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• ACCORD ? ADVANCE ? VADT trials

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• UKPDS??????A1C???????? 0.9
• ????(Kumamoto Study) ??????A1C????? 2
• ?????????????????62? ?A1C lt 6.5,??????????????

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• 2006???36???????????

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• ???????????51.6 ?g/min (meanSD)
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• ??????? (macroalbuminuria)gt200 ?g/min
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• ?????? (normoalbuminuria)lt20 ?g/min

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R.ROSS, NEJM 1999 340117
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Figure 2. Fatty-Streak Formation in
Atherosclerosis.
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Figure 3. Formation of an Advanced, Complicated
Lesion of Atherosclerosis.
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Figure 4. Unstable Fibrous Plaques in
Atherosclerosis.
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LDL????????????,?????????????????????????
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Aspirin and Antioxidants

• The prevention of progression of arterial disease
  and diabetes (POPADAD) trial factorial
  randomised placebo controlled trial of aspirin
  and antioxidants in patients with diabetes and
  asymptomatic peripheral arterial disease
• Jill Belch et al. BMJ 2008337a1840

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Aspirin and Antioxidants

• Design Multicentre, randomised, double blind,
  22 factorial, placebo controlled trial.
• Setting 16 hospital centres in Scotland,
  supported by 188 primary care groups.
• Participants 1276 adults aged 40 or more with
  type 1 or type 2 diabetes and an ankle brachial
  pressure index of 0.99 or less but no symptomatic
  cardiovascular disease.

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Aspirin and Antioxidants

• Interventions Daily, 100 mg aspirin tablet plus
  antioxidant capsule (n320), aspirin tablet plus
  placebo capsule (n318), placebo tablet plus
  antioxidant capsule (n320), or placebo tablet
  plus placebo capsule (n318).
• Main outcome measures Two hierarchical composite
  primary end points of death from coronary heart
  disease or stroke, non-fatal myocardial
  infarction or stroke, or amputation above the
  ankle for critical limb ischaemia and death from
  coronary heart disease or stroke.

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Aspirin and Antioxidants

• Results No evidence was found of any interaction
  between aspirin and antioxidant. Overall, 116 of
  638 primary events occurred in the aspirin groups
  compared with 117 of 638 in the no aspirin groups
  (18.2 v 18.3) hazard ratio 0.98 (95
  confidence interval 0.76 to 1.26). Forty three
  deaths from coronary heart disease or stroke
  occurred in the aspirin groups compared with 35
  in the no aspirin groups (6.7 v 5.5) 1.23
  (0.79 to 1.93). Among the antioxidant groups 117
  of 640 (18.3) primary events occurred compared
  with 116 of 636 (18.2) in the no antioxidant
  groups (1.03, 0.79 to 1.33). Forty two (6.6)
  deaths from coronary heart disease or stroke
  occurred in the antioxidant groups compared with
  36 (5.7) in the no antioxidant groups (1.21,
  0.78 to 1.89).

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Aspirin and Antioxidants

• Conclusion This trial does not provide evidence
  to support the use of aspirin or antioxidants in
  primary prevention of cardiovascular events and
  mortality in the population with diabetes studied.

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Glycemic Control in Diabetes A Tale of Three
Studies

• BLOOMGARDEN DIABETES CARE, VOLUME 31, NUMBER 9,
  SEPTEMBER 2008
• ACCORD
• ADVANCE
• The VADT A1C 6.9 vs. 8.4