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Invited Commentary | Less Is More

Targeting Vascular Risk Factors in Older Adults From Polypill to Personalized Prevention

Enrico Mossello, MD, PhD1
[+] Author Affiliations
1Division of Geriatric Medicine and Cardiology, Department of Experimental and Clinical Medicine, University of Florence and Careggi Teaching Hospital, Florence, Italy
JAMA Intern Med. 2015;175(12):1949-1950. doi:10.1001/jamainternmed.2015.5941.
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For many years vascular disease prevention strategies have been focused on reducing undertreatment, often using a “one-size-fits-all” approach to increase patient adherence. The paradigm of this approach has been the proposal of a polypill targeting multiple vascular risk factors, a standard treatment aimed at maximizing vascular protection. Conversely, during recent years an increasing emphasis has been placed on the issue of potential overtreatment, frequently resulting from the same treatment approach in all patients despite significant individual differences in comorbidity and life expectancy. In type 2 diabetes mellitus (T2DM), data from randomized clinical trials1 have shown uncertain or negative benefit-risk trade-offs associated with aggressive treatment of hypertension and hyperglycemia. These results, added to the well-known exclusion of elderly individuals with multiple morbidities from nearly all clinical trials, have informed recent guidelines, which now recommend more moderate targets for treatment of T2DM and hypertension in older participants, especially those considered frail or affected by important comorbidities.1

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Proposed Stratification of Antihypertensive and Antidiabetic Treatment in Type 2 Diabetes Mellitus According to Patient Vulnerability

Solid line with arrowhead indicates standard vascular risk control strategy. Dashed lines with arrowheads indicate possible vascular risk control strategies for robust and vulnerable patients, with question marks pointing out the need for a choice. Gray box presents the proposed approach for vulnerable individuals. HbA1c indicates hemoglobin A1c; RCTs, randomized clinical trials; SBP, systolic blood pressure; and T2DM, type 2 diabetes mellitus. To convert HbA1c to a proportion of total hemoglobin, multiply by 0.01.

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