts were made to maintain their previously assigned thera- pies. Annual questionnaires were used to follow patients who were unable to attend the clinics, and all patients in years 6 to 10 were assessed through questionnaires. We examined seven prespecified aggregate clinical outcomes from the UKPDS on an intention-to-treat basis, according to previous randomization categories. Results Between-group differences in glycated hemoglobin levels were lost after the first year. In the sulfonylurea-insulin group, relative reductions in risk persisted at 10 years for any diabetes-related end point (9%, P = 0.04) and microvascular disease (24%, P = 0.001), and risk reductions for myocardial infarction (15%, P = 0.01) and death from any cause (13%, P = 0.007) emerged over time, as more events occurred. In the metformin group, significant risk reductions persisted for any diabetes-relat- ed end point (21%, P = 0.01), myocardial infarction (33%, P = 0.005), and death from any cause (27%, P = 0.002). Conclusions Despite an early loss of glycemic differences, a continued reduction in microvascu- lar risk and emergent risk reductions for myocardial infarction and death from any cause were observed during 10 years of post-trial follow-up. A continued benefit after metformin therapy was evident among overweight patients. (UKPDS 80; Current Controlled Trials number, ISRCTN75451837.)
6,565 citations