Program is not suitable for diabetic patients

EDITOR—Hingorani and Vallance describe a clinic based computer program for the management of cardiovascular risk factors.1 However, the program has limitations for diabetic patients.

This program and previous methods, together with the recent joint British recommendations,2 are based on algorithms derived from the Framingham heart study of 5573 people aged 30-74 years originally screened in 1968. However, only 4% (237 subjects) of this cohort had diabetes, as defined by a random glucose concentration >9 mmol/l or the use of diabetic treatment. Importantly, diabetes was not classified according to type, and the presence of proteinuria or microalbuminuria (important cardiovascular risk factors in diabetes) were not included.

The prevalence and characteristics of other risk factors further highlight that people with diabetes are not average patients3; “diabetic dyslipidaemia,” increased prevalence of hypertension, and ethnic origin (for example, south Asian) contribute to an increased atherogenic potential. Despite the strong link between triglyceride concentration and coronary heart disease in diabetes, this important risk factor was omitted from the program.

The glycaemic state was included in the program as a risk factor both as “diabetes” and as a blood glucose concentration. The impact of glycaemia on cardiovascular events is not dichotomous, but, like blood pressure, has a continuous relation.4 The inclusion …