From Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (N.J.P., A.M.N., K.S.P., J.B.G., Y.L., E.D.P.); Diabetes Trials Unit, Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, United Kingdom (M.A.B., R.R.H.); Canadian VIGOUR Centre, University of Alberta, Edmonton, Canada (P.W.A.); St. Michael’s Hospital, University of Toronto, Ontario, Canada (R.G.J.); Division of Cardiology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas (D.K.M.); Noordwest Ziekenhuisgroep, Department of Cardiology, Alkmaar, the Netherlands (J.C.H.); Department of Cardiology, Oslo University Hospital, and University of Oslo, Norway (S.H.); University of Helsinki and Helsinki University Hospital, Finland (T.E.S.); University of Oulu, Center for Life Course Health Research, Finland (T.E.S.); and Department of Endocrinology and Metabolism, School of Medicine (Kastamonu), Hacettepe University, Ankara, Turkey (T.D.).
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Background:Intensive risk factor modification significantly improves outcomes for patients with diabetes mellitus and cardiovascular disease. However, the degree to which secondary prevention treatment goals are achieved in international clinical practice is unknown.Methods:Attainment of 5 secondary prevention parameters—aspirin use, lipid control (low-density lipoprotein cholesterol <70 mg/dL or statin therapy), blood pressure control (<140 mm Hg systolic, <90 mm Hg diastolic), angiotensin-converting enzyme inhibitor or angiotensin receptor blocker use, and nonsmoking status—was evaluated among 13 616 patients from 38 countries with diabetes mellitus and known cardiovascular disease at entry into TECOS (Trial Evaluating Cardiovascular Outcomes With Sitagliptin). Logistic regression was used to evaluate the association between individual and regional factors and secondary prevention achievement at baseline. Cox proportional hazards regression analysis was used to determine the association between baseline secondary prevention achievement and cardiovascular death, myocardial infarction, or stroke.Results:Overall, 29.9% of patients with diabetes mellitus and cardiovascular disease achieved all 5 secondary prevention parameters at baseline, although 71.8% achieved at least 4 parameters. North America had the highest proportion (41.2%), whereas Western Europe, Eastern Europe, and Latin America had proportions of ≈25%. Individually, blood pressure control (57.9%) had the lowest overall attainment, whereas nonsmoking status had the highest (89%). Over a median 3.0 years of follow-up, a higher baseline secondary prevention score was associated with improved outcomes in a step-wise graded relationship (adjusted hazard ratio, 0.60; 95% confidence interval, 0.47–0.77 for those patients achieving all 5 measures versus those achieving ≤2).Conclusions:In an international trial population, significant opportunities exist to improve the quality of cardiovascular secondary prevention care among patients with diabetes mellitus and cardiovascular disease, which in turn could lead to reduced risk of downstream cardiovascular events.Clinical Trial Registration:URL: http://www.clinicaltrials.gov. Unique identifier: NCT00790205.