Background  In the Helsinki policemen Study Hyperinsulinemia was associated with increased all-cause and CV mortality independent of other risk factors  Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial Both all-cause and cardiovascualr(CV) mortality were higher with intensive glycemic treatment  Purpose of this journal  For clarification of the relationship of exogenous insulin dose, glycemic control, and CV mortality, we performed post hoc analysis of ACCCORD baseline and follow-up data

Methods  ACCORD Study Design US and Canada at 77 clinical sites, between Jan 2001 and Oct ,251 participants with type 2 diabetes Either a prior CV event or other evidence of high CV disease risk → two gruops 1.Standard treatment strategy (n=5,123) : A1C 7.0% ~ 7.9% 2.Intensive treatment strategy (n=5,128) : A1C < 6.0% Primary end point Composite of CV mortality, nonfatal myocardial infarction, or nonfatal stroke Secondary end point All-cause mortality

Methods Participants visited clinical sites every 2 to 4 months 4-month intervals, they were asked about hypoglycemia and other medical event and Ac1 measurement Mean follow-up year per participant : 4.97 years

 독립변인 이외에 실험결과에 영향을 미치는 다른 변인이 있어 집단들이 이 특성에서 차이 가 있는데도 실험자는 이 변인을 통제 못할 때가 있다.  통제 못하였기 때문에 조정대상이 되는 이 변인을 공변인 (covariate) 이라고 하며, 공변량분 석법은 그러한 차이를 조정하여 차이가 만약 존재하지 않는다면 실험결과는 어떨 것인가의 형태로 집단들을 비교하게 해준다.  예컨대 세 가지 교수법의 효과를 검증하기 위하여 세 반에 각각의 교수법을 처치하여 영어 학력검사로 효과를 검증하였다 하자. 그런데 나중에 보니까 이들 집단이 지능차가 심하였 다면, 학력검사 결과로 교수법의 효과를 단정하기란 무리이다. 왜냐하면 학력검사상의 차 이는 교수법의 효과가 아니라 지능차 때문인지도 모르기 때문이다. 이와 같은 경우에는 지 능을 공변인으로 하여 공변량 분석하여야 한다. Covariate ( 공변인, 공변량 )

Methods

Results

Model 1 adjusted for age, history of CV disease, heart failure, amputation, education, angiotensin receptor blockers, peripheral neuropathy, Q-T index, baseline A1C, HDL, serum creatinine, urinary albumin-to-creatinine ratio, integrated health plan, and certified diabetes educator on staff at randomization Model 2 adds assignment to blood pressure or lipid trial and treatment assignment within these, severe hypoglycemia, and weight change Model 3 adds updated, average A1C Model 4 adds glycemic treatment strategy assignment

Results

Conclusion  In this journal analysis of ACCORD data average daily insulin dose was not associated with increased CV mortality after adjustment for baseline covariates  These result fail to support the hypothesis that exposure to injected insulin is an independent risk factor for CV mortality  However, these exploratory analyses of ACCORD do not fully lay to rest the possibility of adverse effects of insulin in particularly vulnerable individulas