Survival in patients with hypertension treated in primary care A population-based follow-up study in the Skaraborg Hypertension and Diabetes Project

Objective – To explore risk factors for all-cause mortality in patients with hypertension.

Design – Community-based cohort study.

Setting – Hypertension outpatient clinic in primary health care.

Subjects – Hypertensive men and women who consecutively underwent an annual follow-up during 1992–1993 (n=894).

Methods – Vital status was ascertained up to December 1999 by record linkage with national registers. Gender-specific predictors for mortality from baseline examination were analysed by Cox regression.

Main outcome measure – All-cause mortality.

Results – In both sexes all-cause mortality was predicted by fasting blood glucose (RR by 1 mmol L^?1: 1.2, CI: 1.1–1.3 in men; 1.2, 1.1–1.4 in women), and known type 2 diabetes (RR: 1.9, CI: 1.3–2.9 in men; 2.5, 1.7–3.9 in women). In men, furthermore, mortality was predicted by previous cardiovascular disease, left ventricular hypertrophy and microalbuminuria, whilst in women mortality was predicted by high blood pressure and dyslipidemia. In patients without known diabetes male gender was a strong predictor of mortality (RR: 2.0, CI: 1.4–2.9), whereas in patients with hypertension and type 2 diabetes combined, male gender was not associated with increased mortality (RR: 1.4, CI: 0.9–2.2).

Conclusion – Type 2 diabetes in hypertensive patients treated in primary care predicts mortality and dilutes gender difference in survival. For hypertensive patients general practitioners should be observant regarding disturbed glucose metabolism and regarding the associated major risk increase in women.     

Predictors of acute myocardial infarction mortality in hypertensive patients treated in primary care: a population-based follow-up study in the Skaraborg Project

OBJECTIVE: To explore risk factors for acute myocardial infarction (AMI) mortality in hypertensive patients treated in primary care. DESIGN: Community-based cohort study. SETTING: Hypertension outpatient clinic in primary health care. SUBJECTS: Patients who consecutively underwent an annual follow-up during 1992-1993 (n =894; 377 men and 517 women). METHODS: All events of fatal AMI were ascertained by record linkage to the National Mortality Register to December 31, 2002. Gender-specific predictors for AMI mortality were analysed by Cox regression. MAIN OUTCOME MEASURE: AMI mortality. RESULTS: During a mean follow-up of 8.7 years 32 cases (8.5%) of fatal AMI were observed in men and 31 cases (6.0%) were observed in women. Most important predictors for AMI mortality in men were microalbuminuria (HR 3.8, CI 1.8-8.0) and left ventricular hypertrophy (HR 4.0, CI 1.7-9.4), whilst in women type 2 diabetes (HR 4.8, CI 2.4-9.8) was an important predictor. In hypertensive patients without diabetes male gender was associated with high AMI mortality (HR 2.7, CI 1.4-5.3), but in patients with both hypertension and type 2 diabetes the higher risk in men disappeared (HR 0.8, CI 0.4-1.7). CONCLUSION: Cardiovascular disease risk factors remain strong predictors of AMI mortality in hypertensive patients but with a different pattern in the two genders. Markers of organ damage are more important predictors in men, whereas markers of impaired glucose metabolism are more important predictors in women.     

Survival in patients with type 2 diabetes in a Swedish community: skaraborg hypertension and diabetes project

OBJECTIVE: To explore risk factors for all-cause mortality in patients with type 2 diabetes treated in primary care. RESEARCH DESIGN AND METHODS:A prospective population-based study of 400 patients with type 2 diabetes who consecutively completed an annual checkup in primary care in Skara, Sweden, during 1992-1993. Vital status was ascertained to year 2000. Baseline characteristics as predictors for mortality were analyzed by Cox regression and expressed as relative risks (RRs), with 95% CIs. RESULTS: During a mean follow-up time of 5.9 years, 131 patients died (56 deaths per 1,000 patients per year). In both sexes, all-cause mortality was predicted by HbA(1c) (by 1%; RR 1.14, 95% CI 1.01-1.27), and by LDL-to-HDL cholesterol ratios (1.15, 1.00-1.32). Increased mortality was also seen with prevalent hypertension (1.72, 1.21-2.44), microalbuminuria (1.87, 1.27-2.76), and previous cardiovascular disease (1.70, 1.15-2.50). Subanalyses revealed that increased mortality related to HbA(1c) was restricted to hypertensive patients with type 2 diabetes (1.23, 1.04-1.47). Serum triglycerides (by 1 mmol/l) predicted all-cause mortality in women (1.25, 1.06-1.47). CONCLUSIONS: Poor glucose and lipid control and hypertension predicted all-cause mortality. Survival was also predicted by prevalent microalbuminuria and by previous cardiovascular disease. Confirming results from clinical trials, this population-based study has implications for primary and secondary prevention.     

Association of type and duration of diabetes with erectile dysfunction in a large cohort of men

OBJECTIVE: Differences in risk of erectile dysfunction (ED) by characteristics of diabetes among older men are not well understood. We examined the association of type and duration of diabetes with erectile function in men >50 years of age in a large prospective cohort study. RESEARCH DESIGN AND METHODS: Subjects included 31,027 men aged 53-90 years in the Health Professionals Follow-Up Study cohort. On a questionnaire mailed in 2000, participants rated their ability (without treatment) in the past 5 years to have and maintain an erection sufficient for intercourse. Men who reported poor or very poor function were considered to have ED. Diabetes information was ascertained via self-report and documented with supplementary medical data. RESULTS: Men with diabetes had an age-adjusted relative risk (RR) of 1.32 (95% CI 1.3-1.4) for having ED compared with men without diabetes. In multivariable regression analyses, men with type 1 and type 2 diabetes were at a significantly higher risk for ED (type 1 diabetes RR = 3.0, 95% CI 1.5-5.9; type 2 diabetes RR = 1.3, 1.1-1.5) than nondiabetic men. Men with type 2 diabetes had an increasingly greater risk of ED with increased duration since diagnosis (trend test P value <0.0001) (RR = 1.7, 95% CI 1.1-2.7, for men diagnosed >20 years previously). CONCLUSIONS: For men over age 50 years, increasing duration of diabetes was positively associated with increased risk of ED relative to nondiabetic subjects. This association persisted despite the higher prevalence of other comorbid conditions. ED prevention and diabetes management efforts are likely to go hand-in-hand.     

Soluble intracellular adhesion molecule-1 is associated with cardiovascular disease risk and mortality in older adults

BACKGROUND: Intracellular adhesion molecule-1 (ICAM-1) regulates leukocyte-endothelial attachment, a process crucial to atherosclerosis. Circulating soluble ICAM-1 (sICAM-1) may serve as a marker of cardiovascular disease (CVD) progression. OBJECTIVES: We examined the association of sICAM-1 with measures of subclinical CVD and risk of incident CVD events and death in older men and women (age > or = 65 years) from the Cardiovascular Health Study. METHODS: Selected participants were free of clinical CVD at baseline. Non-exclusive incident case groups were angina (n = 534), myocardial infarction (n = 304), stroke (n = 327), and death (n = 842; CVD death = 310). A total 643 subjects were free of events during follow-up. RESULTS: sICAM-1 was positively associated with C-reactive protein, interleukin-6 and fibrinogen and measures of subclinical CVD in these older men and women. In Cox regression models adjusted for age, gender, and race, increasing levels of sICAM-1 were associated with increased risk of all cause mortality in men and women. Hazard ratios (95% confidence intervals) for a one standard deviation increase in sICAM-1 (89.7 ng mL(-1)) were 1.3 (1.1-1.4) in men and 1.2 (1.1-1.3) in women. sICAM-1 was associated with increased risk of CVD death in women (1.2; 1.0-1.5), but not men (1.1; 0.9-1.3). There were no associations of sICAM-1 with non-fatal CVD events. CONCLUSIONS: While sICAM-1 was associated with death in older men and women, there was a more marked association between sICAM-1 and CVD death in women.     

Factor VIII and other hemostasis variables are related to incident diabetes in adults. The Atherosclerosis Risk in Communities (ARIC) Study.

OBJECTIVE: Our objective was to evaluate whether selected hemostasis variables, some of which may reflect inflammation or endothelial dysfunction, are independently associated with the development of diabetes. RESEARCH DESIGN AND METHODS: We studied a biethnic cohort of 12,330 men and women, 45-64 years of age, of the Atherosclerosis Risk in Communities Study. New cases of diabetes were diagnosed by a reported physician diagnosis, hypoglycemic medication use, or a casual or fasting serum glucose level of > or = 11.1 or > or = 7 mmol/l, respectively. RESULTS: Over an average follow-up of 7 years, 1,335 new cases of diabetes were detected. The odds ratios (4th versus 1st quartile) of developing diabetes, adjusted by logistic regression for age, sex, race, study center, family history of diabetes, fasting glucose, physical activity, and smoking, were 1.2 (95% CI 1.0-1.5) for fibrinogen and 1.4 (1.1-1.6) for factor VII. Associations for factor VIII, von Willebrand factor, and activated partial thromboplastin time were found to be 1.8 (1.3-2.3), 1.4 (1.1-1.8), and 0.63 (0.49-0.82), respectively, in women. Although further adjustment for BMI and waist-to-hip ratio diminished the relationships, a highly statistically significant association (P = 0.001) remained for factor VIII (1.6 [1.2-2.1]) in women. CONCLUSIONS: Factor VIII and other hemostasis variables are associated with the development of diabetes in middle-aged adults. These findings support a role for inflammation and, particularly in women, endothelial dysfunction in the pathogenesis of type 2 diabetes.     

Risk factors for lipodystrophy in the CISAI cohort.

PURPOSE: This study set out to describe the frequency of lipodystrophy, and identify its risk factors, in HIV-positive patients treated with HAART containing at least one protease inhibitor (PI). We analyzed the data collected in the CISAI study. METHODS: The CISAI is a multicenter cohort study that has enrolled 1480 patients. We assessed whether patients had lipodystrophy at a medical visit, with follow-up visits by the same physician at least every 2 months, and also on the basis of patients' own reports. RESULTS: The lipodystrophy syndrome was detected in about 25% of the patients. Multivariate analysis showed the risk of lipodystrophy was correlated with female sex (RR 1.5; 95% confidence interval, CI, 1.2-2.1), with older age, with homosexuality (RR 1.5; 95% CI 1.0-2.4), with overt disease (RR 1.4; 95% CI 1.1-1.8) and with the duration of treatment before entering this study. The RR for ritonavir was higher than for the other PI (RR 1.4; 95% CI 0.9-1.9). Among patients receiving concomitant antiretroviral therapy the risk of lipodystrophy was greater with stavudine (RR 1.7; 95% CI 1.3-2.3). CONCLUSIONS: The study confirmed the high frequency of the lipodystrophy syndrome among patients treated with PI.     

Heart rate recovery following maximal exercise testing as a predictor of cardiovascular disease and all-cause mortality in men with diabetes

OBJECTIVE: Heart rate recovery (HRR) is an independent prognostic indicator for cardiovascular disease (CVD) and all-cause mortality in healthy men. We examined the association of HRR to CVD-related and all-cause mortality in men with diabetes. RESEARCH DESIGN AND METHODS: In this cohort study we examined 2,333 men with documented diabetes (mean age 49.4 years) that had baseline 5-min HRR measurement following maximal exercise (heart rate(peak) - heart rate(5 min of recovery)) at The Cooper Clinic, Dallas, TX. We identified HRR quartiles as quartile 1 <55, quartile 2 55-66, quartile 3 67-75, and quartile 4 >75 bpm. Hazard ratios (HRs) for cardiovascular and all-cause death were adjusted for age, cardiorespiratory fitness, resting heart rate, fasting blood glucose, BMI, smoking habit, alcohol consumption, total cholesterol, triglyceride, and history of CVD at baseline. RESULTS: During a median of 14.9 years follow-up, there were 142 deaths that were considered CVD related and 287 total deaths. Compared with men in the highest quartile of HRR, adjusted HRs in the first, second, and third quartiles were 2.0 (95% CI 1.1-3.8), 1.5 (0.8-2.7), and 1.5 (0.9-2.8), respectively, for cardiovascular death (P for trend < 0.001). Similarly, for all-cause death, adjusted HRs in the first, second, and third quartiles were 2.0 (1.3-3.2), 1.5 (1.0-2.3), and 1.5 (1.1-2.3) (P for trend < 0.001). CONCLUSIONS: Among men with diabetes, a decreased HRR, even measured as long as 5 min after recovery, was independently predictive of cardiovascular and all-cause death.     

Physical activity and life expectancy with and without diabetes: life table analysis of the Framingham Heart Study

OBJECTIVE: Physical activity is associated with a reduced risk of developing diabetes and with reduced mortality among diabetic patients. However, the effects of physical activity on the number of years lived with and without diabetes are unclear. Our aim is to calculate the differences in life expectancy with and without type 2 diabetes associated with different levels of physical activity. RESEARCH DESIGN AND METHODS: Using data from the Framingham Heart Study, we constructed multistate life tables starting at age 50 years for men and women. Transition rates by level of physical activity were derived for three transitions: nondiabetic to death, nondiabetic to diabetes, and diabetes to death. We used hazard ratios associated with different physical activity levels after adjustment for age, sex, and potential confounders. RESULTS: For men and women with moderate physical activity, life expectancy without diabetes at age 50 years was 2.3 (95% CI 1.2-3.4) years longer than for subjects in the low physical activity group. For men and women with high physical activity, these differences were 4.2 (2.9-5.5) and 4.0 (2.8-5.1) years, respectively. Life expectancy with diabetes was 0.5 (-1.0 to 0.0) and 0.6 (-1.1 to -0.1) years less for moderately active men and women compared with their sedentary counterparts. For high activity, these differences were 0.1 (-0.7 to 0.5) and 0.2 (-0.8 to 0.3) years, respectively. CONCLUSIONS: Moderately and highly active people have a longer total life expectancy and live more years free of diabetes than their sedentary counterparts but do not spend more years with diabetes.     

Common carotid intima-media thickness is predictive of all-cause and cardiovascular mortality in elderly community-dwelling people: Longitudinal Investigation for the Longevity and Aging in Hokkaido County (LILAC) study

Several cohort studies have examined the association of carotid intima-media thickness (IMT) with the risk of stroke or myocardial infarction in apparently healthy persons. We investigated the predictive value of IMT of cardiovascular mortality in elderly community-dwelling people, beyond the prediction provided by age and MMSE, assessed by means of a multivariate Cox model. Carotid IMT and plaque were evaluated bilaterally with ultrasonography in 298 people older than 75 years (120 men and 178 women, average age: 79.6 years). The LILAC study started on July 25, 2000. Consultations were repeated every year. The follow-up ended on November 30, 2004. During the mean follow-up span of 1152 days, 30 subjects (21 men and nine women) died. Nine deaths were attributable to cardiovascular causes (myocardial infarction: two men and three women; stroke: two men and two women). The age- and MMSE-adjusted relative risk (RR) and 95% confidence interval (95% CI) of developing all-cause mortality was assessed. A 0.3 mm increase in left IMT was associated with a RR of predicted 1.647 (1.075–2.524), and a similar increase in right IMT with a RR of 3.327 (1.429–7.746). For cardiovascular mortality, the corresponding RR values were 2.351 (1.029–5.372) and 2.890 (1.059–7.891), respectively. Carotid IMT assessed by ultrasonography is positively associated with an increased risk of all-cause and cardiovascular death in elderly community-dwelling people.     

Risk factors of sciatic pain: A prospective study among middle—aged employees

Objective: To study the effects of occupational class, physical and psychosocial working conditions, health behaviours, and pain in the low back and the neck on sciatic pain among middle‐aged employees. Methods: The participants were municipal employees without previous sciatica, aged 40, 45, 50, 55, and 60 years at baseline (n =5261, 80% women). Sciatica was defined as low back pain radiating to the calf or the foot. Data on occupational class, physical and psychosocial working conditions, body mass index, smoking, leisure‐time physical activity, neck pain, local low back pain, and sciatica were obtained from baseline questionnaire surveys in 2000–2002. The question on sciatica was repeated in a follow‐up survey in 2007. Logistic regression analysis was used. Results: In women, manual occupational class (OR 1.3; 95% CI 1.0–1.6 compared with managers/professionals), overweight (1.3; 1.1–1.5), obesity (1.4; 1.1–1.7), smoking (1.5; 1.2–1.7), low leisure‐time physical activity (1.3; 1.0–1.7), previous acute (1.5; 1.3–1.7) and chronic (1.5; 1.1–2.0) local low back pain, and acute (1.20; 1.0–1.4) and chronic (1.5;1.2–1.9) neck pain predicted the onset of sciatica in a multivariable model. In men, semi‐professionals (1.5; 1.1–2.1) and manual workers (2.0; 1.4–2.8) had an increased risk compared with managers/professionals; also acute (1.5; 1.2–2.0) and chronic (2.1; 1.2–3.9) local low back pain predicted sciatica. Conclusions: Manual occupational class in both genders and semi‐professional occupations in men, unhealthy behaviours and previous pain both in the neck and the lower back predicted sciatica, while physical and psychosocial working conditions had no independent effect.     

Lower-extremity amputation in diabetes. The independent effects of peripheral vascular disease, sensory neuropathy, and foot ulcers.

OBJECTIVE: To identify risk factors for lower-extremity amputation (LEA) in individuals with diabetes and to estimate the incidence of LEA. RESEARCH DESIGN AND METHODS: This is a prospective study of 776 U.S. veterans in a general medicine clinic in Seattle, Washington. The outcome was first LEA during follow-up. Potential risk factors evaluated in proportional hazards models included, among others, peripheral vascular disease (PVD), sensory neuropathy, former LEA, foot deformities and ulcers, diabetes duration and treatment, and hyperglycemia. RESULTS: Associated with an increased risk for LEA were PVD defined as transcutaneous oxygen < or = 50 mmHg (relative risk [RR] = 3.0, 95% CI 1.3-7.1), insensitivity to monofilament testing (RR = 2.9, odds ratio = 1.1-7.8), lower-extremity ulcers (RR = 2.5, CI 1.1-5.4), former LEA, and treatment with insulin when controlling for duration of diabetes and other factors in the model. PVD defined as absent or diminished lower-extremity pulses or an ankle arm index < or = 0.8 was also associated with a significantly higher risk of LEA in separate models. Foot ulcers were associated with an increased ipsilateral risk of amputation. The age-adjusted incidence among men only for LEA standardized to the 1991 U.S. male diabetic population was 11.3/1,000 patient-years. CONCLUSIONS: This prospective study shows that peripheral sensory neuropathy, PVD, foot ulcers (particularly if they appear on the same side as the eventual LEA), former amputation, and treatment with insulin are independent risk factors for LEA in patients with diabetes.     

Explanations of socioeconomic differences in excess risk of type 2 diabetes in Swedish men and women

OBJECTIVE: We investigated to what extent socioeconomic differences in type 2 diabetes risk could be explained by established risk factors (obesity, physical inactivity, smoking, and heredity) and psychosocial factors (low decision latitude at work and low sense of coherence). RESEARCH DESIGN AND METHODS: This cross-sectional study comprised 3,128 healthy Swedish men and 4,821 women, aged 35-56 years, living in the Stockholm area. An oral glucose tolerance test identified 55 men and 52 women with type 2 diabetes. The relative contribution of established and psychosocial factors to socioeconomic differences in diabetes risk was assessed by comparing analyses with adjustment for different sets of these factors. RESULTS: The relative risks (RRs) for type 2 diabetes in middle and low socioeconomic groups in men were 2.4 (95% CI 1.0-5.3) and 2.9 (1.5-5.7), respectively, and in women 3.2 (1.5-6.6) and 2.7 (1.3-5.9), respectively. In men, the RRs decreased to 1.9 (0.8-4.4) and 2.1 (1.0-4.2) after adjustment for established risk factors; no further change was found when psychosocial factors were included. In women, the RRs changed to 2.4 (1.1-5.2) and 1.6 (0.7-3.8) by including established risk factors and to 2.3 (1.0-5.1) and 1.9 (0.8-4.3) by inclusion of psychosocial factors. After adjustment for both established and psychosocial factors, the RRs were 1.4 (0.6-3.6) and 1.0 (0.4-2.5), respectively. CONCLUSIONS: In men, the excess risk of type 2 diabetes was partly explained by established risk factors (36-42%), whereas psychosocial factors had no effect. In women, most of the socioeconomic differences in type 2 diabetes were explained by simultaneous adjustment for established risk factors and psychosocial factors (81-100%).     

Prognostic value of dobutamine stress echocardiography in patients with normal left ventricular systolic function.

BACKGROUND: Patients with normal left ventricular systolic function are considered to be at a relatively low risk for cardiac events. There are scarce data regarding association of ischemia on stress imaging techniques with outcome in these patients. OBJECTIVES: We sought to assess the prognostic significance of dobutamine-induced myocardial ischemia for patients with normal left ventricular systolic function. METHODS: We studied 528 patients with normal baseline left ventricular systolic function who underwent high-dose dobutamine-atropine stress echocardiography and were followed up for 4.7 +/- 2.1 years for occurrence of death and hard cardiac events (cardiac death and nonfatal myocardial infarction). RESULTS: Ischemia (new wall-motion abnormalities) was detected in 127 patients (24%). Follow-up events were death in 69 patients (13%) and hard cardiac events in 55 patients (10%). The annual hard cardiac event rate was 5% for patients with ischemia and 1.1% for patients without. In a multivariate analysis model, ischemia was the only independent predictor of hard cardiac events (risk ratio [RR] 4.3, 95% confidence intervals [CI] 2.5-7.4). Predictors of all causes of mortality were advanced age (RR 1.08, CI 1.05-1.11), higher resting rate pressure product (RR 1.11, CI 1.02-1.22), and ischemia (RR 2.1, CI 1.2-3.6). CONCLUSION: Dobutamine-induced wall-motion abnormalities are independently associated with increased risk of all-cause mortality and hard cardiac events in patients with normal baseline left ventricular function.     

Cardiac decompensation during an ischemic event weakens the predictive power of myocardial injury markers

Our objection was to find determinants of long-term outcome in routine data collected for differential diagnosis of suspected acute myocardial infarction. Study population consisted of 263 discharged patients who were initially hospitalized for differential diagnosis of suspected acute myocardial infarction between October 1992 and January 1993. Follow-up time for all cause and cardiac mortality was 5 years. The variables studied as predictors of outcome were computerized ECG, peak creatine kinase isoenzyme MB, peak troponin I, radiographic evidence of pulmonary congestion (cardiac decompensation), treatment for hyperlipidemia, hypertension or diabetes, smoking, previous myocardial infarction, age and gender. Total mortality was 32% at 5 years, of which 77% (64/83) was of cardiac origin. Pulmonary congestion in chest X-ray was the most powerful predictor of outcome (RR=3.3, 95% CI=2.0-5.2, P<0.001). In multivariate analysis congestion (RR=3.3, CI=2.0-5.2) was the only independent predictor of 5-year total mortality in addition to age (RR=1.06, CI=1.04-1.08). These two variables together with previous myocardial infarction (RR=1.9, CI=1.2-3.1) and hyperlipidemia (RR=2. 0, CI=1.1-3.5) were independent predictors of cardiac mortality. Radiographic evidence of cardiac decompensation during hospitalization is a strong and independent predictor of long-term outcome in unselected patients with suspected AMI. The predictive power of cardiac markers is confined to patients without pulmonary congestion.     

Relation of lower-extremity amputation to all-cause and cardiovascular disease mortality in American Indians: the Strong Heart Study

OBJECTIVE: To compare risk of all-cause and cardiovascular disease (CVD) mortality in people with a lower-extremity amputation (LEA) attributable to diabetes and people without an LEA. RESEARCH DESIGN AND METHODS: The Strong Heart Study is a study of CVD and its risk factors in 13 American-Indian communities. LEA was ascertained at baseline by direct examination of the legs and feet. Mortality surveillance is complete through 2000. RESULTS: Of 2,108 participants with diabetes at baseline, 134 participants (6.4%) had an LEA. Abnormal ankle-brachial index (53%), albuminuria (87%), and long diabetes duration (mean 19.8 years) were common among diabetic subjects with LEA. Mean diabetes duration among diabetic participants without LEA and in those with toe and below-the-knee amputations was 11.9, 18.6, and 21.1 years, respectively. During 8.7 (+/-2.9) years of follow-up, 102 of the participants with LEA (76%) died from all causes and 35 (26%) died from CVD. Of the 1,974 diabetic participants without LEA at baseline, 604 (31%) died from all causes and 206 (10%) died from CVD. The unadjusted hazard ratios (HRs) for all-cause and CVD mortality in diabetic participants with LEA compared with those without were 4.0 and 4.1, respectively. Adjusting for known and suspected confounders, LEA persisted as a predictor of all-cause (HR 2.2, 95% CI 1.7-2.9) and CVD mortality (HR 1.9, 95% CI 1.3-2.9). We observed a significant interaction between baseline LEA and sex on CVD mortality, with female sex conferring added risk of CVD mortality. CONCLUSIONS: LEA is a potent predictor of all-cause and CVD mortality in diabetic American Indians. The combination of female sex and LEA is associated with greater risk of CVD mortality than either factor alone.     

Serum insulin,obesity, and the incidence of type 2 diabetes in black and white adults: the atherosclerosis risk in communities study: 1987-1998

OBJECTIVE: In this study, we tested the hypothesis that fasting serum insulin is higher in nonobese black adults than in white adults and that high fasting insulin predicts type 2 diabetes equally well in both groups. RESEARCH DESIGN AND METHODS: At the baseline examination (1987-1989) of the Atherosclerosis Risk in Communities Study, fasting insulin and BMI were measured in 13,416 black and white men and women without diabetes. Participants were examined at years 3, 6, and 9 for incident diabetes based on fasting glucose and American Diabetes Association criteria. RESULTS: Fasting insulin was 19.7 pmol/l higher among nonobese (BMI <30 kg/m(2)) black women compared with white women (race and obesity interaction term, P < 0.01). There were no differences among men. Among nonobese women, the relative risk for developing diabetes was similar between racial groups: 1.4 (95% CI 1.2-1.5) and 1.3 (1.2-1.4) per 60 pmol/l increase in insulin (P < 0.01) for black and white women, respectively (interaction term, P = 0.6). Findings were similar among men. Adjusting for established risk factors did not attenuate this association. CONCLUSIONS: Nonobese black women have higher fasting insulin levels than nonobese white women, and fasting insulin is an equally strong predictor of diabetes in both groups. These results suggest one mechanism to explain the excess incidence of diabetes in nonobese black women but do not explain the excess among black men. Future research should evaluate additional factors: genetic, environmental, or the combination of both, which might explain higher fasting insulin among black women when compared with white women.     

Pharmacologic stress echocardiography predicts total mortality early after acute myocardial infarction.

OBJECTIVE: The aim of this multicenter, prospective, observational study was to assess the value of inducible ischemia in a large population of survivors of a first uncomplicated myocardial infarction (MI). METHODS AND RESULTS: Pharmacologic stress echocardiography either with high-dose dipyridamole (0.84 mg/kg over 10 minutes) or high-dose dobutamine (up to 40 microg/kg over 3 minutes) (DET) was performed 9 +/- 10 days after a first acute uncomplicated MI in 1681 patients (1499 males; 57 +/- 10 years) with technically satisfactory rest echocardiographic study. Patients were followed up for a mean of 16 +/- 18 months (range: 1-122). DET was positive for myocardial ischemia in 884 (52.5%) and negative in 797 (47.5%) patients. During the follow-up there were 49 deaths for all-cause mortality (2.9% of the total population), 22 of which were cardiac; 62 (3.6%) nonfatal MIs; and 164 (9.7%) hospital readmissions for unstable angina. In all, 376 patients (22%) underwent coronary revascularization (bypass operation or angioplasty). RESULTS: Hard events occurred in 71 of the 884 patients with positive and in 40 of the 797 patients with negative DET (8% vs 5%, P =.014). Using the Cox proportional hazards model, age (relative risk [RR] 1.07, 95% confidence interval [CI] 1.03-1.1), history of angina (RR 3.8, 95% CI 1.6-8.6), peak wall-motion score index (RR 2.2, 95% CI 1.1-4.4), and pharmacologic dose at ischemia (RR 1.5, 95% CI 1.04-2.3) were independent predictors of all-cause death. CONCLUSIONS: In survivors of a first acute uncomplicated MI DET allows effective risk stratification on the basis of the presence, severity, and extent the induced ischemia.     

Does diabetes mellitus explain the higher hospital mortality of women with acute myocardial infarction? Results from the Berlin Myocardial Infarction Registry.

BACKGROUND: Women with acute myocardial infarction (AMI) exhibit greater hospital mortality than do men. In general, diabetes mellitus is one of the major factors influencing the outcome of patients with AMI. The aim of this study was to analyze the interaction between diabetes and gender, specifically with regard to the higher hospital mortality of female AMI patients aged < or = 75 years. METHODS: We prospectively collected data from 3,715 patients aged < or = 75 (2,794 men, 921 women) with acute myocardial infarction who were treated in 25 hospitals in Berlin, Germany, from 1999 to 2002. In a multivariate analysis, we specifically studied the interaction between the factors diabetes mellitus and gender in their effects on hospital mortality. RESULTS: After adjustment in multivariate analysis, the interaction between gender and diabetes was statistically significant, and the estimated odds ratios were as follows: female diabetic patients compared with male diabetic patients, odds ratio (OR) = 2.28 (95% confidence interval [CI] 1.42-3.68); female diabetic patients compared with male nondiabetic patients, OR = 2.90 (95% CI 1.90-4.42); and female diabetic patients compared with female nondiabetic patients, OR = 2.92 (95% CI 1.75-4.87). There was no statistically significant difference between the risk of dying for female nondiabetic patients or for male diabetic patients when compared with male nondiabetic patients. CONCLUSIONS: In AMI patients aged < or = 75 years, female gender alone is not an independent predictor of hospital mortality. Detailed, multivariate analysis reveals that specifically diabetic women demonstrate higher hospital mortality than do men. Special attention should be provided to these female diabetic patients.