Systolic blood pressure, diabetes and the risk of cardiovascular diseases in the Asia-Pacific region

OBJECTIVE: To assess the association between systolic blood pressure (SBP) and cardiovascular diseases (CVD) among participants with and without diabetes from cohorts in the Asia-Pacific region. RESEARCH DESIGN AND METHODS: Hazards ratios and 95% confidence intervals (CI) for CVD were calculated from Cox models, stratified by sex and region and adjusted for age using individual participant data from 36 cohort studies. Repeat measurements of SBP were used to adjust for regression dilution bias. RESULTS: During follow-up, 7387 fatal or non-fatal cardiovascular endpoints were recorded among 368 307 participants (6.4% with diabetes). SBP was associated with coronary heart disease (CHD), ischaemic stroke and haemorrhagic stroke in a continuous log-linear fashion among individuals with diabetes, as well as those without diabetes. Overall, each 10 mmHg higher usual SBP was associated with 18% (95% CI: 9-27%) and 23% (19-26%) greater risk for CHD among those with and without diabetes, respectively. The corresponding values for ischaemic stroke were 29% (14-45%) and 43% (37-50%), and for haemorrhagic stroke, 56% (32-83%) and 74% (66-82%). The test for heterogeneity by diabetes status in each of these associations was not significant (P >or= 0.10). CONCLUSIONS: Systolic blood pressure is an important marker of risk of CVD in people with and without diabetes. A given reduction in systolic blood pressure is likely to have a similar relative effect on reducing the risk of a cardiovascular event, regardless of diabetes status.     

Risk of mortality and adverse cardiovascular outcomes in type 2 diabetes: a comparison of patients treated with sulfonylureas and metformin

Aims/hypothesis The aim of this study was to evaluate the risk of adverse cardiovascular outcomes in patients with type 2 diabetes newly treated with sulfonylureas and metformin.Subjects and methods The Diabetes Audit and Research in Tayside Scotland (DARTS) diabetes information system and the Medicines Monitoring Unit (MEMO) dispensed prescribing database for the population of Tayside, Scotland (400,000 people) were employed. Patients newly prescribed with oral hypoglycaemic agents between 1994 and 2001 were classified into five study cohorts according to the treatment received: metformin only, sulfonylureas only, sulfonylureas added to metformin, metformin added to sulfonylureas, and both drugs simultaneously. In Cox regression analyses, we estimated relative risks for all-cause mortality, cardiovascular mortality and cardiovascular hospital admission for patients in the five study cohorts, with metformin monotherapy as the reference group.Results Of the 5,730 study patients, 1,000 died during a maximum of 8 years follow-up. Patients in the sulfonylureas only cohort had increased risks of mortality and cardiovascular mortality, with unadjusted relative risks of 3.12 (95% CI 2.54–3.84) and 3.71 (95% CI 2.64–5.22), respectively. After adjusting for differences between groups (age, sex, duration of diabetes, blood pressure, cholesterol, HbA_1c, smoking, previous hospital admission, treatment with cardiovascular medication), these relative risks were 1.43 (95% CI 1.15–1.77) and 1.70 (95% CI 1.18–2.45), respectively. Patients in the combination cohorts had significantly increased risks of cardiovascular hospital admission, as well as increased risks of mortality and cardiovascular mortality.Conclusions/interpretation In this cohort study of patients newly treated with oral hypoglycaemic agents, those treated with sulfonylureas only, or combinations of sulfonylureas and metformin, were at higher risk of adverse cardiovascular outcomes than those treated with metformin alone.     

Insulin sensitivity measured by the euglycaemic insulin clamp and proinsulin levels as predictors of stroke in elderly men

Aims/hypothesis  Our aim was to investigate the predictive power of a panel of variables in glucose and insulin metabolism for the incidence of stroke or transient ischaemic attacks (TIA). We hypothesised that proinsulin and insulin resistance contributes to an increase of risk for fatal and non-fatal stroke/TIA, independently of diabetes and established risk factors. Methods  The study is based on the Uppsala Longitudinal Study of Adult Men cohort. The examinations were performed at age 70 years. Results  In 1,151 men free from stroke at baseline, 150 developed stroke or TIA during a median follow-up of 8.8 years. In unadjusted Cox proportional hazards analyses, a 1 SD increase of a predictor variable was associated with an increased risk for stroke/TIA, e.g. plasma insulin (HR 1.19, 95% CI 1.01–1.40), fasting intact proinsulin (HR 1.28, 95% CI 1.09–1.49); whereas a 1 SD increase in insulin sensitivity measured by the euglycaemic insulin clamp method decreased the risk for stroke/TIA (HR 0.81, 95% CI 0.68–0.96). The predictive values of fasting intact proinsulin and insulin sensitivity endured but not that of plasma insulin when adjusting for diabetes. In models adjusting for diabetes, hypertension, atrial fibrillation, electrocardiographic left ventricular hypertrophy, serum cholesterol and smoking, proinsulin remained as a significant predictor of later stroke/TIA (HR 1.22, 95% CI 1.00–1.48) whereas clamp insulin sensitivity did not (HR 0.87, 95% CI 0.71–1.07). Conclusions/interpretation  Fasting intact proinsulin level and insulin sensitivity at clamp predicted subsequent fatal and non-fatal stroke/TIA, independently of diabetes in elderly men whereas fasting insulin did not.     

Risk of cardiovascular disease and mortality in overweight and obese patients with type 2 diabetes: an observational study in 13,087 patients

Aims/hypothesis  The aim of this study of type 2 diabetic patients in the Swedish National Diabetes Register was to study the associations of BMI, overweight (BMI 25–29.9 kg/m²) and obesity (BMI ≥ 30 kg/m²) with cardiovascular disease in type 2 diabetes, as these associations have not previously been clarified. Methods  Patients aged 30–74 years with no previous CHD or stroke (N = 13,087) were followed for a mean of 5.6 years until 2003 for fatal or non-fatal CHD, stroke, cardiovascular disease (CHD or stroke) and total mortality. In total, 1,922 cardiovascular-disease events occurred, based on 64,864 person-years. Results  The relative risks of CHD, stroke, cardiovascular disease and total mortality for a 5 unit increase in BMI at baseline were 15%, 11%, 13% and 27%, respectively, using Cox regression analysis, after adjusting for age, sex, diabetes duration, hypoglycaemic treatment and smoking (model 1), and were 9%, 4% (not significant), 7% and 20%, respectively, when adjusting also for HbA_1c, blood pressure, antihypertensive drugs, lipid-reducing drugs and microalbuminuria (model 2). Adjusted hazard ratios (model 1) for CHD, cardiovascular disease and total mortality with overweight were 1.27 (95% CI 1.09–1.48), 1.24 (1.09–1.41) and 1.16 (0.94–1.45), respectively, and 1.49 (1.27–1.76), 1.44 (1.26–1.64) and 1.71 (1.36–2.14) with obesity, as compared with normal weight. Significant hazard ratios were attenuated when adjusted according to model 2. For a 1 unit increase in BMI during follow-up, the relative risk of CHD (model 2) was 1.13 (1.04–1.23; p = 0.005). Conclusions/interpretation  Both overweight and obesity independently increased the risk of CHD and cardiovascular disease in patients with type 2 diabetes. The CHD risk was higher with increasing BMI than with stable or decreasing BMI during the study.     

Risk of Cardiovascular Events and Death—Does Insurance Matter?

BACKGROUND Many Americans lack health insurance. Despite good evidence that lack of insurance compromises access to care, few prospective studies examine its relationship to health outcomes. OBJECTIVE To determine the relationship between insurance and cardiovascular outcomes and the relationship between insurance and selected process measures. DESIGN AND PARTICIPANTS We used data from 15,792 participants in the Atherosclerosis Risk in Communities Study, a prospective cohort study. Participants were enrolled in 1987–1989 and returned for follow-up visits every 3 years, for a total of 4 visits. MAIN OUTCOME MEASURES We estimated the hazard of myocardial infarction, stroke, and death associated with insurance status using Cox proportional hazard modeling. We used generalized estimating equations to examine the association between insurance status and risk of (1) reporting no routine physical examinations, (2) being unaware of a personal cardiovascular risk condition, and (3) inadequate control of cardiovascular risk conditions. RESULTS Persons without insurance had higher rates of stroke (adjusted hazard ratio, 95% CI 1.22–2.22) and death (adjusted hazard ratio 1.26, 95% CI 1.03–1.53), but not myocardial infarction, than those who were insured. The uninsured were less likely to report routine physical examinations (adjusted risk ratio 1.13, 95% CI 1.08–1.18); more likely to be unaware of hypertension (adjusted risk ratio 1.12, 95% CI 1.00–1.25) and hyperlipidemia (adjusted risk ratio 1.11, 95% CI 1.03–1.19); and more likely to have poor blood pressure control (adjusted risk ratio 1.23, 95% CI 1.08–1.39). CONCLUSIONS Lack of health insurance is associated with increased rates of stroke and death and with less awareness and control of cardiovascular risk conditions. Health insurance may improve cardiovascular risk factor awareness, control and outcomes.     

Coffee consumption and risk of cardiovascular events and all-cause mortality among women with type 2 diabetes

Aims/hypothesis  Coffee has been linked to both beneficial and harmful health effects, but data on its relationship with cardiovascular disease and mortality in patients with type 2 diabetes are sparse. Methods  This was a prospective cohort study including 7,170 women with diagnosed type 2 diabetes but free of cardiovascular disease or cancer at baseline. Coffee consumption was assessed in 1980 and then every 2–4 years using validated questionnaires. A total of 658 incident cardiovascular events (434 coronary heart disease and 224 stroke) and 734 deaths from all causes were documented between 1980 and 2004. Results  After adjustment for age, smoking and other cardiovascular risk factors, the relative risks were 0.76 (95% CI 0.50–1.14) for cardiovascular diseases (p trend = 0.09) and 0.80 (95% CI 0.55–1.14) for all-cause mortality (p trend = 0.05) for the consumption of ≥4 cups/day of caffeinated coffee compared with non-drinkers. Similarly, multivariable RRs were 0.96 (95% CI 0.66–1.38) for cardiovascular diseases (p trend = 0.84) and 0.76 (95% CI 0.54–1.07) for all-cause mortality (p trend = 0.08) for the consumption of ≥2 cups/day of decaffeinated coffee compared with non-drinkers. Higher decaffeinated coffee consumption was associated with lower concentrations of HbA_1c (6.2% for ≥2 cups/day versus 6.7% for <1 cup/month; p trend = 0.02). Conclusions  These data provide evidence that habitual coffee consumption is not associated with increased risk of cardiovascular diseases or premature mortality among diabetic women. Electronic supplementary material  The online version of this article (doi:) contains supplementary material, which is available to authorised users.     

Impact of gender on relative rates of cardiovascular events in patients with diabetes

AimTo investigate whether diabetes confers higher relative risks of cardiovascular events in women compared with men using contemporary data and also whether such gender-differences are dependent on age.MethodsAll patients discharged from French hospitals in 2013 with at least 5 years of follow-up and no history of major adverse cardiovascular events including heart failure (MACE-HF; heart failure, myocardial infarction, ischaemic stroke, cardiovascular death) were identified and categorized by diabetes status. Overall and age-stratified incidence rates, hazard ratios (HRs) and women-to-men ratios (WMRs) for MACE-HF leading to hospitalization were also calculated. Adjustments were then made for age and baseline characteristics according to cardiovascular risk factors and non-cardiovascular comorbidities.ResultsThe study included 2,953,816 subjects, among whom 349,928 (11.9%) had diabetes. Of those with diabetes, the absolute rate of MACE-HF was higher in men than in women (96 vs 66 per 1000 person-years); corresponding absolute rates in men and women without diabetes were 44 vs 27 per 1000 person-years. Comparing those with and without diabetes, women had a higher unadjusted HR of MACE-HF (2.45, 95% CI: 2.42–2.47) than men (2.15, 95% CI: 2.14–2.17), with an adjusted WMR of 1.13 (95% CI: 1.12–1.15). HRs of MACE-HF related to diabetes were highest in women aged around 45 years and in the youngest men and decreased with advancing age in both these groups. However, HRs were higher in women of all ages > 40 years. After adjustment, this effect was more apparent for myocardial infarction (adjusted WMR: 1.43, 95% CI: 1.38–1.48) than for either ischaemic stroke (adjusted WMR: 1.10, 95% CI: 1.07–1.14) or heart failure (adjusted WMR: 1.13, 95% CI: 1.11–1.14).ConclusionAlthough men have higher absolute risks of cardiovascular complications, the relative risks of cardiovascular complications associated with diabetes are higher in women than in men.     

Increased serum levels of advanced glycation endproducts predict total, cardiovascular and coronary mortality in women with type 2 diabetes: a population-based 18 year follow-up study

Aims/hypothesis AGEs, modification products formed by glycation or glycoxidation of proteins and lipids, have been linked to premature atherosclerosis in patients with diabetes. We investigated whether increased serum levels of AGEs predict total, cardiovascular (CVD) or CHD mortality in a population-based study. Subjects and methods Serum levels of AGEs were determined by immunoassay in a random sample of 874 Finnish diabetic study participants (488 men, 386 women), aged 45–64 years. These participants were followed for 18 years for total, CVD and CHD mortality. Results Multivariate Cox regression models revealed that serum levels of AGEs were significantly associated with total (p = 0.002) and CVD mortality (p = 0.021) in women, but not in men. Serum levels of AGEs in the highest sex-specific quartile predicted all-cause (hazards ratio [HR] 1.51; 95% confidence intervals [CI], 1.14–1.99; p = 0.004), CVD (HR 1.56; 95% CI 1.12–2.19; p = 0.009), and CHD (HR 1.68; 95% CI 1.11–2.52; p = 0.013) mortality in women, even after adjustment for confounding factors, including high-sensitivity C-reactive protein. Conclusions/interpretation Increased serum levels of AGEs predict total and CVD mortality in women with type 2 diabetes. B. K. Kilhovd and A. Juutilainen contributed equally to this study.     

QT<Subscript>c</Subscript> interval and resting heart rate as long-term predictors of mortality in type 1 and type 2 diabetes mellitus: a 23-year follow-up

Aims/hypothesis We evaluated the association of QT interval corrected for heart rate (QT_c) and resting heart rate (rHR) with mortality (all-causes, cardiovascular, cardiac, and ischaemic heart disease) in subjects with type 1 and type 2 diabetes. Methods We followed 523 diabetic patients (221 with type 1 diabetes, 302 with type 2 diabetes) who were recruited between 1974 and 1977 in Switzerland for the WHO Multinational Study of Vascular Disease in Diabetes. Duration of follow-up was 22.6 ± 0.6 years. Causes of death were obtained from death certificates, hospital records, post-mortem reports, and additional information given by treating physicians. Results In subjects with type 1 diabetes QT_c, but not rHR, was associated with an increased risk of: (1) all-cause mortality (hazard ratio [HR] 1.10 per 10 ms increase in QT_c, 95% CI 1.02–1.20, p = 0.011); (2) mortality due to cardiovascular (HR 1.15, 1.02–1.31, p = 0.024); and (3) mortality due to cardiac disease (HR 1.19, 1.03–1.36, p = 0.016). Findings for subjects with type 2 diabetes were different: rHR, but not QT_c was associated with mortality due to: (1) all causes (HR 1.31 per 10 beats per min, 95% CI 1.15–1.50, p < 0.001); (2) cardiovascular disease (HR 1.43, 1.18–1.73, p < 0.001); (3) cardiac disease (HR 1.45, 1.19–1.76, p < 0.001); and (4) ischaemic heart disease (HR 1.52, 1.21–1.90, p < 0.001). Effect modification of QT_c by type 1 and rHR by type 2 diabetes was statistically significant (p < 0.05 for all terms of interaction). Conclusions/interpretation QT_c is associated with long-term mortality in subjects with type 1 diabetes, whereas rHR is related to increased mortality risk in subjects with type 2 diabetes.     

Risk of stroke in people with type 2 diabetes in the UK: a study using the General Practice Research Database

Aims/hypothesis Risk estimates for stroke in patients with diabetes vary. We sought to obtain reliable risk estimates for stroke and the association with diabetes, comorbidity and lifestyle in a large cohort of type 2 diabetic patients in the UK.Materials and methods Using the General Practice Research Database, we identified all patients who had type 2 diabetes and were aged 35 to 89 years on 1 January 1992. We also identified five comparison subjects without diabetes and of the same age and sex. Hazard ratios (HRs) for stroke between January 1992 and October 1999 were calculated, and the association with age, sex, body mass index, smoking, hypertension, atrial fibrillation and duration of diabetes was investigated.Results The absolute rate of stroke was 11.91 per 1,000 person-years (95% CI 11.41–12.43) in people with diabetes (n = 41,799) and 5.55 per 1,000 person-years (95% CI 5.40–5.70) in the comparison group (n = 202,733). The age-adjusted HR for stroke in type 2 diabetic compared with non-diabetic subjects was 2.19 (95% CI 2.09–2.32) overall, 2.08 (95% CI 1.94–2.24) in men and 2.32 (95% CI 2.16–2.49) in women. The increase in risk attributable to diabetes was highest among young women (HR 8.18; 95% CI 4.31–15.51) and decreased with age. No investigated comorbidity or lifestyle characteristic emerged as a major contributor to risk of stroke.Conclusions/interpretation This study provides risk estimates for stroke for an unselected population from UK general practice. Patients with type 2 diabetes were at an increased risk of stroke, which decreased with age and was higher in women. Additional risk factors for stroke in type 2 diabetic patients included duration of diabetes, smoking, obesity, atrial fibrillation and hypertension.     

Chronic Kidney Disease,Basal Insulin Glargine,and Health Outcomes in People with Dysglycemia: The ORIGIN Study

Background

Early stages of chronic kidney disease are associated with an increased cardiovascular risk in patients with established type 2 diabetes and macrovascular disease. The role of early stages of chronic kidney disease on macrovascular outcomes in prediabetes and early type 2 diabetes mellitus is not known. In the Outcome Reduction with an Initial Glargine Intervention (ORIGIN) trial, the introduction of insulin had no effect on cardiovascular outcomes compared with standard therapy. In this post hoc analysis of ORIGIN, we compared cardiovascular outcomes in subjects without to those with mild (Stages 1-2) or moderate chronic kidney disease (Stage 3).

Impact of glycaemic control, hypertension and insulin treatment on general and cause-specific mortality: an Italian population-based cohort of Type II (non-insulin-dependent) diabetes mellitus

Summary The aims of this study were to assess the impact of diabetes and associated variables (fasting plasma glucose, blood pressure, antidiabetic treatment, body mass index) on general and cause-specific mortality in an Italian population-based cohort with Type II (non-insulin-dependent) diabetes mellitus, comprising mainly elderly patients. The patients (n = 1967) who had Type II diabetes were identified in 1988 with an 80 % estimated completeness of ascertainment. In 1995, a mortality follow-up (98 % completeness) of the cohort was done amounting to a total of 11 153 person-years. Observed and expected number of deaths were 577 and 428.7, respectively, giving a standardized mortality ratio (SMR) of 1.35 (95 % CI 1.24–1.46). The most common underlying causes of death were malignant neoplasm, ischaemic heart disease and cerebrovascular diseases, which accounted for 18 %, 17.8 % and 17.5 % of deaths, respectively. Cardiovascular disease as a whole (international classification of disease ICD-9 390–459) accounted for 260 of 577 deaths (SMR 1.21, 95 % CI 1.07–1.36). In internal analysis, the most important predictors of general mortality were insulin-treatment (relative risk [RR] 1.72, 95 % CI 1.19–2.49) and a fasting plasma glucose greater than 8.89 mmol/l ([RR] 1.29, 95 % CI 1.04–1.60), whereas the most important predictors of cardiovascular diseases were insulin-treatment and hypertension. In conclusion, this population-based study showed: 1) slight mortality excess of 35 % in Type II diabetes being associated with 2) a 30 % increased mortality in subjects with baseline fasting glucose greater than 8.89 mmol/l and 3) a 40 % increased risk of death from cardiovascular diseases in hypertensive patients. [Diabetologia (1999) 42: 297–301] Received: 27 July 1998 and in final revised form: 17 November 1998     

Association Among C-Reactive Protein,Fatty Liver Disease,and Cardiovascular Risk

Nonalcoholic fatty liver disease (NAFLD) is associated with several metabolic disturbances involving inflammation. Ultrasensitive C-reactive protein (uCRP), a marker of coronary heart disease and other chronic diseases, has not been investigated in NAFLD. We tested the relationship between uCRP and NAFLD in middle-aged asymptomatic subjects, independently of other metabolic disturbances associated with metabolic syndrome and cardiovascular risk. We compared 310 subjects with steatosis visible on ultrasound (cases) with 630 and without (controls). Body mass index (BMI), blood pressure and serum levels of uCRP, glucose, lipids, and lipoproteins were measured in all subjects. Differences between groups and the impact of serum uCRP levels were tested by univariate and multivariate logistic regression analysis. Cases were statistically different from controls in the frequency of metabolic syndrome (66.4% vs. 26.7%; P < 0.001). Cases were significantly older (P < 0.001), and had significantly higher values for BMI, glucose, total cholesterol and triglycerides (P < 0.001), and mean uCRP concentrations (4.5 vs. 2.79 mg/L; P < 0.001). By univariate analysis, variables significantly associated with cases were glucose (OR, 4.09; 95% CI, 2.98–5.61), BMI (OR 5.54; 95% CI, 4.09–7.49), and uCRP (OR 7.06; 95% CI, 4.51–11.02). By multivariate analysis, uCRP levels were associated with hepatic steatosis (OR 5.83; 95% CI, 3.07–11.06). Cardiovascular risk was also higher in subjects with NAFLD (4.7 vs. 2.8). Subjects with hepatic steatosis showed an increased concentration of uCRP independently of other metabolic disturbances; this suggests an increased risk of cardiovascular diseases and could be used as a marker of chronic inflammation.     

Association of impaired fasting glucose and coronary artery calcification as a marker of subclinical atherosclerosis in a population-based cohort—results of the Heinz Nixdorf Recall Study

Aims/hypothesis  Atherosclerosis and cardiovascular diseases are often present at the time of diagnosis of type 2 diabetes mellitus. Whether subclinical atherosclerosis can be detected in the pre-diabetic (borderline fasting hyperglycemia) state is not clear. This study investigated the association of impaired fasting glucose (IFG) and coronary artery calcification (CAC), a marker of subclinical atherosclerosis, among participants without a history of coronary heart disease or manifest diabetes mellitus. Methods  Study participants (aged 45–75 years) of the population-based Heinz Nixdorf Recall Study were categorised into those with normal fasting glucose (glucose <6.1 mmol/l) and those with IFG (glucose ≥6.1 to <7.0 mmol/l), excluding participants with a history of CHD or diabetes mellitus. CAC was assessed by electron-beam computed tomography, and risk factors were assessed by extended interviews, anthropometric measurements and laboratory tests. Various CAC cut-off points were used in multiple logistic and ordinal logistic regression models to estimate ORs and 95% CIs. Results  Of the 2,184 participants, more men had IFG than did women (37% vs 22%). Participants with IFG showed a higher prevalence of CAC  > 0 (men OR 1.90, 95% CI 1.33–2.70; women 1.63, 1.23–2.15). Risk factor adjustment weakened this association in both sexes (men 1.63, 1.12–1.36; women 1.26, 0.93–1.70). When the age- and sex-specific 75th percentile was used as the cut-off point for CAC, the association further decreased in men (1.10, 0.81–1.50), but became stronger in women (1.41, 1.02–1.94). Conclusions/interpretation  These data support the hypothesis that CAC is already present in the pre-diabetic state and that IFG has a modest and independent impact on the atherosclerotic process. Biological sex appears to modify the association between IFG and CAC. Electronic supplementary material  The online version of this article (doi:) contains supplementary material, which is available to authorised users.     

Atrial Fibrillation With and Without Cardiovascular Risk Factors and Stroke Mortality

Aim: The association between atrial fibrillation (AF) and risk of stroke mortality among men and women without traditional cerebrocardiovascular risk factors (TCVRFs) is unclear. This study aimed to determine whether AF was a risk factor for stroke and total cardiovascular disease mortality among individuals without TCVRFs.Methods: A total of 90,629 Japanese subjects from the Ibaraki Prefectural Health Study aged 40–79 years, with and without TCVRFs, were studied from 1993 to 2013. Hazard ratios (HRs) were calculated using the Cox proportional hazard regression model stratified by sex and the presence of TCVRFs. Covariates were age, systolic blood pressure, anti-hypertensive medication use, and serum total cholesterol levels. A standard 12-lead electrocardiogram at rest was used to screen AF. Cause-specific mortality was classified according to the International Classification of Disease code.Results: Compared with participants without AF, multivariable-adjusted hazard ratios (with 95% confidence intervals) for stroke mortality among participants without TCVRFs were 4.3 (1.1–17.8) and 15.0 (5.5–40.8) for men and women with AF, respectively. HRs for total cardiovascular disease mortality were 6.2 (2.8–14.2) for men and 10.7 (4.8–24.1) for women. For participants with TCVRFs, multivariable-adjusted HRs for stroke mortality were 3.1 (2.2–4.6) and 4.3 (2.6–7.3), whereas HRs for total cardiovascular disease mortality were 2.9 (2.2–3.8) and 3.5 (2.4–5.1) for men and women, respectively.Conclusions: AF was found to be an independent risk factor for stroke and total cardiovascular mortality even in individuals without other TCVRFs.     

低心血管病危险人群死亡的相对危险及期望寿命

目的：探讨低心血病危险与冠心病、脑卒中、恶性肿瘤死亡及总死亡的关系,以及对平均期望寿命的影响。方法：1982－1985年在我国不同地区的10组人群（年龄35－59岁）共3万余人中进行心血管病危险因素调查,并随访至2000年底,登记并核实其全部残因情况。结果：24900人中（男性12497人,女性12403人）,7．7％的男性,28．9％的女性基线心血管病危险因素处于低危险水平,在其后平均15．2年的随访过程中,总死亡、冠心病死亡（女性）、脑卒中死亡明显低于其他人群,男性和女性平均期望寿命分别延长2．6年和4．0年。结论：低心血管危险人群,不仅心血管病死亡减少,且总病死率降低,平均期望寿命延长。     

Incident ischaemic stroke and Type 2 diabetes: trends in incidence and case fatality in Scotland 2004–2013

Aim

To describe trends in first ischaemic stroke incidence and case fatality in adults with and without a diagnosis of Type 2 diabetes prior to their ischaemic stroke event in Scotland between 2004 and 2013.

Methods

Using population‐wide hospital admission, death and diabetes datasets, we conducted a retrospective cohort study. Negative binomial and logistic regression models were used to calculate year‐specific incidence and case‐fatality rates for people with Type 2 diabetes and for people without diabetes.

Results

During 41.0 million person‐years of follow‐up there were 69 757 ischaemic stroke events. Type 2 diabetes prevalence among patients who experienced ischaemic stroke increased from 13.5% to 20.3% between 2004 and 2013. Stroke incidence rates declined by 2.7% (95% CI 2.4, 3.0) annually for people with and without diabetes [diabetes/year interaction: rate ratio 0.99 (95% CI 0.98, 1.01)]. Type 2 diabetes was associated with an increased risk of ischaemic stroke in men [rate ratio 1.23 (95% CI 1.17, 1.30)] and women [rate ratio 1.41 (95% CI 1.35, 1.48)]. Case‐fatality rates were 14.2% and 12.7% in people with Type 2 diabetes and without diabetes, respectively. Case fatality declined by 3.5% (95% CI 2.7, 4.5) annually [diabetes/year interaction: odds ratio 1.01 (95% CI 0.98, 1.02)].

Conclusions

Ischaemic stroke incidence declined no faster in people with a diagnosis of Type 2 diabetes than in people without diabetes. Increasing prevalence of Type 2 diabetes among stroke patients may mean that declines in case fatality over time will be less marked in the future.     

Predictors of cognitive impairment and dementia in older people with diabetes

Aims/hypothesis Diabetes is associated with an increased risk of dementia but the reasons for this association are unclear because there are many potential mechanisms. We explored the relative contribution of diabetes-related variables as predictors of dementia in older individuals with diabetes. Methods Survivors, aged ≥70 or more, were recruited from an existing observational cohort study 7.6 ± 1.0 years after baseline, when they underwent a comprehensive assessment of diabetes, complications and cardiovascular risk factors. Dementia, probable Alzheimer’s disease and cognitive impairment without dementia were diagnosed clinically. Logistic regression modelling determined independent predictors of cognitive diagnoses. Results Of 302 participants, aged 75.7 ± 4.6 years, 28 (9.3%) had dementia (16 with probable Alzheimer’s disease) and 60 (19.9%) had cognitive impairment without dementia. The major independent longitudinal predictors of dementia were older age (per decade; odds ratio 4.0, 95% CI 1.59–10.10), diabetes duration (for each 5 years; odds ratio 1.69, 95% CI 1.24–2.32), peripheral arterial disease (odds ratio 5.35, 95% CI 2.08–13.72) and exercise (which was protective; odds ratio 0.26, 95% CI 0.09–0.73). For Alzheimer’s disease, diabetes duration was an independent predictor in addition to age and diastolic blood pressure. The results of the cross-sectional analyses were similar with respect to diabetes duration and peripheral arterial disease. Conclusions/interpretation Peripheral arterial disease is a strong independent risk factor for dementia in diabetes. After adjustment for a wide range of potential risk factors, diabetes duration remains independently associated with dementia and probable Alzheimer’s disease, indicating that factors not measured in this study may be important in the pathogenesis of dementia in diabetes.     

Adjusted indirect comparison of celecoxib versus rofecoxib on cardiovascular risk

To compare the magnitude of celecoxib versus rofecoxib on the cardiovascular risk. We performed adjusted indirect comparison of celecoxib versus rofecoxib for cardiovascular events using two data on The Adenomatous Polyp Prevention on Vioxx (APPROVe) trial and Adenoma Prevention with Celecoxib (APC) trial. Baseline characteristics of the patients and placebos were comparable in both trials, in terms of age, sex, hypertension, diabetes mellitus, smoking, and hypercholesterolemia. The overall incidence of cardiovascular events was similar in both groups (rofecoxib 48/1,287 versus celecoxib 48/1,356, p = 0.79). The relative risks (RRs) of all myocardial infarction or sudden death from cardiac causes were increased in both rofecoxib and celecoxib groups [rofecoxib versus placebo; RR 1.35, 95% confidence interval (CI) 1.07–1.69, p = 0.03, celecoxib versus placebo; RR 1.35, 95% CI 1.14–1.51, p = 0.01]. The RRs for cardiovascular events derived from the adjusted indirect comparisons of the two coxibs did not significantly differ from unity (celecoxib versus rofecoxib; RR 0.95, 95% CI 0.76–1.19, p = 0.67). The adjusted indirect comparison analysis shows that celecoxib and rofecoxib may have similarly effect of cardiovascular events when used for 3 years.     

Socioeconomic Position and Cardiovascular Disease in Adults with and Without Diabetes: United States Trends, 1997–2005

Background  Diabetes and its cardiovascular complications are more common in adults of low socioeconomic position (SEP). In the US, the past decade has seen the establishment of many programs to reduce cardiovascular risk in persons with diabetes, but their effect on socioeconomic disparities is uncertain. Objective  We sought to investigate recent time trends in socioeconomic disparities in cardiovascular disease (CVD) among persons with and without diabetes. Participants and Design   Two hundred fifty-five thousand nine hundred sixty-six individuals aged 25 years or older included in the National Health Interview Survey between 1997 and 2005. Measurements  Educational attainment was used as a marker for SEP and self-reported history of CVD as the main outcome. Educational disparities were measured using prevalence rate ratios (PRR) and the relative index of inequalities (RII). Main Results  Among adults with diabetes, CVD prevalence was persistently higher in those who did not complete high school (HS) than in college graduates (adjusted PRR [aPRR] 1.20, 95% confidence interval [95%CI] 1.05–1.38 in 1997–1999, and aPRR 1.12, 95% CI 1.00–1.25 in 2003–2005). However, the HS vs. college graduates disparity in CVD declined from 1997–1999 (aPRR 1.20, 95% CI 1.04–1.37) to 2003–2005 (aPRR 1.01, 95% CI 0.90–1.12). Among adults without diabetes educational disparities in CVD widened markedly over time. Conclusions  Concurrently with improvements in diabetes management, the widening of socioeconomic health disparities has remained limited in the diabetic population during the past decade. This provides evidence for the potential impact of improvements in disparities in health care access and process, such as experienced among persons with diabetes, in limiting socioeconomic health disparities.