Does early intensive multifactorial therapy reduce modelled cardiovascular risk in individuals with screen‐detected diabetes? Results from the ADDITION‐Europe cluster randomized trial

Abstract

AimsLittle is known about the long-term effects of intensive multifactorial treatment early in the diabetes disease trajectory. In the absence of long-term data on hard outcomes, we described change in 10-year modelled cardiovascular risk in the 5 years following diagnosis, and quantified the impact of intensive treatment on 10-year modelled cardiovascular risk at 5 years.MethodsIn a pragmatic, cluster-randomized, parallel-group trial in Denmark, the Netherlands and the UK, 3057 people with screen-detected Type 2 diabetes were randomized by general practice to receive (1) routine care of diabetes according to national guidelines (1379 patients) or (2) intensive multifactorial target-driven management (1678 patients). Ten-year modelled cardiovascular disease risk was calculated at baseline and 5 years using the UK Prospective Diabetes Study Risk Engine (version 3β).ResultsAmong 2101 individuals with complete data at follow up (73.4%), 10-year modelled cardiovascular disease risk was 27.3% (sd 13.9) at baseline and 21.3% (sd 13.8) at 5-year follow-up (intensive treatment group difference –6.9, sd 9.0; routine care group difference –5.0, sd 12.2). Modelled 10-year cardiovascular disease risk was lower in the intensive treatment group compared with the routine care group at 5 years, after adjustment for baseline cardiovascular disease risk and clustering (–2.0; 95% CI –3.1 to –0.9).ConclusionsDespite increasing age and diabetes duration, there was a decline in modelled cardiovascular disease risk in the 5 years following diagnosis. Compared with routine care, 10-year modelled cardiovascular disease risk was lower in the intensive treatment group at 5 years. Our results suggest that patients benefit from intensive treatment early in the diabetes disease trajectory, where the rate of cardiovascular disease risk progression may be slowed.

A randomised trial of the effect and cost-effectiveness of early intensive multifactorial therapy on 5-year cardiovascular outcomes in individuals with screen-detected type 2 diabetes: the Anglo–Danish–Dutch Study of Intensive Treatment in People with Screen-Detected Diabetes in Primary Care (ADDITION-Europe) study

“…55 Cardiovascular risk factors (weight, blood pressure, cholesterol and modelled CVD risk 82 ), including health-related behaviours (smoking), improved substantially following detection of diabetes by screening, even among those receiving RC. The small differences between groups in the intensity of treatment during the 5 years following diagnosis were associated with a non-significant 17% reduction in the primary composite cardiovascular end point in favour of the IT group.…”

“…There was evidence of suboptimal treatment in this pragmatic trial. 55 Finally, future research should focus on whether or not the slowing of CVD risk progression observed in ADDITION-Europe trial participants in the first 5 years following diagnosis 82 leads to a sustained reduction in CVD events over the long term. Outcomes tended to favour the IT group among ADDITION-Europe participants; however, the low frequency of events means that the 5-year duration of follow-up may have been insufficient to detect potentially clinically important differences between the RC group and the IT group.…”

Optimizing management of glycaemia

“…Universal screening is not effective but large programmes such as the ADDITION trial (57) indicate that patients diagnosed through screening have a lower modelled CVD risk following intensive CVD risk management (58). HbA1c, which is stable, does not require fasting samples, is easily performed, and has been widely adopted, simplifying screening and diagnosis (59).…”

Intensive versus standard multifactorial cardiovascular risk factor control in screen‐detected type 2 diabetes: 5‐year and longer‐term modelled outcomes of the ADDITION‐Leicester study

“…The Anglo‐Danish‐Dutch study of Intensive Treatment In peOple with Newly diagnosed screen detected Diabetes in primary care (ADDITION‐Europe) demonstrated that screening for type 2 diabetes is feasible and subsequent modelling studies have suggested modest improvements in coronary heart disease risk maybe sustained up to 10 years after identification through screening . To date, however, screening has not been shown to improve mortality in the short‐term and longer follow‐up of screened cohorts such as ADDITION‐Europe are required .…”

“…[6][7][8] The Anglo-Danish-Dutch study of Intensive Treatment In peOple with Newly diagnosed screen detected Diabetes in primary care (ADDITION-Europe) demonstrated that screening for type 2 diabetes is feasible and subsequent modelling studies have suggested modest improvements in coronary heart disease risk maybe sustained up to 10 years after identification through screening. 7,9 To date, however, screening has not been shown to improve mortality in the short-term and longer follow-up of screened cohorts such as ADDITION-Europe are required. 10 Furthermore, predicted longer term trajectory of ischaemic heart disease, stroke, and congestive cardiac failure risk and its response to risk factor intensification amongst those initially identified through screening has not been described.…”