I am bothered by the emphasis placed on ACCORD and RECORD trials.

Is it possible that the problem is with the TZD used in these trials.

I think less is more sends wrong message to clinicians who in my opinion are

already are not aggressive about glycemic control. what if one tries to get lower

A1c with metformin, pioglitazone and DPP4 or GLP agent. without putting pt. at risk of hypoglycemia.

I think the therapy will be modified according to the Genetic and Molecular Biology in the future. The Clinical Studies don't consider the genetic individual. 

To Dr Topol,

     Are your comments available in print?  Statistical averages do not have heart attacks, people do.  You may recall the atherothrombosis prediction graph I sent you a number of years ago when you were at the Cleveland Clinic--a copy of the graph is available in the current issue of the Journal of Clinical Lipidology, pages 135-136--and it looks at individuals, not statistical averages.

More is also sometimes more. Individualization of preventive care is available today, just not often used. 

ARBITER 6-HALTS demonstrated that more is more with respect to the addition of extended release niacin in achieving regression of CIMT, a result not attainable with statin alone.  Over the last 5 years, I have used extended release niacin in my patients with progression of plaque by serial EBT imaging and have found it instrumental in halting plaque progression and dramatically reducing MI incidence.

Individualization of  care can be achieved now, and should be used in the primary prevention setting.  Coronary calcium is the best measure of the presence of heart attack risk and treating to the goal of coronary calcium stability is the best measure of adequacy of treatment.  Utilizing this technology will result in using statins alone when that is adequate and expanding to use niacin, high dose omega-3 fatty acids, Vit D and more aggressive glucose control when needed. 

The future of personalization of atherosclerosis treatment through atherosclerosis imaging is available today, unfortunately too few clinicians take advantage of it.