Action to Control Cardiovascular Risk in Diabetes (ACCORD)
Action to Control Cardiovascular Risk in Diabetes (ACCORD)
The purpose of this study is to prevent major cardiovascular events (heart attack, stroke, or
 cardiovascular death) in adults with type 2 diabetes mellitus using intensive glycemic
 control, intensive blood pressure control, and multiple lipid management.
BACKGROUND:

 Currently, about 17 million Americans have been diagnosed with diabetes and more than 90
 percent of them have type 2 diabetes. The number of people with this form of diabetes,
 formerly known as adult onset or non-insulin dependent diabetes, is growing rapidly. By 2050,
 the number of Americans with diagnosed diabetes is projected to increase by 165 percent to 29
 million, of whom 27 million will have the type 2 form. Cardiovascular disease (CVD) is the
 leading cause of death in people with type 2 diabetes; these individuals die of CVD at rates
 two to four times higher than those who do not have diabetes. They also experience more
 nonfatal heart attacks and strokes.

 Type 2 diabetes is associated with older age and is more common in those who are overweight
 or obese and have a family history of diabetes. Women with a history of diabetes during
 pregnancy, adults with impaired glucose tolerance, people with a sedentary lifestyle, and
 members of a minority race/ethnicity are also at a greater risk for developing type 2
 diabetes. African Americans, Hispanic/Latino Americans, American Indians, and some Asian
 Americans and Pacific Islanders are at particularly high risk for type 2 diabetes.

 DESIGN NARRATIVE:

 The three strategies tested in ACCORD included the following: (1) Blood sugar - ACCORD was
 designed to determine whether lowering blood glucose to a level closer to normal than called
 for in current guidelines reduces CVD risk. The study estimated effects on CVD of that level
 compared with a level that is usually targeted. (2) Blood pressure - many people with type 2
 diabetes have high blood pressure. The blood pressure part of the trial was designed to
 determine the effects of lowering blood pressure in the context of good blood sugar control,
 that is to determine whether lowering blood pressure to normal (systolic pressure less than
 120 mm Hg) will better reduce CVD risk, as compared to a usually-targeted level in current
 clinical practice (i.e., below the definition of hypertension; systolic pressure less than
 140 mm Hg). (3) Blood Fats - Many people with diabetes have high levels of LDL ("bad")
 cholesterol and triglycerides, as well as low levels of HDL ("good") cholesterol. ACCORD
 participants who are selected for this part of the trial were assigned to an intervention to
 improve blood fat levels. This part of the study looked at the effects of lowering LDL
 cholesterol and blood triglycerides and increasing HDL cholesterol compared to an
 intervention that only lowers LDL cholesterol, all in the context of good blood sugar
 control. A drug from a class of drugs called "fibrates" was used to lower triglycerides and
 increase HDL cholesterol, whereas a drug from the class of drugs called "statins" was used to
 lower LDL cholesterol.

 All ACCORD participants received blood sugar treatment from the study. Based on the second
 trial (Blood Pressure or Lipid) they were assigned to, participants also received their high
 blood pressure or cholesterol care from the study. Study participants received all medication
 and treatments related to the study free of charge. Individuals who selected for and
 consented to participate in the ACCORD study continued to see their personal physician for
 all other health care.

 In summary, the ACCORD Study was a double 2x2 factorial design with factors consisting of:
 intensive versus standard glycemic control, intensive versus standard blood pressure control,
 and blinded fenofibrate or placebo in combination with simvastatin to maintain desirable
 LDL-C levels. All 10,251 participants were randomized to the glycemic interventions; a
 subgroup of 4,733 participants who met the blood pressure entry criteria were randomized to
 the blood pressure interventions in one 2x2 trial; and a distinct subgroup of 5,518
 participants who met the lipid entry criteria were randomized to the lipid interventions in
 the second 2x2 trial. All participants had established type 2 diabetes and were recruited
 from 77 clinical centers in the United States (64 sites) and Canada (13 sites).

 On February 6, 2008, the National Heart, Lung and Blood Institute (NHLBI) announced that
 participants in the intensive glycemia treatment would be transitioned to the ACCORD standard
 glycemic treatment approach due to higher mortality in the intensive treatment group
 terminating the experimental arm of the Glycemia Trial early. The Blood Pressure and Lipid
 trials continued as designed to their planned termination in 2009.
Inclusion Criteria:

 -  Diagnosed with type 2 diabetes mellitus, as determined by the new American Diabetes
 Association guidelines, which include a fasting plasma glucose level greater than 126
 mg/dl (7.0 mmol/l), or a 2-hour postload value in the oral glucose tolerance test of
 greater than 200 mg/dl, with confirmation by a retest

 -  For participants aged 40 years or older, history of CVD (heart attack, stroke, history
 of coronary revascularization, history of peripheral or carotid revascularization, or
 demonstrated angina)

 -  For participants aged 55 years or older, a history of CVD is not required, but
 participant must be considered to be at high risk for experiencing a CVD event due to
 existing CVD, subclinical disease, or 2+ CVD risk factors

 -  HbA1c 7.5%-9% (if on more drugs) or 7.5%-11% (if on fewer drugs)