Physicians' Academy for Cardiovascular Education

BP regulation appears central to CV benefit seen with improved glycemic control

Blood Sugar Regulation for Cardiovascular Health Promotion and Disease Prevention

Literature - Schwarz PEH, Timpel P, Harst L, et al. - J Am Coll Cardiol 2018;72:1829–44

Introduction and methods

Hyperglycemia is a modifiable risk factor for the development of CV disease (CVD), and pre-diabetes is a major risk factor for progression to type 2 diabetes (T2DM), which is associated with elevated CV risk. The effective reduction of hyperglycemia decreases CVD risk, mainly through the reduction of non-fatal events [1-3].

It would be useful to know which interventions provide the most benefit. While conventional glucose-lowering agents have not shown significant macrovascular benefits, newer agents did show reductions in hard CVD endpoints [4-6]. It is important to understand the mechanisms tackled by the individual approaches to regulate blood glucose, including lifestyle interventions, in order to guide individual- or population-based prevention.

The primary objective of this umbrella review is to investigate which of the following interventions are most helpful in lowering blood glucose-related CV risk, which may inform therapeutic decisions by better consideration of blood glucose regulation pathways involved:

Moreover, studies related to competencies and standardized health promotion care pathways were identified and analyzed. For this purpose, 44 systematic reviews of randomized clinical trials or meta-analyses reporting glucose-related outcomes, published in 2016 and 2017, of good to very good quality, were included for data extraction and analysis. For quality assessment of the identified reviews, a modified version of Oxman and Guyatt’s OQAQ was used [7], and studies with an OQAQ score <14 were rejected.

Main results

Pharmacological interventions:

Evidence-based individual-level interventions for supporting behavior change to regulate glycemia

Evidence-based population-level interventions for supporting behavior change to regulate glycemia

Competencies and standardized health promotion care pathways

Recommendations based on the findings of this umbrella review are summarized in two tables in the article.


This review of recent high-quality systematic reviews and meta-analyses demonstrates that intensive glucose lowering can reduce both microvascular and macrovascular morbidities and CV mortality.. The results with patients treated with insulin and sulfonylureas suggest that glucose lowering in itself does not reduce CV events. Pharmacological interventions improving glycemic control and multifactorial approaches can reduce CV outcomes, and BP regulation seems to be a key pathway mediating this effect. Nonpharmaceutical interventions can also efficiently reduce blood glucose, as well as BP and dyslipidemia. Multidisciplinary teams are effective in delivering multicomponent interventions in community-based settings.


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Find this article online at J Am Coll Cardiol

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