Heart protection: a key target in the management of patients with diabetes.

Cardiovascular disease is responsible for 70% of all mortality among patients with type 2 diabetes and is also a major contributor to diabetes-related healthcare costs. The ADVANCE trial clearly demonstrated that a simple and easily applicable pharmacological strategy based on perindopril/indapamide fixed combination could substantially reduce total and cardiovascular mortality (-14% and -18%, respectively). The observed benefits were largely caused by a substantial decrease in systolic blood pressure (SBP), confirming the need to have ambitious therapeutic goals in such high-risk patients. This point is of importance because most of the patients included in the trial were being treated for hypertension, and baseline brachial SBP and diastolic blood pressure at inclusion were very close to normal. Previous mechanistic studies have highlighted the positive effect of perindopril/indapamide fixed combination on large artery function as well as on microvascular structure. For example, in the REASON trial, in patients treated with perindopril/indapamide, the decrease in central aortic SBP, which closely correlated with the decrease in left ventricular hypertrophy, reflected a significant improvement in large artery function and a changing pattern in both peripheral reflection coefficients and structural arteriolar network. These data are supported by those from other studies, which show increases in coronary blood flow reserve with perindopril/indapamide treatment. In conclusion, normalization of SBP, pulse pressure, arterial function and myocardial perfusion, a haemodynamic profile known to improve survival in the hypertensive populations at high cardiovascular risk, seems to be more easily achieved when a strategy based on the perindopril/indapamide combination is applied.