Skip to main content

Cardiovascular events, diabetes and guidelines: the virtue of simplicity


Cardiovascular (CV) events or their minor syndromes, as various forms of ischemia, are medical emergencies that do not allow enough time for a guiding anamnesis or proper clinical examination, and lead to relying on Treatment Guidelines, but in many situations it is appropriate to deviate from them. Pathological studies have associated 75% of coronary artery events with atherosclerotic plaque rupture; it is now known that rupture alone is not enough for obstruction or occlusion of the vessel lumen. Concomitant conditions are required for the clinical manifestation of cardiovascular disease, including prothrombogenic and dysfunctional endothelium, less fibrinolytic capacity to protect it, increased platelet activation, increased adrenergic tone, microcirculation vasoconstriction, and other countless factors that contribute to thrombus formation, causing ischemia or infarction. But in most cases, repair of plaque rupture and re endothelization of the lesion are asymptomatic and silent. Atherosclerotic process is a chronic and progressive immune inflammation. Most of the therapeutic indications include statins, which cause side effects in 10% of patients, with a range varying between 7 and 21%, according to different authors. Many investigators have proved that statin use contribute to the genesis of diabetes, reports vary between 1 and 46%, where marked elevation of blood glucose fasting levels and glycosylated hemoglobin have been observed, be it by increased tissue resistance to insulin or by reduced β-cell insulin secretion. Physicians should base their indications on the recommendations provided by Guidelines, but they should not forget that every patient is different, and they should not get confused due to lack of time in an emergency nor be influenced by the latest publications or techniques until they have been properly tested.

“If it were not for the great variability among individuals, medicine might as well be a science and not an art”

Sir William Osler

Cardiovascular (CV) events or their minor syndromes, as various forms of ischemia, are medical emergencies that do not allow enough time for a guiding anamnesis or proper clinical examination, and lead to relying on supporting complementary tests, the magic power of recent publications, or the introduction of new techniques, all factors that govern physician behavior, particularly when experience is scarce and generally not based on “real life”. Under such circumstances, relying on Treatment Guidelines is the most common and less risky approach.

Preambles in the Guidelines for Diagnosis and Treatment from scientific organizations always indicate that their main purpose is to satisfy the needs of the majority of patients in all cases. But they also point out that it is the physician who should take the final decision regarding patient care depending on the coexisting circumstances in each patient and the concepts of clinical judgment, or the so-called ‘art of medicine’. On more than one occasion, these two stances (or concepts) may not be identical and may lead to situations in which “it is appropriate to deviate from the guidelines”.

Two-thirds of CV events are caused by rupture of atherosclerotic plaques. The remaining third is attributed to endothelial erosion, calcified nodules, and other minor causes [1]. Most CV events are the result of atherosclerosis, a chronic inflammatory disease that begins at a very early age—even in the intrauterine stage—and progresses asymptomatically until the fourth or fifth decade (middle age), when it manifests abruptly as a myocardial or encephalic event or an event in other vascular territories [2].

Although pathological studies have associated 75% of coronary artery events with atherosclerotic plaque rupture, it is now known that rupture alone is not enough for obstruction or occlusion of the vessel lumen. Concomitant conditions are required for the clinical manifestation of CV disease. These conditions include a prothrombogenic, dysfunctional endothelium with little or no fibrinolytic capacity to protect it, increased platelet activation, increased adrenergic tone, arterial vasoconstriction –particularly in the microcirculation–, and other countless factors that contribute to thrombus formation, causing ischemia or infarction. When these conditions do not coexist, the thrombus is most likely lysed normalizing blood flow, the plaque heals and ends up in a fibrous nodule that usually calcifies over time increasing the calcium score in the computed tomography, or may obstructs the vessel lumen to some degree and eventually even rupture generating new inflammation and causing another CV event [3]. But in most cases, repair of plaque rupture and re endothelization of the lesion are asymptomatic and silent [4].

The inflammatory factor

Atherosclerotic process is a chronic and progressive immune inflammation, but when a CV event occurs, other types of inflammations caused by other mechanisms occur [5].

  • The atheromatous plaque caused by the chronic immune inflammation requires acute exacerbation of the inflammatory state with increased activity of metalloproteinase’s for rupture or ulceration, these lesions generate further inflammation intended for repair, necessary but that can become provocative; thus, “inflammation causes more inflammation”.

  • Ischemia or necrosis of the affected territory is another source of inflammation to repair such a lesion, but it also amplifies or enhances the process.

  • Occasional rescue angioplasty and/or stent implantation are further inflammatory stimuli that progress differently.

All these processes involve inflammatory cytokines triggered by innate immunity cells: monocytes and T lymphocytes, among others. Monocytes are of different types; they are involved in all the inflammatory processes, can migrate from the blood to tissues in response to signals and can differentiate into macrophages, dendritic cells, and foam cells, functioning as process activators or modulators, all key stages in atherogenesis. The same happens with T lymphocytes [6].

Anti-inflammatory therapies acting specifically on macrophages and inflammatory cytokines have been analyzed with monoclonal antibodies [7]. Inhibition of interleukins (IL)-1B showed limited activity in the management of rheumatoid arthritis, but was effective in gout [8]. Tumor Necrosis Factor-α (TNF-α) or IL-6 inhibition evidenced greater impact on rheumatoid arthritis [9]. IL-17 inhibition was effective in psoriasis, but, paradoxically, low levels were associated with increased coronary risk [10].

Over the past decades, dozens of different genes associated with increased coronary disease have been detected, which could translate into new therapeutic goals, including some that affect the metabolism of the LDL cholesterol particles, especially apolipoprotein(a), component of Lp(a) [11]. In addition, the influence of mRNA on epigenetic modifications suggests that these types of molecules could be responsible for residual risk in an ischemic cardiomyopathy despite preventive treatment, and it would similarly explain why patients with risk factors, do not suffer CV events [12].

Continuous communications indicated new factors that influence interaction between inflammation and diabetes: the understanding the relations on nature and nurture [13], promoting health habits from children [14], the newest knowledge of the interaction between endothelial nitric oxide synthetase cholesteryl ester-transfer proteins and angiopoietin-like protein [15], gene expression in peripheral mononuclear cells [16], genetic variant and the altered triglycerides levels [17], and many others that opens new horizons in investigations.

Therapeutic indications

All the factors described, genetic susceptibility, antigenic substances, endothelium, inflammation, leukocytes, macrophages, different inflammatory cytokines, adrenergic state, vasoconstriction in micro- and macro circulation, balance between thrombogenesis and fibrinolysis, platelet aggregation, in addition to mood, psychic depression, anxiety, fear, and many other not clearly known factors, have to occur in a timely manner to cause a CV event, and it is not always possible to know which of these factors is mainly responsible or, at least, triggers the event [18]. And maybe these factors could also explain that while human beings of all races have atheromatous plaques, only between 0.3 and 1.1% of the general world population suffers a myocardial infarction [19], nearly as many as the sum of traffic accidents [20] and criminal homicides [21].

It is very difficult to guess and even more difficult to identify the determinant factor that causes each CV event, and to be able to select the appropriate therapy to avoid or neutralize it. Therefore, it is uncertain to assume which antiplatelet or anti-inflammatory drug is suitable, or the stimulator of modulating macrophages or inhibitor of inflammatory macrophages, or the monoclonal antibody for the specific cytokines or for blocking the action of the involved metalloproteinase, or even emotional influence as in Takotsubo’s syndrome, which can occur either with feelings of happiness or sadness [22].

To counteract the deleterious effects of CV events, physicians prefer therapeutic interventions that have been tested in large trials, because of the emergency, time is scarce and it is often impossible to find out more about the patient and his particular situation, reperfusion is attempted with mechanical (angioplasty, stenting, etc.) or pharmacological (fibrinolytics, antiplatelet drugs, antithrombotic agents, etc.) techniques. In addition, ACE inhibitors or ARB II agents, beta-blockers, and gastric proton pump inhibitors to resist polypharmacy are administered, together with high statin doses even if the patient is already taking them. Discussions focus on which procedure is most suitable for each form of particular CV event, and the arguments are based on multicenter clinical trials and adherence to Guidelines. In these situations, an important factor is not to rely on statistics of clinical trials but on statistics and experience of the medical center where the treatment procedure will be performed.

On many occasions, due to the generalization of the procedures or the application of Guideline recommendations without taking into account each case in particular, the resulting effect is capricious, multifaceted outcomes not always in line with the results from publications, and patients are often discharged with an indication of multiple-drug therapy without justification.

A frequent long-term consequence is that polypharmacy is maintained without balancing the pros and cons, or because physicians do not have enough time to learn more about the patient or do not want to take risks with the discontinuation of any of the drugs recommended in the Guidelines, even though the recommendation is general or weak.

Biomarkers and preventive diagnostic techniques

In order to predict CV events, hundreds of molecules involved in this condition have been studied, as they may act as markers to predict the risk for a CV event, and their association has generated encouraging scores with the mathematical results they project. Thus, right from the start, initially with ESR and WBC, later as knowledge progressed included multiple more specific molecules that were discovered as investigations advanced, neopterine, adhesive molecules, interleukins, faze reactants such as fibrinogen and CRP and many others referred to by their acronyms, for example SAA, MPO, PAPP-A, LpPLA2, CPK, CD40L, and many more to which were later added progenitor cells and telomeres length [18], have all been analyzed, but in every case, the increased sensitivity and specificity to detect immediate risk has been low and has not always fulfilled the expectations [23,24,25]. It is evident that there are so many “predictive markers and/or risk criteria” because none of them is ideal. And who will suffer a CV event, and when, cannot be predicted yet, although it is presumed in those considered higher risk factors.

It is quite evident that the main characteristic of atherosclerosis is the presence of lesions; the predictive value of visualizing those lesions with imaging techniques has been analyzed. All imaging techniques have been tested. The predictive value of visualization of these lesions has been tested. All imaging techniques have been tried [26]. Many of them are non-invasive: ultrasound, vascular echography, flow modulated vascular reactivity and endothelial function, computed tomography, RMN, positron emission, calcium scores, and even very sophisticated tests such as fluorodeoxyglucose and fluorescence of cysteine protease uptake. Others imaging techniques are invasive for example coronary angiography, IVUS, optical coherence tomography and many more. Again, the increase in sensitivity and specificity has not been satisfactory, only slightly better considering the combination of some of them for instance calcium score or RMN and carotid plaque detection [27]. Lately cardiac RMN has been used to detect coronary lesion that could be treated without taking into account confounding statistical factors such as genetic susceptibility or psychological factors [28]. Also, the difference between personalities implies different behaviors, as in the case of depressed and optimistic individuals [29]. Or between those who have achieved expected success and those who have lost a beloved one or suffered a love or work failure [30]. Recently, Cediel et al., showed that stanniocalcin-2 and IGFBP-4 emerge as independent predictors in heart failure patients [31]. In addition, culprit lesions in diabetic patients, may be predicted employing optical coherence tomography [32, 33].

One of the best alternatives to risk prediction is clinical evidence, which can be easily achieved with two questions, two measurements, and two exams: (1) ask the patient if he/she smokes and/or is sedentary; (2) measure waist and blood pressure; and (3) study lipid and glycemic profiles [34]. However, this practice requires time to talk with the patient, and examine and evaluate him/her as a whole. The virtue of simplicity.

The epics of the coronary care unit and medical emergencies

Anyone who is admitted in the Coronary Care Unit due to either a coronary, encephalic or peripheral CV event is treated according to the Guidelines and administered large doses of statins. But in other hospitalizations, such as those due to paroxysmal tachycardia, atrial fibrillation, or simply vasogenic syncope in young people, full doses of statins are also added to the adequate treatment although the Guidelines do not indicate or recommend them. Tolerability and efficacy of statins in the treatment and reduction of CV events both as primary or secondary prevention have been well demonstrated. Statin benefits are mediated by the reduction of LDL-cholesterol fraction levels. Many authors have proposed other benefits, called “pleiotropic”, that are independent from their effect on lipids, although no strong evidence has been provided yet. The studies on these drugs report outstanding effects on prevention, but always in relative values and not always taking into account confounding statistical factors. In absolute values, the event reduction in primary prevention is less than 1%, and little more than 3% in secondary prevention [35].

The difference between primary and secondary prevention is not always accurate because a suspicious precordial pain, ST segment elevation, vascular ultrasound, or non-invasive coronary angiography is enough to move a patient from primary to secondary prevention. Therefore, how can the difference between 1 and 3% be explained? Simply, because those who suffer a CV event probably have other influencing factors, genetic, lifestyle, personality factors, etc. that are still unknown, but make them more vulnerable to CV events.

In a study of the American Heart Association “Get with the Guidelines” Group, Sachdeva et al. showed that 136,905 patients with myocardial infarctions hospitalized in 541 University hospitals in the United States from 2000 to 2006 had total cholesterol levels and their fractions within normal limits for the Guidelines at that time in 75% of cases, 18% had LDL < 70 mg/dl, 10% had HDL > 60 mg/dl, and 21% were under statin therapy [36].

Khot et al. studied the history of cigarette smoking, diabetes, hyperlipidemia, and hypertension, all known risk factors, in 122,458 patients hospitalized due to myocardial infarction. Among them, 19.4% lacked any of the four conventional risk factors, 43% presented only one risk factor, and less than 1% presented the four risk factors [37]. These findings suggest the so-called Helmut Schmidt syndrome or the Winston Churchill syndrome [38]. That does not imply disregarding the risk factors or not treating them properly, but suggests adapting the preventive strategies to make them more convenient according to what each patient needs.

Evolution of knowledge

Not only do researchers value the qualities of their investigations with great affection, but they also exacerbate their virtues. In the 1980s, dyslipidemia was treated only with fibrates and nicotinic acid, which increase the HDL fraction and are less effective on LDL. All the publications of that time highlighted the importance of this fact and considered LDL less important provided HDL was high [31]. In the early 1990s, the equation was reversed with the advent of statins and the chance to lower LDL. Of course, greater efficacy of statins and learning more about the pathophysiology of atherogenesis played an important role in this process, but the HDL particles were ignored to the point of not being considered in the 2013 ACC/AHA Guidelines, which even led to complaints by European cardiology organizations, that quieten over time [39]. Recent studies show that patients with high HDL have less CV events. Other studies show a U curve, considering that patients are at lower risk with a low or high HDL concentration levels than with acceptable concentration levels, supporting the concept that HDL quality is more important than HDL quantity.

Recently, new proprotein convertase subtilisin/kexin type 9 inhibitors (PCSK9) have appeared that inhibiting the degradation of the LDL cholesterol fraction receptor, allowing a larger amount of receptors to produce greater LDL uptake and > 50% reduction of plasma concentrations compared to baseline values [40]. Since then, multiple criticisms on statin resistance and adverse secondary events have appeared. Is it a coincidence? It is for the reader to judge.

Statins cause side effects in 10% of patients, with a range varying between 7 and 21%, according to different authors [41]. The newer statins have more side effects than the older ones [42, 43]. The most common adverse events include myalgia, myositis with increased creatine phosphokinase (CPK), and rhabdomyolysis in very few cases. Myalgias are not considered significant as long as they do not increase CPK or cause myositis or rabdomyolysis [44]. If the striated muscle hurts it is because it is affected, but how it is affected is still unknown. On the other hand, the myocardium is also a striated muscle but without sensory roots to perceive pain; we do not know to what extent it is not affected as the striated muscle is, and statin therapy has not improved heart failure significantly. Furthermore, the occurrence of dilated cardiomyopathy caused by statins has been reported [45]. In addition, statins do not significantly benefit heart failure treatment [46].

Coronary arteries and diabetic patients

Statins inhibit the 3-hydroxy-3-methylglutaryl-coenzime-A (HMG-CoA), an intracellular enzyme, which plays a preponderant role in the synthesis of cholesterol. In this way the LDL fraction of cholesterol is effectively decreased and vascular events are reduced, including in diabetic patients. Many investigators have proved that statin use contribute to the genesis of diabetes, reports vary between 1% and 46%, where marked elevation of blood glucose fasting levels and glycosylated hemoglobin have been observed, be it by increased tissue resistance to insulin or by reduced β-cell insulin secretion [47, 48].

This effect has been observed in nearly all the large studies, with more or fewer consequences according to which statin was used. Different mechanisms have been mentioned as the possible cause of this effect, reduction of protein geranylgeranylation, diminished phosphorylation of AKT insulin receptor substrate, 3β glycogen synthetase kinase, a reduced GLUT4 regulation, all these factors reduce tissue glucose phosphorylation uptake [49].

Other studies have shown that statins increase Interleukin -Iβ, which influences the inflammasome activation, a mechanism that increases the adipocyte and adipose tissues’ resistance to insulin. Insulin production by the β-cells of the pancreas requires calcium influx through calcium sensitive channels controlled by ATP activated by potassium channels. In this way, through mechanisms involved in inflammation they contribute to insulin resistance and/or a reduction in insulin secretion [50,51,52].

Cerderberg et al. in a 6-year follow-up study of patients treated with different doses of all the statins currently prescribed, observed 46% increased risk of diabetes due to enhanced resistance and/or reduced insulin production [53]. If we consider that between one quarter and one-third of the adult population in the United States takes statins, such a marked increase of diabetes over the past years might be due, in part, to statins, or at least be a confounding statistical factor.

Both statins and PSCK9 inhibitors increase insulin resistance or reduce insulin release, which could increase the risk of diabetes in predisposed individuals. Two recent publications on PCSK9 genetic variants with mendelian randomization and meta-analysis reported increased glucose, increased weight, and increased diabetes with this medication [54]. Ravnskov et al. evaluated 68,000 patients from 30 cohorts and found no benefit of statin therapy in primary prevention to people over 60 years of age, and in secondary prevention for people over 75 years of age [55]. Other studies report similar results with different cohorts [56].

The problem of the increase in diabetes appears to be not only due to statin side effects, but are apparently shared with the new PCSK9. It has been suggested that cholesterol and glucose have several points in common that can influence each other. Perhaps in future studies more light can be thrown on this subject [43, 54].

All human cells membranes have between 0.5 and 0.9% cholesterol, except the crystalline lens were the concentration is 3%, marked reduction in cholesterol concentration has not been investigated as a cause of cataracts [55].

However, none of these observations reduce the effectiveness and usefulness of statins in primary and secondary prevention of CV events. It is only important to remember them so as not prescribing them to patients who are not at risk, not only when they are discharged from the Coronary Care Unit but also in a simple medical consultation, because it leads to loss of confidence in a drug that, if properly administered, is very useful [56,57,58,59].

It seems that statins have “a Yin and a Yang” made up of their benefits and their adverse effects; evidence shows that they have more benefits than drawbacks. It is not a question of putting statins in the running water of cities but of prescribing them to the adequate populations. We have to counteract the physician’s inertia.


The best way to prevent a CV event will be achieved by educating the population from childhood, teaching people how to eat healthily, avoid overweight and physical inactivity, and to eradicate smoking. Scientific Cardiology Societies have committed to a 25% reduction of CV events in 25 years, and it will not be achieved with medication but with a healthy lifestyle. Physicians should base their indications on the recommendations provided by Guidelines, but they should not forget that every patient is different, and they should not get confused due to lack of time in an emergency nor be influenced by the latest publications or techniques until they have been properly tested [60, 61].

Always remember Norman Cousin’s teachings: “Diagnosis belongs to science; Prognosis belongs to patients.”



cardiovascular events




Tumor Necrosis Factor

Lpa :

Lipoprotein La


Angiotensin Converting Enzime


Angiotensin Receptor Blocking


Eritrocytes Sedimentation


white blood cells


C reactive protein


Resonance Magnetic Nuclear


Intravascular Ultrasound


Low Density Lipoprotein


High Density Lipoprotein


proprotein convertase subtilisin/kexin type 9 inhibitors


creatine phosphokinase


3-hydroxy-3-methylglutaryl-coenzime-A reductase


  1. Alfieri O, Bongani M, Mayosi SJP, Sarrafzadegan N, Virmani R. Exploring unknowns in cardiology. Nat Rev Cardiol. 2014;11:664–70.

    Article  Google Scholar 

  2. Stary HC, Chandler AB, Glagov S, Guyton JR, Insull W Jr, Rosenfeld ME, et al. A definition of initial, fatty streak, and intermediate lesions of atherosclerosis A report from the Committee on Vascular Lesions of the Council on Arteriosclerosis American Heart Association. Circulation. 1994;89:2462–78.

    Article  CAS  Google Scholar 

  3. Libby P, Folco EJ, Esper RJ. Inmunidad, inflamación y ateroesclerosis. In: Esper RJ, Vilariño JO (Eds): Progresos en Ateroesclerosis, Buenos Aires, Ediciones Médicas del Sur, 2011, p. 23–47.

  4. Viles-Gonzalez JF, Fuster V, Esper RJ, Vilariño JO, Badimon JJ: Enfermedad Aterotrombótica. In: Esper RJ (Ed): Aterotrombosis en el tercer milenio. Barcelona, Prous Sciences, 2004, p. 1–22.

  5. Esper RJ. Ateroesclerosis, una enfermedad inmuno-inflamatoria. Prensa Med Argent. 2009;96:552–70.

    Google Scholar 

  6. Esper RJ, Nordaby RA, Vilariño JO, Paragano A, Cacharrón JL, Machado RA. Endothelial dysfunction: a comprehensive appraisal. Cardiovasc Diabetol. 2006; 5: 4.

  7. Ridker PM, Lüscher TF. Anti-inflammatory therapies for cardiovascular diseases. Eur Heart J. 2014;35:1782–91.

    Article  CAS  Google Scholar 

  8. Crea F, Liuzzo G. Anti-inflammatory treatment of acute coronary syndromes: the need for precision medicine. Eur Heart J. 2016;37:2414–6.

    Article  Google Scholar 

  9. Choy EH, Kavanaugh AF, Jones SA. The problem of choise current biologic agents and future prospects in RA. Nat Rheumatol. 2013;9:154–63.

    Article  CAS  Google Scholar 

  10. Liuzzo G, Trotta F, Pedicino D. Interleukin-17 in atherosclerosis and cardiovascular disease: the good, the bad and the unknow. Eur Heart J. 2013;34:556–9.

    Article  Google Scholar 

  11. Feinberg MW. No small task: therapeutic targeting of Lp(a) for cardiovascular disease. Lancet. 2016;388:2211–2.

    Article  Google Scholar 

  12. Lüscher TF. Frontiers in precision medicine: genes and their modulation by miRNAs. Eur Heart J. 2016;37:3247–50.

    Article  Google Scholar 

  13. El-Mowafy AM. Advances in averting cardiovascular anomalies to diabetes. J Cardiovasc Med. 2009;1:18–20.

    Article  Google Scholar 

  14. Fernández-Gimenez R, Al-Kazar M, Jaslow R, Carvajal I, Fuster V. Children present a window of opportunity for promoting health. J Am Col Cardiol. 2018;72:3310–9.

    Article  Google Scholar 

  15. El-Lebedy D. Interaction between endothelial nitric oxide synthase rs1799983, cholesteryl ester-transfer protein rs708272 and angiopoietin-like protein 8 rs2278426 gene variants highly elevates the risk of type 2 diabetes mellitus and cardiovascular disease. Cardiovasc Diabetol. 2018;17:97.

    Article  PubMed  PubMed Central  Google Scholar 

  16. Fandini GP, Avogaro A. How to interpret the role of SDF-1α on diabetic complications during therapy with DPP-4 inhibitors. Cardiovasc Diabetol. 2018;17:22.

    Article  Google Scholar 

  17. Bogari NM, Aljohani A, Amin AA, Al-Allaf FA, Dannoun A, Taher MM, et al. A genetic variant c.553G > T (rs2075291) in the apolipoprotein A5 gene is associated with altered triglycerides levels in coronary artery disease (CAD) patients with lipid lowering drug. BMC Cardiovasc Disorders. 2019;19:2.

    Article  Google Scholar 

  18. Esper RJ, Antivero Esper P. Depresión, ataques de pánico, estados de ánimo y eventos cardiovasculares. In: Esper RJ, Vilariño JO (Eds): Prevención Cardiovascular, Desafíos y Oportunidades. Buenos Aires, Intermedica, 2014, p: 205-218.

  19. Sipido KR, Tedgui A, Kristensen SD, Pasterkamp G, Schunkert H. Identifying needs and opportunities for advancing translational research in cardiovascular disease. Cardiovasc Res. 2009;83:425–35.

    Article  CAS  Google Scholar 

  20. Indice de Mortalidad por Accidentes. Cumbre Anual del International Transport Forum (ITF) y Organización para la Cooperación y el Desarrollo Económicos (OCDE). Buenos Aires, La Nación, Argentina, 29 de mayo de 2015.

  21. Fleitas Ortiz de Rosas, D. Homicidios años 2002-2012. Asociación para políticas públicas. Buenos Aires, La Nación, Argentina, 15 de octubre 2014.

  22. Lüscher TF. Takotsubo. A japanese contribution to cardiology. Eur Heart J. 2016;37:2803–5.

    Article  Google Scholar 

  23. Aukrust P, Halvorsen B, Yndestad A, Ueland T, Øie E, Otterdal K, et al. Chemokines and cardiovascular risk. Arterioscler Thromb Vasc Biol. 2008;28:1900–19.

    Article  Google Scholar 

  24. Wang TJ, Gona P, Larson MG, Tofler GH, Levy D, Newton-Cheh C, Jacques PF, et al. Multiple biomarkers for the prediction of first major cardiovascular events and death. N Engl J Med. 2006;355:2631–9.

    Article  CAS  Google Scholar 

  25. Ware JH. The limitations of risk factors as prognostic tools. N Engl J Med. 2006;355:2615–7.

    Article  CAS  Google Scholar 

  26. Badimon JJ, García MJ. Diagnóstico de la aterosclerosis por imágenes. In: Esper RJ, Vilariño JO (Eds): Progresos en Aterotrombosis. Buenos Aires, Ediciones Médicas del Sur, 2011; p. 283–98.

  27. Kopp AF, Ohnesorge B, Becker C, Schröder S, Heuschmid M, Küttner A, et al. Reproducibility and accuracy of coronary calcium measurements with multidetector row versus electron-beam CT. Radiology. 2002;225:113–9.

    Article  CAS  Google Scholar 

  28. Arbab-Zadeh A, Fuster V. The risk continuum of atherosclerosis and its implications for defining chd by coronary angiography. J Am Coll Cardiol. 2016;68:2467–78.

    Article  Google Scholar 

  29. Lichtman KH, Froelicher ES, Blumenthal JA, Carney RM, Dering LV, Frasure-Smith N, et al. Depression as a risk factor for poor prognosis among patients with acute coronary syndrome: systematic review and recommendations. A scientific statement from the American Heart Association. Circulation. 2014;129:1350–69.

    Article  Google Scholar 

  30. Kubzansky LD, Sparrow LD, Vokonas P. Veterans affairs normative aging study minnesota multiphasic personality inventory bipolar revised optimism-pessimism scale. Psychosom Med. 2001;63:910–6.

    Article  CAS  Google Scholar 

  31. Cediel G, Rueda F, Oxvig C, Oliveras T, Labata C, de Diego O, et al. Prognostic value of the Stanniocalcin-2/PAPP-A/IGFBP-4 axis in ST-segment elevation myocardial infarction. Cardiovasc Diabetol. 2018;17:63.

    Article  PubMed  PubMed Central  Google Scholar 

  32. Zhang S, Dai J, Jia H, Hu S, Du H, Li N, et al. Non-culprit plaque characteristics in acute coronary syndrome patients with raised hemoglobinA1c: an intravascular optical coherence tomography study. Cardiovasc Diabetol. 2018;17:90.

    Article  PubMed  PubMed Central  Google Scholar 

  33. Kobayashi N, Hata N, Tsaurumi M, Shibata Y, Okazaki H, Shirakabe A, Takano M, Seino Y, Shimizu W. Relation of coronary culprit morphology determined by optical coherence tomography and cardiac outcomes to preinfarction angina in patients with acute myocardial infarction. Int J Cardiol. 2018;269:365.

    Article  Google Scholar 

  34. Fuster V. Conferencia Inaugural 40 Congreso Argentino de Cardiología. Buenos Aires, 2014; Octubre 16.

  35. Esper RJ., Vilariño JO. Riesgo Residual, Endotelio, Genética y Tratamiento Personalizado. In: Esper RJ, Vilariño JO (Eds): Progresos en Aterotrombosis. Buenos Aires, Ediciones Médicas del Sur, 2011, p. 109–126.

  36. Sachdeva A, Cannon CP, Deedwania PC, LaBresh KA, Smith SC Jr, Dai D, et al. Lipid Levels in patients hospitalized with coronary artery disease: an analysis of 136.905 hospitalizations in Get with the Guidelines. Am Heart J. 2009;157:111–7.

    Article  CAS  Google Scholar 

  37. Khot UN, Khot MB, Bajzer CT, Sapp SK, Magnus Ohman E, Brener SJ, et al. Prevalence of conventional risk factors in patients with coronary heart disease. JAMA. 2003;290:898–904.

    Article  Google Scholar 

  38. Gotto AM, Moon J. Dislipidemias. In: Esper RJ, Vilariño JO (Eds): Progresos en aterotrombosis. Buenos Aires, Ediciones Médicas del Sur 2011, p. 79–96.

  39. Lüscher TF. Manejo actual de los desórdenes lipídicos. Enfoques entre las Guías Europeas (ESC/EAS) y americanas (ACC/AHA). In: Esper RJ, Vilariño JO (Eds): Prevención Cardiovascular. Desafíos y Oportunidades. Buenos Aires, Intermedica, 2015, p. 53–62.

  40. Ference BA, Robinson JG, Brook RD, Catapano AL, Chapman J, Neff DR, et al. Variation in PCSK9 and HMGCR and risk of cardiovascular disease and diabetes. N Engl J Med. 2016;375:2144–53.

    Article  CAS  Google Scholar 

  41. Stroes ES, Thompson PD, Corsini A, Vladutiu GD, Raal FJ, Ray KK, et al. Statin-associated muscle symptoms: impact on statin therapy-European Atherosclerosis Society Consensus Panel statement on assessment, aetiology, and management. Eur Heart J. 2015;36:1015–22.

    Article  Google Scholar 

  42. Kim K, Lee SH, Lee KY. Efect of statins on fasting glucose in non-diabetic individuals: nationwide population-based health examination in Korea. Cardiovasc Diabetol. 2018;17:155.

    Article  PubMed  PubMed Central  Google Scholar 

  43. Yang SH, Xia R, Cui CJ, Wang Y, Du Y, Chen ZG, et al. Liraglutide downregulates hepatic LDL receptor and PCSK9 expression in HepG2 cells and db/db mice through a HNF-1a dependent mechanism. Cardiovasc Diabetol. 2018;17:48.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  44. Kaufman TM, Warden BA, Minnier J, Miles JR, Barton Duell P, Purnell JQ, et al. Application of PCSK9 inhibitors in practice. Part 2: the patient experience. Circ Res. 2019;124:32–7.

    Article  CAS  PubMed  Google Scholar 

  45. Naci H, Brugts J, Ades T. Comparative tolerability and harms of individual statins. A study-level network meta-analysis of 246 955 participants from 135 randomized controlled trials. Circ Cardiovasc Qual Outcomes. 2013;06:390–9.

    Article  Google Scholar 

  46. Search Collaborative Group. SLCO1B1 variants and statin-induced myopathy-a genomic study. N Engl J Med. 2008;359:789–99.

    Article  Google Scholar 

  47. Preiss D, Campbell RT, Murray HM, Ford I, Packard CJ, Sattard N, et al. The effect of statin therapy on heart failure events: a collaborative meta-analysis of unpublished for the SEARCH Collaborative Group. SLCO1B1 data from major randomized trials. Eur Heart J. 2015;36:1536–46.

    Article  CAS  Google Scholar 

  48. Betteridge EJ, Carmena R. The diabetogenic action of statins. Mechanisms and clinical implications. Nat Rew Endocrinol. 2016;12:99–110.

    Article  CAS  Google Scholar 

  49. Wang S, Cai R, Yuan Y, Varghese Z, Moorhead J, Ruan XZ, et al. Association between reductions in low-density lipoprotein cholesterol wit statins therapy and the risk of new-onset diabetes: a meta-analysis. Sci Rep. 2017;7:39982.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  50. Agarwala A, Kulkarni S, Maddox T. The association of statin therapy with incident diabetes: evidence, mechanisms, and recommendation. Curr Cardiol Rep. 2018;20:50.

    Article  CAS  PubMed  Google Scholar 

  51. Laakso M, Kuusisto J. Diabetes secondary to treatment with statins. Curr Dian Rep. 2017;10:2–10.

    Google Scholar 

  52. Crandall JP, Mather K, Rajpathak SN, Goldberg RB, Watson K, Foo S, et al. Statin use and risk of developing diabetes: results from the Diabetes Prevention Program. BMJ Open Diab Res Care. 2017;5:e000438.

    Article  PubMed  Google Scholar 

  53. Cederberg H, Stančáková A, Yaluri N, Modi S, Kuusisto J, Laakso M. Increased risk of diabetes with statin treatment is associated with impaired insulin sensitivity and insulin secretion: a 6 year follow-up study of the METSIM cohort. Diabetologia. 2017.

    Article  Google Scholar 

  54. Schmidt AF, Swerdlow DI, Holmes MV, Patel RS, Fairhurst-Hunter Z, Lyall DM, et al. PCSK9 genetic variants and risk of type 2 diabetes: a mendelian randomisation study. Lancet Diabetes Endocrinol. 2017.

    Article  PubMed  PubMed Central  Google Scholar 

  55. Ravnskov U, Diamond DM, Hama R, Hamazaki T, Hammarskjöld B, Hynes N, et al. Lack of an association or an inverse association between low-density-lipoprotein cholesterol and mortality in the elderly: a systematic review. BMJ Open. 2016;6(6):e010401.

    Article  PubMed  PubMed Central  Google Scholar 

  56. Hippisley-Cox J, Coupland C. Unintended effects of statins in men and women in England and Wales: population based cohort study using the QResearch database. BMJ. 2010;340:c2197.

    Article  Google Scholar 

  57. Rodriguez F, Maron DJ, Knowles JW, Viraniy SS, Lin S, Heidenreich PA. Association between intensity of statin therapy and mortality in patients with atherosclerotic cardiovascular disease. JAMA Cardiol. 2017;2(1):47–54.

    Article  Google Scholar 

  58. Halter JB, Musi N, McFarland Horne F, Crandall JP, Goldberg A, Harkless L, et al. Diabetes and cardiovascular disease in older adults: current status and future directions. Diabetes. 2014;63:2578–89.

    Article  CAS  Google Scholar 

  59. Goldfine A. Is it really time to reassess benefits and risks? N Engl J Med. 2012;366:1752–5.

    Article  CAS  Google Scholar 

  60. Borracci RA. Fallibility of the ethics committees in medical research. Rev Argent Cardiol. 2016;84:606–9.

    Google Scholar 

  61. Doval H. Changing the paradigm of primary care: behavioral interventions, subsidies and taxes to “change lifestyle”. Rev Argent Cardiol. 2018;86:361–5.

    Article  Google Scholar 

Download references

Authors’ contributions

Both authors read and approved the final manuscript.


No acknowledgements.

Competing interests

The authors declare that they have no competing interests.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the authors on request.

Consent for publication

All participants provided written informed consents.

Ethics approval and consent to participate

The article was approval by the Ethical Committee of the University del Salvador, Buenos Aires, and all participants provided written informed consents.


No funding have been use.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Author information

Authors and Affiliations


Corresponding author

Correspondence to Ricardo J. Esper.

Rights and permissions

Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (, which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Esper, R.J., Nordaby, R.A. Cardiovascular events, diabetes and guidelines: the virtue of simplicity. Cardiovasc Diabetol 18, 42 (2019).

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: