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Diabetes Management in Older Adults with Cardiovascular Disease

Older adults with type 2 diabetes mellitus are a large, heterogeneous and growing population who are at high risk for adverse cardiovascular events.1 Unfortunately, there is a paucity of randomized control data on cardiovascular outcomes in patients with diabetes who are over the age of 80. Mean age of participants in the three major relevant trials, VADT (Veterans Affairs Diabetes Trial), ACORRD (Action to Control Cardiovascular Risk in Diabetes) and ADVANCE (Action in Diabetes and Vascular Disease: Preterax and Diamicron MR Controlled Evaluation), were 60, 62 and 66 years respectively.2-4 The ASCVD risk calculator, which helps clinicians make decisions about prescribing statins and aspirin based on a patient's cardiovascular risk factors, including diabetes, is based on a pooled cohort analysis from five studies of patients aged 40-79.5 Therefore caring for patients over age 80 requires an individualized rather than guideline driven approach.6 Choosing Wisely, a collective initiative of multiple professional societies that focuses on reducing medical tests and treatment that may be harmful or of marginal medical value, supports this patient-based approach.

In many older patients, the risks of over-treating diabetes outweigh the benefits. The American Geriatrics Society recommends a goal a1c of 7.5-8% in older patients with moderate comorbidities and life expectancy less than 10 years;7 the American Diabetes Association recommends a more relaxed goal of 8-8.5% for older patients with complex medical issues.1 These recommendations are supported by evidence that low a1c targets did not reduce risk of macrovascular complications in VADT, ADVANCE and ACCORD.2-4 In fact, strict glycemic control increased cardiovascular events in patients who experienced hypoglycemic episodes. Secondary analysis of ADVANCE data found that participants with severe hypoglycemic episodes had significantly higher adjusted risk of major cardiovascular events and death from major cardiovascular events.10 This is explained by the pathophysiology of hypoglycemia in patients with underlying cardiovascular disease, in whom low blood glucose and the resultant catecholamine surge can induce cardiac arrhythmias, contribute to sudden cardiac death, and cause ischemic cerebral damage