Macrovascular risk factor treatment of persons with type 2 diabetes

Brian Hoogwerf (Cleveland, OH) discussed the use of angiotensin-converting enzyme inhibitors (ACEIs). Physiologically, the renal effect of the agents appears to involve lowering of intrarenal pressures. Early studies showed the importance of blood pressure treatment in protecting against loss of renal function (1,2). With growing evidence that captopril preserves renal function in patients with type 1 diabetes and established nephropathy (3), this treatment has gradually gained prominence. Further study showed a long-term effect of ACEIs on the development of nephropathy in persons with type 2 diabetes, showing stabilization of albuminuria and creatinine clearance with enalapril with both hypertension (4) and normal blood pressure (5). Finally, the Heart Outcomes Prevention Evaluation (HOPE) study of >3,500 subjects with diabetes who had a previous cardiovascular disease (CVD) event or at least one other CVD risk factor treated with ramipril 10 mg vs. placebo produced a 25% decrease in primary outcome of myocardial infarction, stroke, or CVD death over 4.5 years, which appeared to progressively improve with longer duration of ACEI treatment (6). Albuminuria progression also decreased. Hoogwerf concluded by pointing out that albuminuria has a continuous and graded relationship to CVD risk (7) and that risk reduction is seen regardless of renal insufficiency, diabetes, or hypertension (8).

A metaregression analysis has shown that the decrease in proteinuria with ACEIs is independent of change in blood pressure, duration of treatment, type of diabetes, or stage of nephropathy, in contrast with other antihypertensive treatments, with which the degree of benefit is related to blood pressure reduction (9). Furthermore, there is evidence from analysis of 698 patients with type 1 diabetes in 12 …