Primary prevention of cardiovascular disease with atorvastatin in type 2 diabetes in the Collaborative Atorvastatin Diabetes Study (CARDS): multicentre randomised placebo-controlled trial

Introduction Type 2 diabetes is associated with a two to fourfold increased risk of both coronary heart disease and stroke. Case-fatality rates for myocardial infarction and stroke are also raised, emphasising the need for primary prevention. Findings of observational studies suggest that lipid lowering should have an important place in the primary prevention of cardiovascular disease in people with diabetes. Although LDL-cholesterol is not usually greatly increased in such individuals, it is as least as strong a predictor of coronary heart disease risk as in the general population. In the UK Prospective Diabetes Study, a 1·57-fold increased risk of coronary heart disease was reported for every 1 mmol/L increment in LDLcholesterol. LDL-cholesterol also predicts stroke risk in patients with type 2 diabetes. Trials that included participants with diabetes and coronary heart disease have shown that cholesterol lowering with statins substantially reduces risk of subsequent cardiovascular events. The benefit of lipid lowering for primary prevention of cardiovascular disease is based on evidence showing a significant 33% reduction of this disorder in 2912 patients with diabetes but no previous occlusive vascular disease in the Heart Protection Study (HPS) and a non-significant 16% reduction in coronary heart disease in 2532 hypertensive patients with diabetes without previous occurrence of coronary heart disease in the Anglo-Scandinavian Cardiac Outcomes Trial-Lipid Lowering Arm (ASCOT-LLA). Current prescription rates for lipid lowering in patients with diabetes remain low, even in those with existing cardiovascular disease. Researchers on the international AUDIT study reported that most diabetes specialists were not convinced of the need for lipid lowering down to current guideline targets for primary prevention of cardiovascular disease in type 2 diabetes. Lancet 2004; 364: 685–96