Combination lipid therapy in type 2 diabetes.

To the Editor: In the Action to Control Car­ diovascular Risk in Diabetes (ACCORD) trial (ClinicalTrials.gov number, NCT00000620) report­ ed on by Ginsberg et al. (April 29 issue),1 the use of fenofibrate in patients with type 2 diabetes mellitus who were receiving simvastatin and who were at high risk for cardiovascular disease great­ ly reduced triglyceride levels but hardly increased levels of high­density lipoprotein (HDL) cholester­ ol and did not reduce cardiovascular risk. To put these findings into context, it is important to know which lipid variables most strongly predict risk among high­risk patients who receive statins. We therefore prospectively recorded vascular events among 491 patients with angiographically proven coronary artery disease who were receiv­ ing statins. The event rate was 40.5% over 7.2 years. In a Cox regression model including, in addition to lipid variables, age, sex, body­mass index, smoking status, hypertension, and type 2 diabetes, the HDL cholesterol level significantly predicted vascular risk (standardized adjusted hazard ratio, 0.82; 95% confidence interval [CI], 0.68 to 0.99; P = 0.04), whereas the level of triglyc­ erides did not (hazard ratio, 1.12; 95% CI, 0.97 to 1.30; P = 0.11). This finding, in particular, held true among patients with type 2 diabetes: the HDL cholesterol level predicted risk (hazard ratio, 0.70; 95% CI, 0.50 to 0.99; P = 0.04), whereas the level of triglycerides did not (hazard ratio, 1.16; 95% CI, 0.97 to 1.38; P = 0.10). In light of these data and of the encouraging results from surro­ gate end­point trials,2,3 drugs such as niacin that increase the level of HDL cholesterol remain a very promising option to reduce the residual vascular risk after the failure of fenofibrate, which pri­ marily lowers levels of triglycerides. Christoph H. Saely, M.D.