Coronary risk assessment using traditional risk factors with CT coronary artery calcium scoring in clinical practice

As coronary artery calcium (CAC) is atherosclerosis and not just a marker of cardiovascular (CV) disease, measurement of a patient's coronary artery calcium score (CACS) is a strong predictor of risk. Clinically performed in asymptomatic patients, the CACS, along with several CV risk factors, namely age, sex, ethnicity, diabetes, tobacco use, family history, cholesterol level, blood pressure, and use of cholesterol or hypertensive medications, provide a predictive model of 10 year risk for CV events. A smartphone “App” makes this quick to obtain and use. This helps the clinician in making recommendations for both lifestyle changes and statin therapy. Those patients in which the most benefit occur from measurement of a CACS are those at an intermediate CV risk. Measurement of the CACS has become an integral part of the clinician's assessment of a patient's CV risk and for guiding preventative therapies.     

The association between extracoronary calcification and coronary artery disease in patients with type 2 diabetes mellitus

Cardiovascular complications are the major cause of diabetes-associated morbidity and mortality. However, not all patients with diabetes are at increased risk for cardiovascular disease (CVD). Coronary artery calcification was found to be a powerful predictor of coronary artery disease (CAD). The presence of extracoronary cardiac calcification as a useful predictor of CAD is not yet established, especially in type 2 diabetes mellitus (T2DM). The aim of this study was to evaluate the relation between extracoronary calcification and extent of CAD in a group of T2DM patients who were scheduled for computed tomographic coronary angiography (CTCA). We prospectively studied 380 patients (151 had T2DM) under the age of 60 years who were scheduled for CTCA because of suspected CAD. Severity of CAD was assessed by Gensini score. Coronary artery calcium score (CACS) as well as calcium score in the aortic valve, mitral annulus, ascending aorta, and descending aorta were measured by a 256-row multidetector computed tomography scanner with dedicated software for calcium calculation. Patients with known CAD were excluded. Diabetic and nondiabetic patients had comparable age and gender distribution. However, the diabetic group had higher Gensini score, CACS, and extracoronary calcium score (ECCS). Logistic regression analyses identified male gender and ECCS as significant predictors for the presence of CAD in diabetic patients. Age, smoking, and ECCS were the significant predictors of CAD in nondiabetic patients. Type 2 diabetic patients had increased coronary and extracoronary calcification. ECCS was found to be a significant predictor of CAD in diabetic and nondiabetic patients only when CACS was not taken into account.     

Coronary artery calcium scoring: an evidence-based guide for primary care physicians

Primary care physicians often must decide whether statin therapy would be appropriate (in addition to lifestyle modification) for managing asymptomatic individuals with borderline or intermediate risk for developing atherosclerotic cardiovascular disease (ASCVD), as assessed on the basis of traditional risk factors. In appropriate subjects, a simple, noninvasive measurement of coronary artery calcium can help clarify risk. Coronary atherosclerosis is a chronic inflammatory disease, with atherosclerotic plaque formation involving intimal inflammation and repeated cycles of erosion and fibrosis, healing and calcification. Atherosclerotic plaque formation represents the prognostic link between risk factors and future clinical events. The presence of coronary artery calcification is almost exclusively an indication of coronary artery disease, except in certain metabolic conditions. Coronary artery calcification can be detected and quantified in a matter of seconds by noncontrast electrocardiogram-gated low-dose X-ray computed tomography (coronary artery calcium scoring [CACS]). Since the publication of the seminal work by Dr. Arthur Agatston in 1990, a wealth of CACS-based prognostic data has been reported. In addition, recent guidelines from various professional societies conclude that CACS may be considered as a tool for reclassifying risk for atherosclerotic cardiovascular disease in patients otherwise assessed to have intermediate risk, so as to more accurately inform decisions about possible statin therapy in addition to lifestyle modification as primary preventive therapy. In this review, we provide an overview of CACS, from acquisition to interpretation, and summarize the scientific evidence for and the appropriate use of CACS as put forth in current clinical guidelines.     

Approaches to Decongestion in Patients with Acute Decompensated Heart Failure

Type 2 diabetes increases the risk of cardiovascular disease (CVD) from two- to four-fold. In our large Finnish population-based study published in 1998 subjects with medication for type 2 diabetes had as high a risk of fatal and nonfatal myocardial infarction (MI) during the 7- year follow-up as non-diabetic subjects with a prior MI, suggesting that type 2 diabetes is a CVD equivalent. In another large study, including all 3.3 million residents of Denmark, subjects requiring glucose-lowering therapy exhibited a CVD risk similar to that of non-diabetic subjects with a prior MI. Subsequent studies have not systematically replicated aforementioned results. Some studies have supported the concept that type 2 diabetes is a CVD equivalent only in some subgroups, and many studies have reported negative findings. This is likely to be due to many differences across the studies published, for example ethnicity, gender, age and other demographic factors of the populations involved, study design, validation of diabetes status and CVD events, statistical analyses (adjustments for confounding factors), duration of diabetes, and treatment of hyperglycemia among diabetic participants. Varying results reflect the fact that not all diabetic patients are at a similar risk for CVD. Therefore, CVD risk assessment and the tailoring of preventive measures should be done individually, taking into consideration each patient’s long-term risk of developing cardiovascular events.     

The association of coronary calcium score and conventional cardiovascular risk factors in Type 2 diabetic subjects asymptomatic for coronary heart disease (The PREDICT Study).

AIM: To determine the association between coronary calcification score (CACS) obtained by electron beam computed tomography (EBCT) and cardiovascular risk factors in Type 2 diabetic subjects entered into a prospective cohort study. METHODS: Type 2 diabetic subjects attending routine hospital diabetic clinics without known coronary heart disease (CHD) underwent EBCT to measure CACS. Demographic data were obtained and conventional cardiovascular risk factors were measured at baseline. RESULTS: Four hundred and ninety-five subjects were assessed of whom 67.7% were male. They had a mean (SD) age of 62.9 (7.1) years, with median (inter-quartile range) duration of diabetes of 8 (4-13) years. None had a history of coronary artery disease. Forty-five per cent were receiving lipid-lowering agents (including 36% statins). In a univariate analysis, there were significant associations between increased CACS and age, duration of diabetes, male gender, waist-hip ratio (WHR), systolic blood pressure, and the use of statins. In a multivariate model adjusting for the possible interaction of these and other factors, the significant association between CACS and WHR, systolic blood pressure, male gender and statin use remained. CONCLUSIONS: The close association between CACS and WHR and the association with systolic blood pressure suggest that coronary calcification may be particularly linked to the metabolic syndrome in Type 2 diabetes.     

Screening patients for subclinical atherosclerosis with non-contrast cardiac CT

Accurate risk assessment may be helpful in decreasing cardiovascular events through more appropriate targeting of preventive measures. Traditional risk assessment may be refined with the selective use of coronary artery calcium score (CACS) or other methods of subclinical atherosclerosis measurement. This article reviews information pertaining to the clinical use of CACS for assessing coronary atherosclerosis as a useful predictor of coronary artery disease (CAD) in certain population of patients. Coronary calcification is a marker of atherosclerosis that can be quantified with the use of cardiac CT and it is proportional to the extent and severity of atherosclerotic disease. The published studies demonstrate a high sensitivity of CACS for the presence of coronary artery disease but a much lower specificity for obstructive CAD depending on the magnitude of the CACS. Several large clinical trials have found clear, incremental predictive value of CACS over the Framingham risk score when used in asymptomatic patients. However, early detection of CAD by Electron Beam Tomography (EBT) screening has not convincingly demonstrated a reduction in mortality and morbidity. Nevertheless, relevant prognostic information obtained may be useful to initiate or intensify appropriate treatment strategies to slow the progression of existing atherosclerotic vascular disease. Current data suggest intermediate-risk patients may benefit most from further risk stratification with cardiac CT, as CAC testing is effective at identifying increased risk and in one study motivating effective behavioral changes. Randomized clinical trials will help determine if selective use of cardiac CT in the intermediate-risk patient would lead to more appropriate use of pharmacologic therapy and improved clinical outcomes.     

Abnormal peripheral circulation in type 2 diabetic patients with normal ankle-brachial index associates with coronary atherosclerosis, large artery stiffness, and peripheral vascular resistance

We tested the hypothesis that impaired peripheral circulation in diabetes arises from different aspects of vascular abnormalities even when accompanied by a normal ankle-brachial index (ABI > 0.9). One hundred fourteen type 2 diabetic patients with normal ABI and 33 age-matched non-diabetic subjects consecutively admitted to our hospital were enrolled. The Agatston coronary artery calcium score (CACS), as a marker of coronary atherosclerosis, was obtained using electron-beam computed tomography. An automatic device was used to measure brachial-ankle pulse wave velocity (baPWV) as an index of arterial distensibility. Total flow volume and resistive index (RI), as a marker of peripheral vascular resistance, at the popliteal artery were evaluated using gated two-dimensional cine-mode phase-contrast magnetic resonance imaging. Diabetic patients had baPWV (P < 0.001) and RI (P < 0.001) higher than those in the non-diabetic subjects, indicating that those parameters are characteristically altered in diabetic patients. When diabetic patients were grouped into three subgroups according to their levels of total flow volume, those with the lowest range showed the highest log-transformed CACS (P < 0.001), baPWV (P < 0.001), and RI (P < 0.001) among the groups. Total flow volume was negatively correlated with log-transformed CACS (P < 0.001), baPWV (P < 0.001), and RI (P < 0.001). Waveform at the popliteal artery could be clearly separated into systolic and early and late diastolic blood flows, which were negatively correlated with log-transformed CACS (P < 0.001), RI (P < 0.001), and baPWV (P < 0.001), respectively. These results suggest that impaired peripheral circulation in diabetes is attributable to coronary atherosclerosis, large artery stiffness, and peripheral vascular resistance even when ABI is normal.     

Coronary risk assessment using traditional risk factors with computed tomography coronary artery calcium scoring: Illustrative cases

A patient's coronary artery calcium score (CACS) is a strong independent predictor of cardiovascular risk. Used in conjunction with traditional measures of risk, the CACS helps the clinician discuss cardiovascular (CV) risk and recommend therapies with the patient. We present several cases in which measurement of the CACS and traditional risk factors were used to help guide the clinician–patient conversation and guide therapies.     

冠状动脉钙化积分预测老年冠心病的相关研究

目的进一步探讨预测老年冠心病的新指标,预防心血管事件的发生。方法对≥60岁老年人66例(冠心病48例,非冠心病18例)进行多层螺旋CT(MSCT)冠状动脉扫描和计算机自动测定冠状动脉钙化积分(CACS),对CACS结果进行分析。结果老年冠心病组的CACS明显高于非冠心病组(P<0·01)。3支血管钙化者CACS明显高于1支及2支血管钙化者,且钙化发生在任意血管段都有明确意义(P<0·01,P<0·05)。结论CACS优于传统危险因子,可作为预测冠心病的新指标之一。     

Different prognostic value of silent peripheral artery disease in type 2 diabetic and non-diabetic subjects with stable cardiovascular disease

ObjectiveABI is a good predictor of morbidity and motality in diabetic subjects with no known cardiovascular disease. However, its prognostic value in diabetic patients with prior coronary or cerebrovascular disease has not previously been evaluated.MethodsMulticenter, prospective study of 1 year of follow-up, in 1096 patients (73.6 years, 65% males, 45.4% with diabetes) with cardiovascular disease and without known peripheral arterial disease. The main outcome measure was the first occurrence of a major cardiovascular event (non-fatal acute coronary syndrome, non-fatal stroke, revascularization procedure, or cardiovascular death). Secondary endpoints included major cardiovascular events, cardiovascular death and death from any cause.ResultsPrevalence of an abnormal ABI (<0.9 or >1.4) was 38.2% in diabetic and 26.8% in non-diabetic subjects. There were 150 major cardiovascular events (38.3/1000 person-years in diabetics vs. 30.6/1000 person-years in non-diabetics subjects, p = 0.012) and 60 cardiovascular deaths (11.8/1000 person-years in diabetics vs. 10.7/1000 person-years in non-diabetics subjects, p = 0.156). Patients with abnormal ABI had a higher rate of vascular complications. There was a significant interaction between ABI and diabetes. In non-diabetic patients, an abnormal ABI was associated with an increase risk of the primary endpoint (HR 2.71; 95% CI 1.54–4.76), cardiovascular mortality (HR 4.62; 95% CI 1.47–14.52) and total mortality (HR 2.80; 95% CI 1.08–7.27). These associations were not observed in patients with diabetes.ConclusionIn patients with cardiovascular disease, ABI is a good predictor of risk of recurrent cardiovascular events and death, only in non-diabetic subjects.     

The effects of lipid-lowering drug therapy on cardiovascular responsiveness in type 2 diabetic patients

Type 2 diabetes is associated with a high prevalence of dyslipidaemia and a high incidence of cardiovascular disease. Lipid lowering therapy with HMG Co-A reductase inhibitors (statins) reduce the risk of cardiovascular events in type 2 diabetic and non-diabetic patients, effects which are believed to be partly due to improvements in vascular function. The aetiology of abnormal vascular function in type 2 diabetics is likely to be multifactorial and the pattern of vascular dysfunction in type 2 diabetes may differ from that which occurs in non-diabetic patients with dyslipidaemia. Abnormalities in endothelium derived hyperpolarising factor (EDHF) mediated vasodilation in resistance vessels may be more prominent in both type 1 and type 2 diabetes than in non-diabetic patients with endothelial dysfunction. The effects of lipid lowering therapy on vascular responsiveness may differ in type 2 diabetic patients from those found in non-diabetic patients. Statin therapy does not appear to improve responses to endothelial dependent vasodilators in type 2 diabetics, but may alter the ratio between nitric oxide (NO) and EDHF mediated responses. Fibrate therapy improves flow mediated dilation of brachial arteries in type 2 diabetic patients, but only appears to improve endothelium dependant vasodilator responses in resistance vessels when given in conjunction with co-enzyme Q.     

Coronary calcification, homocysteine, C-reactive protein and the metabolic syndrome in Type 2 diabetes: the Prospective Evaluation of Diabetic Ischaemic Heart Disease by Coronary Tomography (PREDICT) Study.

AIMS: The PREDICT Study aims to determine: (i) the association between cardiovascular risk factors and coronary artery calcification score (CACS) obtained by electron beam tomography and (ii) the predictive value of CACS for coronary heart disease (CHD) events in Type 2 diabetes. METHODS: Having previously reported relationships between CACS and conventional risk factors, we have now studied the novel risk factors, plasma high-sensitivity C-reactive protein (CRP) and homocysteine, insulin resistance, serum apoprotein A1 and B concentrations, the serum triglyceride/high-density lipoprotein cholesterol ratio and metabolic syndrome (International Diabetes Federation definition) in 573 subjects of the PREDICT Type 2 diabetes cohort. RESULTS: In univariate analyses, the only significant positive novel correlate of CACS was homocysteine (P = 0.0004). CRP was increased in those with detectable calcification, but decreased with increasing calcification score (P = 0.006). In a multivariate model that included all significant univariate correlates, CACS was independently associated with age (P < 0.0001), waist-hip ratio (P < 0.02), male gender (P < 0.05) and duration of diabetes (P < 0.05), but the association with homocysteine was no longer significant. The negative association between CACS and CRP remained in multivariate analysis, and was independent of statin use. CONCLUSIONS: Age was the major factor influencing CACS in Type 2 diabetes, with weaker contributions from waist hip-ratio and duration of diabetes. Other novel cardiovascular risk factors appear to have little positive effect.     

CHD: a major burden in type 2 diabetes

Patients with type 2 diabetes have a two- to four-fold greater risk of cardiovascular mortality than non-diabetic individuals. In order to prevent coronary events in the diabetic population, it is important to treat modifiable cardiovascular risk factors. Data from the Multiple Risk Factor Intervention Trial (MRFIT) show that serum cholesterol level, systolic blood pressure level and cigarette smoking were significant predictors of cardiovascular disease mortality in men with and without diabetes. At every risk factor level, the absolute risk of age-adjusted coronary death rate was three times greater for diabetic men than non-diabetic men (p<0.0001). Patients with diabetes have an abnormal (dyslipidaemic) lipoprotein profile with high levels of very low density lipoprotein cholesterol and triglycerides, and a low level of high density lipoprotein cholesterol. Although levels of total cholesterol or low density lipoprotein (LDL) cholesterol do not differ significantly between patients with and without diabetes, those with diabetes have higher levels of atherogenic small dense LDL particles. MRFIT data show that at any serum cholesterol level, diabetes confers two-three times the risk for a coronary event. These findings constitute the rationale for considering hypolipaemic therapy, e.g. with HMG-CoA reductase inhibitors (statins), in diabetic patients with dyslipidaemia, particularly in those with evidence of coronary heart disease. Evidence shows that statins significantly lower cholesterol, exhibit beneficial effects on many components of atherosclerosis, and can significantly reduce the incidence of stroke.     

Should pulse pressure and day/night variations in blood pressure be seen as independent risk factors requiring correction or simply as markers to be taken into account when evaluating overall vascular risk?

Patients with a blunted fall in nocturnal BP (known as non-dippers) have a high risk of micro- and macrovascular complications, particularly if they have hypertension, but also in normotensive patients with diabetes. A blunted fall in nocturnal BP reflects the high level of CV risk in these patients. ABPM data indicating an altered circadian BP rhythm reverse circadian BP profile should alert the physician to the potential risk of complications and should lead to efforts to treat hypertension effectively, especially at night, and to check for sleep apnoea syndrome, particularly in cases of resistant hypertension, or autonomic neuropathy (postural hypotension), a well known risk factor for cardiovascular (CV) events. Patients should be carefully screened for nephropathy. However, the definitions of "non-dipper" vary widely. Suitable treatments are poorly defined, but angiotensin-converting enzyme inhibitors (ACEi), diuretics, salt restriction and the maintenance of continuous positive airway pressure (CPAP) can be used as non-specific treatments. The efficacy of taking blood pressure-lowering drugs at bedtime rather than in the morning is still debated but deserves attention. In the diabetic population, brachial pulse pressure (PP) is an independent predictor of cardiovascular mortality, but not of all-cause mortality. It is also associated with complications of both type 2 and type 1 diabetes, this effect being stronger for nocturnal than for diurnal PP, and is strongly predictive of coronary heart disease in patients with type 2 diabetes. The stronger association between PP and age in diabetic than in non-diabetic populations suggests that diabetes accelerates vascular ageing. In patients with incipient nephropathy or overt renal failure, PP increases CV risk. However, misinterpretation could be related to confusion between brachial PP and central PP. The therapeutic implications of PP measurement remain poorly documented in diabetes.     

Association between low serum free thyroxine concentrations and coronary artery calcification in healthy euthyroid subjects

Background: Considerable evidence suggests that hypothyroidism could promote atherosclerotic vascular changes. We planned this study to investigate whether serum free thyroxine (FT4) or thyroid-stimulating hormone (TSH) levels are associated with coronary artery calcification measured in healthy euthyroid subjects. Methods: A cross-sectional analysis was performed among subjects who visited our hospital for a health checkup. Among 1849 subjects, 669 (mean age 55.3±8.8 years; 392 men) with FT4 and TSH in the normal ranges were included after excluding those with diabetes, a history of current smoking and cardiovascular disease (CVD), or the use of drugs for hypertension, antithyroid drugs, or thyroid hormone preparations. Coronary artery calcium scores (CACS) were measured by multi-detector computed tomography. Results: Subjects with a CACS >100 had lower FT4 levels than those with a lower CACS (p=0.017), whereas no difference was observed in the TSH levels among CACS categories. FT4 levels had an odds ratio of 0.06 for high CACS (95% confidence interval=0.01-0.74; p=0.028) after the adjustment for CVD risk factors. In multivariate regression analysis, CACS was negatively correlated with FT4 levels (β=-0.823, p=0.032), and the inverse association between FT4 and CACS remained significant only in men (p=0.011). Conclusion: FT4 levels were inversely associated with coronary artery calcification in euthyroid healthy subjects, especially in men independent of conventional CVD risk factors. Further studies are needed to validate whether subjects with decreased FT4 levels within the normal reference range are at a high CVD risk and have poor cardiovascular outcomes.     

Microalbuminuria--a risk factor for diabetic nephropathy and cardiovascular disease

In developed countries diabetics patients are the most numerous group with renal replacement therapy (USA 34%). The main and diagnostically irreplaceable criterion of incipient diabetic nephropathy is microalbuminuria which is usually associated with hypertension and poor glycaemic compensation. With advancing microalbuminuria progresses diabetic retinopathy and neuropathy. The increased transcapillary albumin escape rate and changes of some haemocoagulation factors in diabetics patients with microalbuminuria indicate that endothelial dysfunction is involved. In type 1 diabetes microalbuminuria is an indicator of increased mortality in which participate in particular cardiovascular diseases and to a minor extent renal failure. In type 2 diabetes microalbuminuria is an independent risk of generalized vascular disease. Microalbuminuria is also in non-diabetic subjects with hypertension associated with abnormalities such as impaired glucose tolerance and insulin resistance, an unflavourable lipidogram and altered diurnal blood pressure rhythm. The results of a coronarographic investigation revealed that the risk of severe coronary artery disease is more than double in subjects with microalbuminuria. Hypertension and hypercholesterolaemia are causal risk factors of cardiovascular diseases and concurrent microalbuminuria implies a higher expression of already existing microvascular damage in hormonal and metabolic disorders with an atherogenic potential.     

Increased incidence of coronary atherosclerosis in type 2 diabetes mellitus: mechanisms and management

Type 2 diabetes mellitus is a metabolic disease of carbohydrate metabolism. However, it should also be considered a vascular disease because diabetic patients have a strong predilection for atherosclerosis. With the increasing prevalence and earlier age at onset of diabetes, the projected effect of diabetes on cardiovascular health and resource utilization is sobering. The mechanisms of the high rate of atherosclerosis are multifactorial and give clinicians and researchers insights into potential preventive therapies. Effective pharmacologic and lifestyle interventions are available for primary and secondary prevention of cardiovascular complications. However, data show that these interventions continue to be underutilized. Treatment of patients with type 2 diabetes and coronary artery disease is similar to that of patients with coronary artery disease alone. However, patients with diabetes benefit more from treatments that reduce coronary artery disease risk.     

Diabetes mellitus and vascular calcification

Two types of arterial calcification are well recognized:intimal (atherosclerotic) and medial (Monckeberg type). These two calcifications are considered different in pathogenesis. Arterial calcification has recently been reported to be an organized, regulated process similar to bone formation. The relation of calcification to diabetes mellitus remains still unclear. EBCT can noninvasively and accurately detect coronary artery calcification. Diabetic patients seem to have increased prevalence of coronary calcification when compared with non-diabetic patients. Medial artery calcification is an independent predictor of cardiovascular mortality in diabetic patients.     

The progress of coronary heart disease in Type 2 diabetes as measured by coronary calcium score from electron beam computed tomography (EBCT): the PREDICT study

Coronary calcification score (CACS) measured by electron beam tomography is well established in the evaluation of cardiovascular risk in general populations. The PREDICT study aims to evaluate prediction of cardiovascular events by CACS in Type 2 diabetic subjects without previous clinical cardiovascular disease. In the present PREDICT sub-study, the rate of progression of CACS and factors influencing this rate were assessed. CACS was measured at baseline and after a mean interval of 4.0 (range of 2.1-5.0) years in the 202 PREDICT participants who agreed to have a second scan. Participants also had a range of conventional and novel biochemical risk factors measured at baseline. Progression of calcification was apparent in 170 (84%), while in 32 (16%) there was regression or no progression. Those showing progression had a significantly more adverse risk factor profile. Rate of change in CACS was strongly related to baseline CACS (p<0.0001). Rate of change also correlated with, waist:hip ratio (p=0.004), male gender (p=0.009), age (p=0.04), use of antihypertensive drugs (p=0.03) and statins (p=0.05) and, independently of baseline CACS, systolic blood pressure (p=0.0006), waist circumference (p=0.001) and urine albumin:creatine ratio (p=0.04). Most subjects with Type 2 diabetes showed progression of CACS. The absence of a relationship between progression and lipid risk factors and the positive relationship with statin and antihypertensive drug use may reflect earlier risk factor exposure. Independent relationships between progression and established calcification, blood pressure, central adiposity and urine albumin:creatinine ratio suggest areas for risk factor modification that could be especially relevant in Type 2 diabetes.     

Pulse pressure predicts cardiovascular risk in patients with type 2 diabetes mellitus

BACKGROUND: Pulse pressure (PP), a marker of arterial stiffness, is a better predictor of coronary heart disease (CHD) risk than systolic blood pressure (SBP) or diastolic blood pressure (DBP) in older adults. Whether this is also true in subjects with type 2 diabetes, who are at increased risk for cardiovascular disease, is unknown. METHODS: Data on 2911 type 2 diabetic subjects relating to blood pressure (BP), other risk factors, and cardiovascular events were abstracted from The Cardiff Diabetes Database. Logistic regression was used to assess the relationship among BP components and the risk of CHD, cerebrovascular (CVD), and peripheral vascular (PVD) events after correction for age, gender, cholesterol, and smoking status. RESULTS: In the 4-year follow-up period there were 574 CHD, 168 CVD, and 157 PVD events. Both PP and SBP, but not DBP, were positively associated with the risk of all event types. However, PP emerged as the best predictor of CHD events, and SBP as the best predictor of CVD and PVD events. Total and HDL-cholesterol were the most important variables associated with PP after age. CONCLUSIONS: In summary, PP is a better predictor of CHD events than SBP in persons with type 2 diabetes, but the converse is true for CVD and PVD.