New-onset diabetes, antihypertensive treatment, and outcome.

New-onset diabetes (NOD) confers increased risk for cardiovascular disease and all-cause mortality in different clinical settings.1,2 In the specific context of hypertensive subjects exposed to the long-term effects of antihypertensive drugs, a study from our group3 and a recent 28-year follow-up study from Sweden4 showed a greater risk of major cardiovascular disease in hypertensive subjects who developed NOD than in those who did not. Notably, the yearly incidence of NOD ranged from 1.0% in the Swedish study4 to 1.9% in our study.3 This issue of Hypertension hosts a posthoc analysis of the Valsartan Antihypertensive Long-term Use Evaluation (VALUE) database, which tested the hypothesis that NOD is a predictor of cardiac morbidity and cardiac and all-cause mortality.5 The hypertensive subjects who developed NOD showed a 43% higher risk of cardiac morbidity (ie, a composite of sudden death, myocardial infarction, death associated with revascularization, and congestive heart failure requiring hospitalization) when compared with those who did not develop diabetes. When the determinants of the composite pool of cardiovascular events were examined separately, NOD was associated with a marginally higher risk of myocardial infarction (hazard ratio [HR]: 1.30; 95% CI: 0.99 to 1.70; P 0.057) and a significantly higher risk of congestive heart failure (HR: 1.41; 95% CI: 1.06 to 1.87; P 0.017). These findings are in full agreement with a recent report from the ONgoing Telmisartan Alone and in combination with Ramipril Global Endpoint Trial (ONTARGET), in which NOD was associated with a 74% excess risk of congestive heart failure requiring hospitalization.6 In the analysis of the VALUE database, all-cause mortality (HR: 0.61; 95% CI: 0.48 to 0.77) and cardiac mortality (HR: 0.44; 95% CI: 0.28 to 0.70) were lower, not higher, in the subjects with NOD than in their nondiabetic counterparts. Despite some obvious caveats, including the relatively small number of fatal events and the shorter follow-up time in the subjects with NOD than in those without NOD, an interesting potential explanation of these results might be the more aggressive treatment reserved by the VALUE trialists to the subjects with NOD. Statins, aspirin, -blockers, and diuretics were given more frequently to subjects who developed NOD than to those who did not, and all of the differences between the 2 groups were statistically significant.5 This analysis of the VALUE Study confirms that NOD predicts an excess risk of cardiac morbidity and brings in the hypothesis that intensive treatment of cardiovascular risk factors in these subjects might be a rewarding strategy to reduce mortality.