Madam, In the last 20 years studies have indicated that smoking cessation, beta blockers, anti-platelet agents, ACE-inhibitors and lipid lowering agents, reduce the risk of vascular events to a moderate but important degree.1-2 Diabetics have 3-5 times higher risk of coronary heart disease (CHD) death at each level of blood cholesterol than non-diabetic subjects.3 4S, CARE, LIPID and HPS studies have clearly shown that all patients with vascular disease would benefit from statins including the elderly (>75 years of age), women, having LDL < 96 mg/dl, diabetics with no CHD and patients having stroke or peripheral vascular disease.
Although statins prescription has increased in recent years, it is still below the recommended level of treatment as seen in health survey of England which showed that only 19.9% of adults with CHD were receiving lipid-lowering drugs.4
We did a study to assess the use of lipid lowering drugs - Statins in type 2 diabetics coming to our institute (a tertiary diabetes care unit).
First visit records of type-2 diabetic patients older than 18 years who attended the OPD of Baqai Institute of Diabetology and Endocrinology were analyzed. Out of 2152 diabetic patients, 502 (23.3%) were found to have macrovascular symptoms (MI, 24.9%; angina, 56.7%; stroke, 15.7%; PVD, 2.6%). Mean age for males was 57.5 years and for females was 55.9 years; while mean BMI was 25 & 27 respectively. Majority of the subjects had total blood cholesterol > than 200 mg/dl (67.4% males, 74.1% females), LDL cholesterol >130 mg/dl (78.7% males, 80.6% females) and HDL <40 mg/dl in males (69.4%) while <50 mg/dl in females (81.7%).
Only one fourth (16.5%) of diabetic subjects with macrovascular disease were taking statins indicating an alarming trend which has also been reported elsewhere.5 The results of our study indicated that males, relatively more affluent subjects, older diabetics, those having angina and having elevated triglycerides are more likely to be treated by statins.
The very low statins prescribing rate in CHD subjects, is a cause for concern especially since 80% of CHD occurs in developing countries. Physicians are aware about the potential gains from the currently available strategies and it is hoped that enough studies have been done to prove that statins should be prescribed for the vast majority of diabetic patients with CHD in both primary and secondary care. Thus there is a need to review the treatment of all diabetic patients with CHD and make sure that patients receive the benefits of starting early treatment.

We acknowledge the co-operation of PharmEvo Pakistan for providing financial support to the Research department, BIDE. A. Basit, M. Z. I. Hydrie, M. Y. Ahmedani
Baqai Institute of Diabetology and Endocrinology, Baqai Medical University, Karachi.

References

1. Fitzgerald (editorial). Collaborative meta-analysis of randomized trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients. BMJ 2002;324:71-86.
2. Heart Outcomes Prevention Evaluation Study Investigators. Effects of an Angiotensin-converting-enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients. N Engl J Med 2000;342:145-53.
3. Stamler J, Vaccaro O, Neaton JD, et al. Diabetes, other risk factors and 12-year cardiovascular mortality for men screened in the multiple risk factor intervention trial. Diabetes Care1993;16:434-44.
4. Wood D, Durrington P, Mcinnes P, et al. Joint British recommendations on prevention of coronary heart disease in clinical practice. Heart 1998;80 (Suppl 2):S1-29.
5. Reid FDA, Cook DG, Whincup PH. Use of statins in the secondary prevention of coronary heart disease: is treatment equitable? Heart 2002;88:15-19.