A man who has been on the same small pill for nine years arrives to tell me he does not believe in it. A woman on three medications asks if she can stop the small one. Two composite vignettes from one fictional clinic morning.
In high-risk type 2 diabetes, once-daily oral semaglutide 14 mg cut major adverse cardiovascular events versus placebo in the SOUL trial, with no kidney benefit shown. PICO summary and expert commentary.
A new fellow on her first day, learning when to listen. A patient with eleven problems who, asked to pick one, picks sleep. Composite vignettes from a fictional teaching clinic.
CARDS demonstrated that atorvastatin 10 mg reduces major cardiovascular events by 37% and stroke by 48% in patients with type 2 diabetes and normal to mildly elevated LDL-cholesterol without prior CVD, confirming that cardiovascular risk rather than LDL level should determine statin initiation and establishing universal statin use in primary cardiovascular prevention for type 2 diabetes.
HPS demonstrated that simvastatin reduces major vascular events by 24% across all high-risk patients regardless of baseline LDL-cholesterol level, including those with diabetes without established coronary disease, eliminating the treatment threshold concept and establishing absolute cardiovascular risk as the primary criterion for statin therapy — one of the most influential results in preventive cardiology.
WOSCOPS demonstrated that pravastatin reduces the combined incidence of nonfatal MI and coronary death by 31% in men with hypercholesterolaemia and no prior MI, establishing the primary prevention indication for statin therapy and providing the first large randomised evidence for population-level lipid lowering in high-risk individuals without established cardiovascular disease.
The 4S trial demonstrated that simvastatin reduces all-cause mortality by 30%, coronary death by 42%, and major coronary events by 34% in patients with established coronary heart disease and no excess non-cardiovascular mortality, resolving the safety debate and establishing statin therapy as the standard of care in secondary cardiovascular prevention.
The DPPOS demonstrated that cumulative diabetes prevention from the DPP lifestyle intervention and metformin persists over 10 years from original randomisation, with 34% and 18% reductions in cumulative diabetes incidence despite post-DPP convergence of care, establishing a diabetes prevention legacy effect and confirming the durability of early preventive intervention.
The DREAM trial demonstrated that rosiglitazone reduces incident diabetes or death by 60% and achieves normoglycaemia in 50% of high-risk adults with impaired glucose tolerance, the largest pharmacological diabetes prevention effect documented in a large RCT, but the drug's subsequent cardiovascular safety concerns and market withdrawal have prevented translation of these findings into clinical practice.
The Diabetes Prevention Program demonstrated that intensive lifestyle intervention reduces type 2 diabetes incidence by 58% with a NNT of 6.9 over 2.8 years in high-risk adults, outperforming metformin which reduced incidence by 31%, establishing structured lifestyle modification as the primary preventive strategy for pre-diabetes and the evidence base for national prevention programmes.
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