Low educational status is a risk factor for mortality among diabetic people

Diabetes mellitus and its complications are an important cause of mortality in Western populations. The purpose of the present study was to examine the relationship between self-reported diabetes mellitus, gender, attained level of education, and socio-economic resources to all-cause mortality risk in a simple random sample of 39055 subjects, aged 25 to 74 years. Follow-up data were obtained for a maximum of 16 years, from baseline (1979–1985) to 31 December 1995. Diabetic males (2.2 % of the male study group) had a relative risk (RR) for total mortality of 2.24 (CI = 1.96–2.57), adjusted for age, education, marital status, housing tenure, and car ownership, compared with non-diabetic males. The corresponding figure for females with diabetes (1.9 %) was RR = 3.67 (CI = 3.16–4.27). Diabetic women had the highest age-adjusted mortality risk for coronary heart disease (CHD) of 8 compared with non-diabetic women. The corresponding RR for men was just below 3 (p<0.0001). Males and females (with and without diabetes) of low attained educational level had a RR = 1.26 (CI = 1.15–1.39) and RR = 1.54 (CI = 1.31–1.81), respectively. When analysing all people with diabetes separately, adjusting for sex and age, low-educated subjects had a 40 % excess all-cause mortality compared with high-educated subjects. We conclude that diabetic women have a very high relative risk for CHD mortality compared to non-diabetic women. Furthermore, diabetic people with a low attained level of education, have an increased vulnerability to, and a higher total mortality. © 1998 John Wiley & Sons, Ltd.     

Cardiac disease in diabetic end-stage renal disease

Summary Little is known about the epidemiology of cardiac disease in diabetic end-stage renal disease. We therefore prospectively followed a cohort of 433 patients who survived 6 months after the inception of dialysis therapy for an average of 41 months. Clinical and echocardiographic data were collected yearly. At baseline, diabetic patients (n = 116) had more echocardiographic concentric left ventricular hypertrophy (50 vs 38 %, p = 0.04), clinically diagnosed ischaemic heart disease (32 vs 18 %, p = 0.003) and cardiac failure (48 vs 24 %, p < 0.00 001) than non-diabetic patients (n = 317). After adjusting for age and sex, diabetic patients had similar rates of progression of echocardiographic disorders, and de novo cardiac failure, but higher rates of de novo clinically diagnosed ischaemic heart disease (RR 3.2, p = 0.0002), overall mortality (RR 2.3, p < 0.0001) and cardiovascular mortality (RR 2.6, p < 0.0001) than non-diabetic patients. Mortality was higher in diabetic patients following admission for clinically diagnosed ischaemic heart disease (RR 1.7, p = 0.05) and cardiac failure (RR 2.2, p = 0.0003). Among diabetic patients older age, left ventricular hypertrophy, smoking, clinically diagnosed ischaemic heart disease, cardiac failure and hypoalbuminaemia were independently associated with mortality. The excessive cardiac morbidity and mortality of diabetic patients seem to be mediated via ischaemic disease, rather than progression of cardiomyopathy while on dialysis therapy. Potentially remediable risk factors include smoking, left ventricular hypertrophy, and hypoalbuminaemia. [Diabetologia (1997) 40: 1307–1312] Received: 25 March 1997 and in final revised form: 23 June 1997     

Diabetes as a risk factor for stroke. A population perspective

Summary Stroke incidence, case fatality and mortality in diabetic patients were compared to non-diabetic subjects in a 35–74-year-old population in northern Sweden (target population 241,000). During an 8-year period, 1,544 stroke events in diabetic patients and 4,826 events in non-diabetic subjects were recorded. The crude incidence of stroke was 1,000 per 100,000 in the diabetic men vs 247 in the non-diabetic men (relative risk 4.1; 95% confidence interval 3.2–5.2). Among diabetic women, the crude incidence was 757 per 100,000 and 152 in non-diabetic women (relative risk 5.8; 95% confidence interval 3.7–6.9). The 28-day case fatality among men was similar in the diabetic and non-diabetic stroke patients (18.6 vs 17.1%; p=0.311), but significantly higher in diabetic women compared with non-diabetic women (22.2 vs 17.9%; p=0.02). When compared with the non-diabetic population, the overall mortality from stroke in the diabetic population (first and recurrent) was 4.4-times higher in male and 5.1-times higher in the female patients. Hypertension, atrial fibrillation, heart failure or myocardial infarction were all significantly more common in diabetic than in non-diabetic stroke patients. The population attributable risk, a crude estimate of all strokes ascribed to diabetes mellitus, was 18% in men and 22% in women. In Sweden, about 50 strokes are annually directly attributed to diabetes in a population of 100,000 in this age group.Abbreviations MONICA Multinational Monitoring of Trends and Determinants in Cardiovascular Disease - ICD International Classification of Diseases - CT computerised tomography - CI confidence interval - RR relative risk - CF case fatality     

The relationship between dysglycaemia and cardiovascular and renal risk in diabetic and non-diabetic participants in the HOPE study: a prospective epidemiological analysis

Aims/hypothesis Emerging data suggest that different indices of glycaemia are risk factors for clinical events. The aim of this analysis was to investigate the relationship between fasting plasma glucose or glycated haemoglobin (GHb) levels and incident cardiovascular (CV) outcomes, death, heart failure and overt nephropathy in diabetic and non-diabetic individuals enrolled in the Heart Outcomes Prevention Evaluation (HOPE) study.Materials and methods The adjusted 4.5-year risk of CV events (myocardial infarction or stroke or CV death), heart failure, death and overt nephropathy was analysed in relation to baseline and updated GHb levels (in 3,529 diabetic HOPE study participants) and baseline fasting plasma glucose levels (in 1,937 non-diabetic and 1,013 diabetic participants).Results In diabetic participants, a 1% absolute rise in the updated GHb predicted future CV events (relative risk [RR]=1.07, 95% CI 1.01–1.13; p=0.014), death (RR=1.12, 95% CI 1.05–1.19; p=0.0004), heart failure (RR=1.20, 95% CI 1.08–1.33; p=0.0008) and overt nephropathy (RR=1.26, 95% CI 1.17–1.36; p<0.0001) after adjusting for age, sex, diabetes duration, blood pressure, WHR, hyperlipidaemia and ramipril. Similarly, a 1 mmol/l rise in fasting plasma glucose was related to an increased risk of CV outcomes (RR=1.09, 95% CI 1.05–1.13; p<0.0001), death (RR=1.06, 95% CI 1.01–1.12; p=0.017), heart failure (RR=1.16, 95% CI 1.06–1.13; p=0.0007) and overt nephropathy (RR=1.34, 95% CI 1.23–1.45; p<0.0001) in the group composed of diabetic and non-diabetic individuals. The significant relationship between fasting plasma glucose and CV outcomes persisted after adjustment for diabetes status (RR=1.06, 95% CI 1.00–1.12; p=0.043).Conclusions/interpretation There is an independent progressive relationship between indices of glycaemia and incident CV events, renal disease and death. Clinical trials of glucose lowering to prevent these outcomes in diabetic and non-diabetic individuals are indicated.Listed by country in References 13 and 15.     

Hyperglycaemia is associated with all-cause and cardiovascular mortality in the Hoorn population: the Hoorn Study

Aims/hypothesis. The degree of glycaemia has been shown to be associated with all-cause and cardiovascular mortality in diabetic subjects. Whether this association also exists in the general population is still controversial. We studied the predictive value of fasting plasma glucose, 2-hour post-load glucose and HbA_{1 c} in a population-based cohort of 2363 older (50–75 years) subjects, without known diabetes. Methods. Relative risks (RR) of all-cause and cardiovascular mortality were estimated by Cox proportional hazards model, adjusting for age and sex, and additionally for known cardiovascular risk factors. Results. During 8 years of follow-up, 185 subjects died; 98 of cardiovascular causes. Fasting plasma glucose was only predictive in the diabetic range, although the risks started to increase at about 6.1 mmol/l. Post-load glucose and HbA_{1 c} values were, even within the non-diabetic range, associated with an increased risk (p for linear trend < 0.05). These increased risks were mostly, but not completely, attributable to known cardiovascular risk factors. After exclusion of subjects with newly diagnosed diabetes or with pre-existent cardiovascular disease (n = 551), a 5.8 mmol/l increase of post-load glucose (corresponding to two standard deviations of the population distribution) was associated with a higher age-adjusted and sex-adjusted risk of all-cause (RR 2.24) and cardiovascular mortality (RR 3.40) (p < 0.05). After additional adjustment for known cardiovascular risk factors, these relative risks were still statistically significant, with values of 2.20 and 3.00 respectively (p < 0.05). Conclusion/interpretation. High glycaemic variables, especially 2-h post-load glucose concentrations and to a lesser extent HbA_{1 c} values, indicate a risk of all-cause and cardiovascular mortality in a general population without known diabetes. [Diabetologia (1999) 42: 926–931] Received: 18 January 1999 and in revised form: 22 April 1999     

Infection-related mortality is higher for kidney allograft recipients with pretransplant diabetes mellitus

Aims/hypothesis

The risk of infection-related mortality in kidney allograft recipients with pre-existing diabetes mellitus is unknown. We determined the risk of infection-related mortality after kidney transplantation in a population-based cohort stratified by diagnosis of pre-existing diabetes mellitus.

Methods

We linked data between two national registries (Hospital Episode Statistics and the Office for National Statistics) to select all mortality events after kidney transplantation in England between April 2001 and March 2012. The primary outcome measure was infection-related mortality after transplantation comparing diabetic with non-diabetic recipients.

Results

A total of 19,103 kidney allograft recipients were analysed; 2,968 (15.5%) were known to have diabetes before kidney transplantation. After transplantation, 2,085 deaths (10.9%) occurred (median follow-up 4.4 years [interquartile range 2.2–7.3]), with 434 classified as secondary to infection (20.8% of all deaths). Risk of overall (16.0% vs 10.0%, p?<?0.001) and infection-related (3.3% vs 2.1%, p?<?0.001) mortality after kidney transplantation was higher for diabetic than non-diabetic recipients, respectively. No cytomegalovirus-related deaths occurred in diabetic recipients compared with 5.7% in non-diabetic recipients (p?<?0.007), with a trend towards more unspecified sepsis in diabetic recipients (30.6% vs 22.6%, respectively, p?=?0.070). Diabetes at the time of transplantation was an independent risk factor predicting infection-related mortality in kidney allograft recipients after transplantation (HR 1.71 [95% CI 1.36, 2.15], p?<?0.001).

Conclusions/interpretation

Infection-related mortality is more common in kidney allograft recipients with pre-existing diabetes mellitus. Further work is required to determine whether attenuated immunosuppression is beneficial for diabetic kidney allograft recipients.     

Cardiovascular Morbidity and Mortality in Type 2 Diabetic Patients: a 22-year Historical Cohort Study in Dutch General Practice

A historical cohort study was performed to assess cardiovascular morbidity and mortality in Type 2 (non-insulin-dependent) diabetic patients. The data were collected from 1967 to 1989 in four Dutch general practices performing the Continuous Morbidity Registration Nijmegen. Each newly diagnosed Type 2 diabetic patient fulfilling the WHO criteria (n = 265) was matched to a control patient for practice, sex, age, and social class. Inclusion started in 1967, the first year of the still ongoing, Continuous Morbidity Registration Nijmegen. On average, a follow-up of 6.8 years (range 1 month—22 years) was realized. Compared to the non-diabetic control patients, the Type 2 diabetic patients showed higher cardiovascular morbidity (risk ratio 1.76, 95 % CI 1.34–2.30) and a higher mortality rate (risk ratio 1.54, 95 % CI 1.07–2.23). Mortality after 10 years was 36 % vs 20 % (p < 0.01), the median survival time 16 years vs 19 years. The cumulative survival rates were significantly different (p < 0.01) between patients and controls in the age group 65–74 years. The higher mortality in Type 2 diabetic patients was completely due to an excess of cardiovascular death (risk ratio 2.05, 95 % CI 1.24–3.37).     

Influence of diabetes and diabetes-gender interaction on the risk of death in patients hospitalized with congestive heart failure

OBJECTIVES: The purpose of this study was to investigate the influence of diabetes on long-term mortality in a large cohort of patients hospitalized with heart failure (HF). BACKGROUND: Diabetes is common in HF patients, but information on the prognostic effect of diabetes is sparse. METHODS: The study is an analysis of survival data comprising 5,491 patients consecutively hospitalized with new or worsening HF and screened for entry into the Danish Investigations of Arrhythmia and Mortality on Dofetilide (DIAMOND). Screening, which included obtaining an echocardiogram in 95% of the patients, took place at Danish hospitals between 1993 and 1995. The follow-up time was five to eight years. RESULTS: A history of diabetes was found in 900 patients (16%), 41% of whom were female. Among the diabetic patients, 755 (84%) died during follow-up, compared with 3,200 (70%) among the non-diabetic patients, resulting in a risk ratio (RR) of death in diabetic patients of 1.5 (95% confidence interval [CI] 1.4 to 1.6, p < 0.0001). In a multivariate analysis, the RR of death in diabetic patients was 1.5 (CI 1.3 to 1.76, p < 0.0001), but a significant interaction between diabetes and gender was found. Diabetes increased the mortality risk more in women than in men, with the RR for diabetic men being 1.4 (95% CI 1.3 to 1.6, p < 0.0001) and 1.7 for diabetic women (95% CI 1.4 to 1.9, p < 0.0001). The effect of diabetes on mortality was similar in patients with depressed and normal left ventricular systolic function. CONCLUSIONS: Diabetes is a potent, independent risk factor for mortality in patients hospitalized with HF. The excess risk in diabetic patients appears to be particularly prominent in females.     

Influence of Diabetes Mellitus and Glycaemic Control on the Characteristics and Outcome of Common Infections

The aim of the present study was to elucidate the effect of diabetes and metabolic control on the presentation, sources, pathogens and outcome of common infections. Of 515 patients admitted to three departments of internal medicine because of a suspected acute infection, 132 (26 %) had diabetes mellitus. Osteomyelitis was diagnosed in 3 % of the diabetic patients and in 1 % of patients without diabetes, and infection of the extremities in 7 % and 0 %, respectively (p = 0.003). Klebsiella sp. caused 24 % of urinary tract infections in diabetic patients, versus 13 % in patients without diabetes (p = 0.1). The percentage of Staphylococcus aureus infections in diabetic patients was 10 % versus 5 % in non-diabetic patients (p = 0.06). The gross mortality rate in the diabetic patients was 10 %, and in patients without diabetes, 12 %. In patients without fatal underlying disorders, mortality in the diabetic patients was 10 % (2 % in patients with glycosylated haemoglobin (GHb) lower than median, and 17 % in patients with GHb higher than median) and in the non-diabetic patients 4 % (p = 0.04). Five factors were independently and significantly related to mortality in diabetic patients: acute respiratory distress (very large odds-ratio [OR]), coma (OR 3.8, 95 % confidence interval [CI] 1.0–14.3), GHb above the median (OR 3.3, 95 % CI 1.8–6.2), the interaction between GHb and absence of a severe underlying disorder (OR 12.0, 95 % CI 2.9–50.7) and duration of diabetes (OR of 1.072 for 1-year increment, and 1.42 for a 5-year increment). Choice of empiric antibiotic treatment in diabetic patients with suspected bacterial infection should take into account the preponderance of Klebsiella sp. and Staphylococcus aureus infections. The present results favour an association between poor glycaemic control and a fatal outcome of infectious diseases in diabetic patients.     

Early mortality from the time of diagnosis of Type 2 diabetes: a 5-year prospective cohort study with a local age- and sex-matched comparison cohort.

AIMS: To study patterns and predictors of early mortality in individuals with a new diagnosis of Type 2 diabetes, compared with a local age- and sex-matched comparison cohort. METHODS: A total of 736 individuals diagnosed with Type 2 diabetes between 1 May 1996 and 30 June 1998 and non-diabetic age- and sex-matched control subjects were studied. Follow-up was 5.25 years. Age- and gender-specific all-cause mortality odds ratios were calculated for the diabetic cohort compared with the non-diabetic comparator group. Mortality odds ratios were ascertained using conditional logistic regression. RESULTS: There were 147 deaths in the diabetic cohort [cardiovascular (42.2%), cancer (21.1%)]. Compared with the non-diabetic cohort, mortality odds more than doubled [odds ratio (OR) 2.47; 95% confidence interval (CI) 1.74, 3.49]. These increased odds were present in all age bands (including those aged > 75 years at diagnosis) for both cardiovascular and non-cardiovascular causes. In women, a new diagnosis of Type 2 diabetes was associated with a sevenfold increase in mortality odds in those aged 60-74 years (OR 7.00; 95% CI 2.09, 23.47). CONCLUSIONS: Type 2 diabetes is associated with a 2.5-fold increase in the odds of mortality in both men and women over the first 5 years from diagnosis. Our data strongly support the contention that the mortality risk associated with Type 2 diabetes essentially exists from, or may even predate, the time of diagnosis.     

The impact of diabetes mellitus on survival after myocardial infarction: can it be modified by drug treatment?

Aims/hypothesis. Mortality of diabetic patients after myocardial infarction remains high despite recent improvement in their management. This study population-based evaluates the impact of cardiovascular drug therapy on mortality within 28 days and during 5-year follow-up in diabetic compared with non-diabetic patients.¶Methods. Using the MONICA Augsburg register from 1985 to 1992, 2210 inpatients with incident Q-wave myocardial infarction aged 25–74 years were included, of whom 468 had diabetes. Primary end point was mortality within 28 days and over 5 years. General linear model procedures were used for age-adjustment, controlling for sex, and testing significance; hazard risk ratios were calculated using multivariable Cox proportional hazards model procedures.¶Results. During the 5-year follow-up, 598 subjects died (396 diabetic, 202 non-diabetic). The mortality rate within 28 days was 12.6 % in diabetic patients (women 18.0 %, men 9.9 %) and 7.3 % in non-diabetic patients (p = 0.001). Mortality in diabetic patients over 5 years was increased by 64 % (95 % confidence interval 1.39–1.95) compared with non-diabetic patients. This was considerably reduced (p < 0.001) in patients treated with thrombolytic drugs (risk ratio: diabetes 0.57, no diabetes 0.65) and with beta blockers (0.62 and 0.64) and antiplatelets (0.76 and 0.74) at hospital discharge. Mortality of diabetic patients treated with these drugs was reduced to that of non-diabetic patients without such treatment (risk ratio 1.01 to 1.27; p > 0.1).¶Conclusion/interpretation. Diabetic patients after myocardial infarction are at particularly high risk of dying, but benefit clearly from treatment with thrombolytics, beta blockers and antiplatelets. This study does not, however, allow any inferences to be drawn for treatment with angiotensin converting enzyme inhibitors or the impact of left ventricular function. [Diabetologia (2000) 43: 218–226]     

Significantly increased risk of cancer in diabetes mellitus patients: A meta‐analysis of epidemiological evidence in Asians and non‐Asians

Aims/Introduction: Emerging evidence from observational studies suggests that diabetes mellitus affects the cancer risk. However, whether there are differences in the magnitude of the influence of diabetes among ethnic groups is unknown. Materials and Methods: We searched MEDLINE and the Cochrane Library for pertinent articles that had been published as of 4 April 2011, and included them in a meta‐analysis of the risk of all‐cancer mortality and incidence in diabetic subjects. Results: A total of 33 studies were included in the meta‐analysis, and they provided 156,132 diabetic subjects for the mortality analysis and 993,884 for the incidence analysis. Cancer mortality was approximately 3%, and cancer incidence was approximately 8%. The pooled adjusted risk ratio (RR) of all‐cancer mortality was significantly higher than for non‐diabetic people (RR 1.32 [CI 1.20–1.45] for Asians; RR 1.16 [CI 1.01–1.34] for non‐Asians). Diabetes was also associated with an increased RR of incidence across all cancer types (RR 1.23 [CI 1.09–1.39] for Asians; RR 1.15 [CI 0.94–1.43] for non‐Asians). The RR of incident cancer for Asian men was significantly higher than for non‐Asian men (P = 0.021). Conclusions: Diabetes is associated with a higher risk for incident cancer in Asian men than in non‐Asian men. In light of the exploding global epidemic of diabetes, particularly in Asia, a modest increase in the cancer risk will translate into a substantial socioeconomic burden. Our current findings underscore the need for clinical attention and better‐designed studies of the complex interactions between diabetes and cancer. (J Diabetes Invest, doi: 10.1111/j.2040‐1124.2011.00183.x, 2012)     

Insulin use increases risk of asthma but metformin use reduces the risk in patients with diabetes in a Taiwanese population cohort

Objective: Recent reports have suggested that insulin promotes airway smooth muscle contraction and enhances airway hyperresponsiveness, which are cardinal features of asthma. In contrast, metformin can reduce both airway inflammatory and remodeling properties. However, these results are all from in vitro and animal studies. This study investigated whether diabetes and various antidiabetic agents associate with the risk of asthma. Methods: We used a retrospective population-based cohort study using Taiwan's National Health Insurance claim database from 2000 to 2010 and a Cox proportional hazards regression model to compare the incidence of asthma between patients with diabetes (n = 19,428) and a matched non-diabetic group (n = 38,856). We also used a case-control study nested from the above cohort including 1,982 incident cases of asthma and 1,982 age- and sex-matched controls. A time density sampling technique was used to assess the effects of various antidiabetic agents on the risk of asthma. Results: The incidence of asthma was significantly higher in the diabetic cohort than that in the non-diabetic cohort after adjustment for age, sex, and obesity, with a hazard ratio of 1.30 (95% confidence interval [CI]: 1.24–1.38). Insulin was found to increase the risk of asthma among diabetic patients (odds ratio [OR] 2.23; 95% CI: 1.52–3.58). In contrast, the use of metformin correlated with a decreased risk of asthma (OR 0.75; 95% CI: 0.60–0.95). Conclusions: Individuals with diabetes are at an increased risk of asthma. Insulin may further increase the risk of asthma, but the risk could possibly be reduced by using metformin.     

Albumin excretion in diabetic patients in the setting of acute myocardial infarction: association with 3-year mortality

Aims/hypothesis Diabetes mellitus is associated with increased mortality in subjects with acute myocardial infarction (AMI). We aimed to estimate the risk of mortality in AMI patients with and without diabetes using the urinary albumin : creatinine ratio (ACR).Methods This is a prospective study of 121 consecutive, non-selected diabetic AMI patients, 121 age- and sex-matched non-diabetic AMI patients and 61 diabetic non-AMI outpatients as control subjects. All data were obtained during the first 7 days of hospitalisation and each AMI patient was followed for a period of exactly 3 years. Baseline ACR RIA measurements were made on the 1st, 3rd and 7th days of admission.Results Adjusted ACR values were significantly higher in the diabetic AMI patients than in the diabetic control outpatients (p<0.0001), and a significant difference was observed between the weekly ACR slopes for these two groups (p<0.0001). Microalbuminuria was more prevalent in the diabetic AMI patients than in the non-diabetic AMI patients on the 1st day (62% vs 46%, p=0.01) and 3rd day (41% vs 29%, p=0.04). Among the AMI patients with normoalbuminuria (ACR <30 µg/mg), the mortality rate was 11.6% for the patients without diabetes and 33.8% for those with diabetes (p=0.001). The mortality rate was much higher among the AMI patients with microalbuminuria (ACR 30 µg/mg) and similar for the diabetic (68.0%) and non-diabetic patients (74.3%). In a multivariable Cox model, ACR (p<0.0001) and diabetes status (p=0.01) were associated with adverse outcome even when several other clinical variables were included in the model. Furthermore, a negative interaction was found between diabetes and ACR (p=0.01).Conclusions/interpretation Microalbuminuria frequently occurs in diabetic and non-diabetic AMI patients during the first 3 days of admission to hospital and can be used to identify subjects at high risk of mortality.     

The relationship between admission blood glucose levels and hospital mortality

Aims/hypothesis The purpose of this study was to examine the relationship between blood glucose level (BGL) on admission with mortality rates among patients admitted to hospital through the Emergency Department. Methods In a prospective observational study, BGLs were routinely measured on 6,187 consecutive patients requiring blood testing and admitted through the Emergency Department of a tertiary referral hospital. These measurements were matched against demographic data and hospital mortality rates. Results Overall in-hospital mortality was 4.8%. Admission BGL was an independent predictor of mortality (HR 1.04 per 1 mmol/l increase, 95% CI 1.02–1.06, p=0.02). There was a significant interaction between diabetes status and increasing BGL on mortality (p<0.001), with higher BGLs being associated with greater mortality among non-diabetic than among diabetic patients. Among non-diabetic patients, the lowest mortality rate (3.0%) was in people with a BGL of 4.0–5.9 mmol/l. Compared with this group, patients with a BGL of 8.0–9.9 mmol/l had increased mortality rate (7.6%, HR 1.56, 95% CI 1.03–2.35, p=0.04, after adjustment for age and sex). The risk increased further at higher glucose levels. In the cohort with diagnosed diabetes, the increase in mortality rates at higher BGL bands was not significant. Conclusions/interpretation Among people who do not have diabetes, even modest degrees of hyperglycaemia on hospital admission are associated with increased mortality.     

Mortality Rates in Diabetic Patients from a Community-based Population Compared to Local Age/Sex Matched Controls

Using a population-based cohort from 10 general practices in East Dorset, the mortality rate of diabetic patients compared to non-diabetic controls was investigated during 8 years follow-up. From a total population of 90660, 917 diabetic patients were identified; 693 (75 %) with non-insulin-dependent (Type 2) diabetes and 224 (25 %) with insulin-dependent (Type 1) diabetes. A control group of 917 non-diabetic subjects were selected, matched by age and sex. After 8 years, significantly more diabetic patients (334 or 36.4 %) had died than controls (219 or 24 %), (odds ratio (OR) 1.99, 95 % CI 1.60–2.47). Compared with the controls, the odds ratio of all causes of mortality for diabetic men was 1.89 (CI 1.4–2.54) and for diabetic women 2.16 (CI 1.57–2.96). Compared with controls, the odds ratio for mortality from circulatory disease was significantly increased for diabetic patients 2.0 (CI 1.5–2.6) but mortality for respiratory disease or neoplasms was not significantly different (OR 0.7, CI 0.4–1.2 and OR 0.7, CI 0.6–1.0, respectively). Control data were lower than would be expected from national database data. The diabetic population had a significantly higher mortality than controls, both from all causes and circulatory diseases. Our data incidentally show the importance of appropriate controls for estimating the impact of a chronic disease. © 1997 by John Wiley & Sons, Ltd.     

Acute Myocardial Infarction in Diabetic Patients in the Thrombolytic Era

To examine the benefits of thrombolytic therapy in diabetic patients with acute myocardial infarction a retrospective study of all diabetic and non-diabetic patients with acute myocardial infarction admitted to the coronary care unit of the General Hospital, Birmingham between January 1984 and December 1987 was made and findings compared to corresponding groups admitted between January 1990 and May 1992 when thrombolytic therapy was routine. In-hospital mortality and morbidity were assessed in 208 diabetic and 1029 non-diabetic patients with acute myocardial infraction admitted between 1984 and 1987 and in 115 diabetic and 501 non-diabetic patients admitted with myocardial infarction between January 1990 and May 1992. Following the introduction of thrombolytic therapy, there was a reduction in mortality among non-diabetic patients from 17 % to 8.5 %; p± 0.001 (observed reduction: 49 %; 95 % Cl: 30–70 %) and in the incidence of left ventricular failure (from 22 % to 8 %, p ± 0.01 (observed reduction: 52 %; 95 % Cl: 40–85.5 %). Diabetic patients showed a reduction in mortality from 30 % to 17 %; p = 0.02 (observed reduction: 42 %; 95 % Cl: 9.4–73.8 %) and in the incidence of left ventricular failure from 39 % to 21 %; p ± 0.01 (observed reduction: 45 %; 95 % Cl: 20.3–72.5 %). Thrombolytic therapy confers a major benefit on diabetic patients with acute myocardial infarction, although this group remains at a prognostic disadvantage compared to non-diabetic patients.     

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.     

Prognosis of Acute Myocardial Infarction in Diabetic and Non-diabetic Patients

We evaluated the prognosis of 858 patients with acute myocardial infarction (MI), of whom 97 (11%) had a history of diabetes mellitus. Among patients with diabetes the 1-year mortality rate was 41% versus 26% for non-diabetic patients (p < 0.01), and the 1-year reinfarction rates were 23% and 14%, respectively (p = 0.05). Diabetic patients with a history of hypertension had a similar mortality rate as comapred with diabetic patients without hypertension. In a multivariate analysis including age and history of cardiovascular disease, diabetes did not significantly contribute to death or reinfarction. Among diabetic patients the only independent risk factor for death was age. The place and mode of death appeared similar in the two groups. Patients with and without a history of diabetes had a similar infarct size. We conclude that diabetic patients with acute myocardial infarction have a very poor prognosis. Within 1 year nearly half of them are dead and one-quarter develop reinfarction. The mode of death appeared to be similar in diabetic patients as compared with non-diabetic patients.     

Prothrombotic and Antithrombotic Factors are Elevated in Patients with Type 1 Diabetes Complicated by Microalbuminuria

Increased urinary albumin loss in patients with Type 1 diabetes is associated with accelerated atherosclerosis. Prothrombotic factors known to be associated with cerebrovascular and coronary artery disease in the general population, and antithrombotic factors, were studied in 52 patients with Type 1 diabetes and varying urinary albumin loss and 24 non-diabetic control subjects. Fibrinogen increased from 2.5 g I_-1 (95 % confidence interval 2.3–2.8) in control subjects and 2.8 g I_-1 (2.6–3.0) in diabetic patients without microalbuminuria to 3.1 g I_-1 (2.7–3.5) with microalbuminuria (p < 0.005 vs control; p < 0.001 vs without microalbuminuria). Factor VIIc increased from 81 % (75–86 % in non-diabetic control subjects and 84 % (78–90 %) in diabetic patients without microalbuminuria to 103 % (89–117 %) with microalbuminuria (p < 0.005 vs control; p < 0.05 vs without microalbuminuria) and 118% (86–150%) with albuminuria (p < 0.005 vs control and p < 0.001 vs without microalbuminuria). Levels of the antithrombotic factors protein C, protein S, and antithrombin III also rose in the diabetic patients with evidence of renal damage. Elevation of prothrombotic factors has been associated with increased risk of microvascular disease, whereas elevation of antithrombotic factors has no known protective effect. Therefore, this pattern of alteration of haemostatic factors in diabetic renal disease may contribute to the increased risk of vascular disease associated with both microalbuminuria and albuminuria.