[Guidelines on cardiovascular disease prevention in clinical practice. Belgian Working Group on Cardiovascular Prevention and Rehabilitation]. / Recommandations relatives a la prévention des maladies cardiovasculaires en pratique clinique. Groupe de travail belge de prévention des maladies cardiovasculaires.

Since more than 15 years, expert groups and various European Scientific Societies have written Guidelines on Cardiovascular Disease Prevention. Because of the rapid evolution of science, it is necessary to adapt regularly these guidelines. The last version dates from 2007 and has been written by the " Fourth Joint Task Force of European and other Societies on Cardiovascular Disease Prevention in Clinical Practice ". In this issue, the more recent Guidelines are summarised and we focus on highlighting the aspects of these Guidelines that have changed since the previous version published in this journal in 2005.

[Omega-3 fatty acids and cardiovascular diseases]. / Les acides gras oméga-3 et les pathologies cardio-vasculaires.

Most--but not all--epidemiological studies have demonstrated that omega-3 intake, either from nutrition or supplementation, reduces cardiovascular risk. A few intervention studies have shown a reduction of studden death in patients followed after a myocardial infarction. However EBM studies from the Cochrane Library do not confirm the real advantage of omega-3 in any group of subjects. Probably, the most interesting prescription of omega-3 supplementations would benefit to the patients after myocardial infarction, in addition to drugs that have proved their efficacy (aspirine, beta-blocker statin and ACE inhibitor).

[Inhaled human insulin (Exubera): a revolution?]. / L'insulinothérapie par voie inhalée (Exubera), une révolution?

Type 2 diabetes is a step by step process which, at the end, leads to insulin injections. This last step is accomplished in many cases with great delay which increases the risk of micro- and macro-vascular complications. Patients are often reluctant to accept insulin injections and clinicians frequently postpone insulin prescription for many reasons. Any method which could favour more insulin initiation is welcome and this is the case with inhaled insulin. Efficacy has been demonstrated in type 2 and type 1 patients as well as safety if indications are strictly followed by patients and physicians. Long-term results (about 4 years) have been published, indicating efficacy and safety. At the present time, no cost/benefit study has been published and the extra cost of such a treatment will probably retard its clinical application.

[Hospital in-patients with diabetes]. / Le patient diabétique hospitalisé.

As the diabetic population is becoming older, hospitalization is more frequent and of longer duration with increased costs. Hospital stay could be a good opportunity to improve diabetes care. All observational studies demonstrate that improving metabolic control reduces mortality, morbidity and hospitalisation costs. For critically ill patients and those referred for myocardial infarction or submitted to cardiac surgery, randomised controlled studies have proven the efficacy of strict metabolic control and defined the targets to be reached. Unfortunately, for many reasons, it is difficult to treat the patients to the targets and in non specialized departments, diabetes control may even be worse during hospitalisation. We urgently need to find innovating solutions to mitigate the consequences of the reduced number of competent nurses and doctors in the field of diabetes.

[Treatment of type 2 diabetes]. / Le traitement du diabète de type 2.

Type 2 diabetes is characterized by the association of insulin resistance and progressive failure of the beta cell function. This disease is frequently associated with the so-called syndrome X or polymetabolic syndrome which includes many cardiovascular risk factors: hyperinsulinism, hyperglycemia, postprandial hyperglycemia, hyperlipidemia and various anomalies of the coagulation system. Glycemic control is fundamental and the goals have been defined to reach them; it is necessary to start with diet and to introduce various oral hypoglycemic agents given alone or in association, if necessary. Insulin treatment is often started late in the course of the disease and this strategy is questionable. Blood pressure must reach 130-80 mmHg and polytherapy is often required to reach this target. The treatment choices will be based on the clinical status of each patient and according to the presence of additional cardiovascular risk factors, increased levels of microalbuminuria or a history of myocardial infarction. Hyperlipidemia is frequent in type 2 diabetes. Statins or fibrates will be prescribed according to predominant lipid anomalies. Clearly, the management of such patients implies many drugs and compliance is difficult. In the near future, some drugs associations will be on the market and they will certainly make the treatment of type 2 diabetes easier and compliance better.

[Atherosclerosis and nutrition]. / Athéromatose et nutrition.

Atherosclerosis is the main cause of mortality in industrialized countries and even in poorly developed ones. It is linked to age and gender and also to a number of well identified risk factors: lipids anomalies, arterial hypertension, diabetes, smoking and weight excess among others. Risk factors improvement significantly reduces cardiovascular events. It is evident that nutrition plays an important role as it can modulate the evolution of body weight and blood pressure. Nutrition is also able to reduce the prevalence and severity of hyperlipidemias and diabetes. Saturated fatty acids (excepted stearic acid), trans poly-unsaturated acids as well as cholesterol increase serum LDL-cholesterol. Mono- and poly-unsaturated and classical cis-mono-unsaturated acids do the opposite. N-3 poly-unsaturated acids reduce serum triglyceride levels and cardiovascular events. Carbohydrates with a low glycemic index are important determinants of serum HDL-cholesterol levels and reduce cardiovascular risk. Animal proteins bring essential amino-acids to the body but also saturated fats. It seems interesting to eat vegetal proteins among which those derived from soya look promising. Our diet will include enough fiber and phytosterols-containing margarines look interesting as well. Modest alcohol consumption improves cardiovascular mortality in the majority of the prospective studies.

[The importance of syndrome X in daily practice]. / L'importance du syndrome X dans la pratique quotidienne.

Metabolic syndrome X includes glucose intolerance or type 2 diabetes, dyslipidemia and arterial hypertension which are classical cardiovascular (CV) risk factors. In course of time, other CV risk factors have been added to the syndrome: rheological alterations, endothelial dysfunction, anomalies in the coagulation/fibrinolysis system, microalbuminuria and so on.... Insulin resistance is the cornerstone of metabolic syndrome X, with secondary hyperinsulinism. Upper body obesity is associated with metabolic syndrome X. Simple waist measurements can detect the subjects (10-15% of the population) at increased CV risk with a sensitivity of 70%. This is invaluable for such a simple and cheap test. Diet is the first step in treating these patients and reducing caloric intake is necessary in most of them. Saturated fats will be replaced by polyunsaturated and mono-unsaturated ones. Long-chain carbohydrates with low glycemic index will be suggested. Regular physical activity will be promoted. If these life style modifications fail, drugs can be added: biguanide and glitazone are good candidates. Orlistat has improved metabolic syndrome X on a long-term basis. Drugs that could increase insulin resistance are to be avoided.

Usefulness of fluoxetine in obese non-insulin-dependent diabetics: a multicenter study.

Weight reduction is essential in the management of most non-insulin-dependent diabetics, but this therapeutical goal is difficult to obtain. In this double-blind parallel study, 82 non-insulin-dependent diabetics, moderately obese (BMI = 30 - 39 kg/m2), were given for an 8-week period either placebo (P) or fluoxetine (F), a specific serotonin reuptake inhibitor, in addition to their usual antidiabetic treatment. Thirty-nine of them received 60 mg fluoxetine a day and 43 were given the placebo. At admission, both groups had similar weight excess, metabolic control and serum lipid values. In comparison with the P-treated subjects, those treated with fluoxetine (F) lost more weight after 3 weeks (-1.9 vs. -0.7 kg, p < -0.0009) and after 8 weeks (-3.1 vs. -0.9 kg, p < 0.0007). Fasting blood glucose decreased in group F after 3 weeks (-1.5 vs -0.4 mmol/L, p < 0.003) and after 8 weeks (-1.7 vs. -0.02 mmol/L, p < 0.0004). HbAlc decreased from 8.5% to 7.7% in group F and from 8.6% to 8.3% in group P (p = 0.057). Mean triglyceride level was also reduced in group F after 8 weeks (p = 0.042). Fasting C-peptide did not change in either group, but fasting insulin values decreased in group F after 3 weeks (p < 0.02) and after 8 weeks (p < 0.05). The insulin/C-peptide molar ratio decreased significantly in group F after 3 weeks (p < 0.04) and after 8 weeks (p < 0.05) in comparison with group P. The drug was generally well tolerated and no major side effects were reported. In conclusion, the addition of fluoxetine to the usual oral hypoglycemic agent therapy might be beneficial in obese non-insulin-dependent diabetics, at least on a short-term basis.

Efficacy of simvastatin for lowering cholesterol in non-insulin dependent diabetic patients with hypercholesterolemia.

Patients with non-insulin-dependent diabetes mellitus (NIDDM) are at high risk of cardiovascular disease for many reasons and especially due to the fact that dyslipidemias are more frequent in this group of patients. Fibrate derivatives are the drugs of choice when hypertriglyceridemia is the main lipid anomaly. When hypercholesterolemia is predominant, the use of resins and nicotinic acid has been advocated but these drugs are poorly tolerated on a long-term basis. We assessed the effect of simvastatin, a recent HMG-CoA reductase inhibitor in 12 NIDDM patients with hypercholesterolemia. After 4 weeks of placebo, which did not significantly modify the lipid values, patients were given simvastatin at increasing dosages (from 10 to a maximum of 40 mg daily) during 24 weeks. Compliance and clinical tolerance were excellent. There was no major biological side effect, but a significant deterioration of glucose control was noted at the end of the study. Simvastatin reduced total cholesterol by 28%, LDL-cholesterol by 36% and apo B by 31%. Concomitantly, there was an increase of HDL-cholesterol by 15%. This improvement of lipid profile persisted during the 24 weeks of treatment. Comparing the patients with pure hypercholesterolemia to those presenting combined hyperlipidemia, it was evident that the hypolipidemic effect was more marked in the diabetic subjects with combined hyperlipidemia.

[Hyperlipidemia and atherosclerosis: epidemiology, biochemistry and therapy]. / Hyperlipidémie et athérosclérose: épidémiologie, biochimie et thérapeutique.

Cardiovascular diseases cause 40% of deaths in Belgium. The coronary risk is more important in the Southern than in the Northern part of the country, owing probably to different levels of serum cholesterol due to different fat contents of the diet. The features of lipoprotein metabolism are mainly the permanent transfer of apoproteins and the dynamic exchange of neutral lipids. Atherogenic particles include remnants enriched in cholesterol esters and low density lipoproteins (LDL) after their oxidation. New European guidelines insist more on secondary prevention than on primary prevention.

Fluoxetine therapy in obese diabetic and glucose intolerant patients.

A double-blind placebo-controlled trial was conducted, involving 97 obese diabetic and glucose intolerant patients receiving either 60 mg fluoxetine daily (47 patients) or a placebo (50 patients); a similar calorie-restricted diet was prescribed to all patients. Weight loss was significantly higher in the fluoxetine-treated patients, whose diabetic status improved. Drop-out rate was not significantly different for both groups of patients.

[Results of weight-loss treatment at a hospital. Significance of the administration of triiodothyronine in small doses during a protein diet]. / Résultats de cures amaigrissantes en milieu hospitalier. Intérêt de l'administration de triiodothyronine à petites doses au cours de la diète protidique.

We report the short-term effects of very-low-calorie liquid formula diet (n = 51) and of 600 Kcalories diet (n = 13) in patients who were hospitalized during 3 weeks. Weight loss averaged 278 +/- 14 g/day (m +/- SEM). It was slightly higher with the very-low-calorie liquid formula diet (293 +/- 21 g vs 242 +/- 25 g, N.S.). Individual weight-loss was unpredictable and highly variable; it ranged from 62 to 636 g/day. During the very-low-calorie formula diet, the expected low T3 syndrome was observed and 12 patients were given T3 (25 micrograms during the second week and 50 micrograms during the third week). These rather small doses corrected T3 values, but lowered total and free T4 levels. T3 administration did not modify the magnitude of weight loss in our patients.

The usefulness of fructosamine determination in diabetic patients and its relation to metabolic control.

In 116 diabetics and 101 control subjects, we measured both HbA1 and fructosamine values, neither could definitely separate the 2 populations. We observed an excellent correlation between both variables and between each of them and various other parameters of metabolic control. It appeared that the correlation with recent (4 weeks) diabetes control was better with fructosamine than with HbA1 levels. The opposite was true when a 8 week period was considered. The presence of diabetic complications did not modify the fructosamine levels. These results confirm the value of fructosamine measurement in the evaluation of recent diabetes control, but clearly, HbA1 determination remains the best parameter of long-term glycemic control.