1. Diabetes Journal Club March 17, 2011
Margaux Añel-Tiangco, MD

2. Background ACCORD Cohort of 10,250 adults Mean age 62
Action to Control Cardiovascular Risk in Diabetes
Cohort of 10,250 adults
Mean age 62
Median DM duration of 10 years
A1c ≥ 7.5%
At high risk for CV disease
Known CVD or two risk factors in addition to DM
Assigned to:
Intensive treatment: A1c <6%
Standard treatment: A1c 7-7.9%

3. Background
In 2008, the intensive treatment arm was stopped due to total and CV deaths (HR 1.22, 9% CI )
On an average of 3.7 years, there was an excess of 3 deaths per 1000 subjects in the intensive tx arm
No cause for excess mortality was found
Not from increased hypoglycemia
Not from a specific medication or combination of meds

4. Methods
Intensive treatment arm was managed like the Standard treatment arm after year 3.7
Goal A1c 7-7.9%
Pts were followed till year 5

5. Results
By the final visit, both groups were similar in numbers of pts on oral agents, insulin, and their combinations
Rates of severe hypoglycemia and other adverse events within the two groups were similar after the transition

6. Kaplan-Meier Curves
Primary outcome: composite of nonfatal MI, nonfatal stroke, or death from CV causes

7. Hazard Ratios for the Prespecified Primary and Secondary Outcomes

8. Causes of Death

9. Incident Event Rates after the Transition Date

10. Conclusion
Intensive DM therapy to A1c <6% did NOT decrease major CV events after 5 years and even led to more deaths than achieving an A1c 7-7.9%

11. Discussion Unclear reasons for mortality
Equivalent rates of hypoglycemia in the post-transition period
Degree of reduction in A1c cannot be implicated
Those is intensive therapy were on multiple drug combos not used in standard therapy group
42% of pts were on ≥ 3 oral agents ± insulin
Compared with only 19% of pts in the standard therapy

12. Discussion
Results may not be applicable to those with newly diagnosed DM
Holman et al. NEJM 2008; 359:
Newly dx DM Type 2 with normal goal A1c, median A1c 7%
Neutral CV effect after 10 yrs
 MI and death after 20 years