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Does Normalizing A1c Reduce Cardiac Risk or Raise It?


From The Book of Blood Sugar 101 what They do not tell you about Diabetes by Jenny Ruhl

Two large studies published within weeks of each other in early 2008 came to dramatically different results on this question.  Sadly, because most doctors have time only to read the headlines and don’t look into the details of these studies, many patients are being given the toxic—and inaccurate—advice to keep their A1cs high to protect their hearts. The first published study, called ACCORD, found that a population of people with diabetes and heart disease who had followed an aggressive program of lowering blood sugar had slightly more heart attack deaths than a control group who pursued laxer blood sugar control even though the group who followed the aggressive program attained an average A1c of 6.4%. However, the second study, ADVANCE, which had enrolled twice as many subjects as ACCORD and lasted longer, found no increase in deaths in the group of participants treated more aggressively. They too attained an average A1c of 6.4%.
Subsequent analyses of the ACCORD data revealed what it was that was to blame for the very slight increase in mortality in the group shooting for lowered A1cs: high blood sugars.
Though people in the ACCORD “tight control” group were shooting for lower A1cs, many in that group did not achieve them, and it was those people who appear to have had a higher risk of death. As one analysis concluded, “Higher average A1C was associated with greater risk of death.” [emphasis mine] A principle investigator for one site involved in the ACCORD study is also quoted as saying.

 A1c below 7% alone does not appear to explain the excess deaths in the ACCORD trial and is not necessarily a predictor of mortality risk. ... Further, the rate of one-year change in A1c showed that a greater decline in A1c was associated with a lower risk of death.



The Heart-Toxic Drugs Avandia and Actos Were Also to Blame

There are many different ways to lower A1c—but in both these studies patients eating high carbohydrate/low fat diets controlled their blood sugars entirely through the use of antidiabetic drugs. Which drugs were used varied from study to study. Supplementary material published with the ADVANCE study, the one which found no increase in deaths in the group that lowered A1c, shows that ADVANCE relied mostly on the sulfonylurea drug, gliclazide, which as we will see later, in Chapter Eight, is a safe drug that doesn’t harm the heart.  Patients in ADVANCE who did not get to goal with gliclazide were put on metformin and several other drugs including basal and fast acting insulin. But only 32 (.6%) of the 5,571 people in the intensive control arm of ADVANCE were taking Avandia or Actos.

The case was very different in ACCORD. 4,702 of the 5,128 people in the intensive treatment arm of ACCORD were taking either Avandia or Actos—and 91.7% of those were taking Avandia. As you’ll read in Chapter Eight, it is now known that Avandia causes heart attacks. Both Avandia and Actos can also cause heart failure. Another bit of information that got lost in the reporting about ACCORD is that the full text of the research paper makes it clear that the increased risk of excess death in the tight control group was largely found in people who had already experienced heart attacks before the study started—those who would have been most prone to the heart failure Actos and Avandia promote. Among those who had not had heart attacks before the study, the risk of heart disease dropped with tight control.

 

If your doctor warns you that lowering your A1c below 6.5% raises the risk of heart attack, share these findings with him—the citations can be found in the Reference section of this book. And remind your doctor, too, that both ADVANCE and ACCORD found that lowering A1c lowered the incidence of the classic diabetic complications—neuropathy, retinopathy, and kidney disease.

This is exactly copied from Jenny Ruhl book of Blood sugar 101

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