Mortality in diabetic and nondiabetic patients after amputations performed from 1990 to 1995: a 5-year follow-up study

OBJECTIVE: To compare survival rates after first amputation between patients with and without diabetes. RESEARCH DESIGN AAND METHODS: We performed a retrospective study of all nontraumatic amputations performed at our center in the years 1990-1995 in patients with (n = 100) and without (n = 151) diabetes. Survival status was assessed from the first amputation until 31 December 2001. RESULTS: Altogether, 61% of the patients with and 54.3% of those without diabetes died 5.2 (4.5-5.8) and 5.3 (4.7-5.9) [mean (95% CI)] years after the first amputation, respectively (P = 0.80). Survival was not different between patients with and without diabetes after controlling for the level (major versus minor) (P = 0.67) or the cause (ischemia versus infection) of amputation (P = 0.72). No sex differences were found for survival in either study group. Independent predictors of mortality in the diabetic group were duration of diabetes (P = 0.05), history of stroke (P = 0.02), and serum creatinine level (P < 0.0001), while in the nondiabetic group independent predictors were history of stroke (P = 0.04), serum creatinine level (P = 0.005), and higher white blood cell count (P = 0.02). The peak incidence of amputations was observed in the decade of 67-76 years of age in both groups. Major amputations were more common among nondiabetic patients in all age-groups. Median hospital stay and postoperative complications were comparable between the two groups. CONCLUSIONS: All-cause mortality is high after an amputation in both diabetic and nondiabetic patients. Mortality rates, hospital stay, and postoperative complications are not different between diabetic and nondiabetic amputees. No modifiable factors, with the exception of nephropathy, were found to improve survival in amputees. Peripheral vascular disease and neuropathy are the main cause of amputations; prevention, therefore, of these complications is warranted to prevent amputations and the subsequent high mortality.     

Effect of diabetes on the mortality risk of cardiogenic shock in a community-based population

OBJECTIVE: To examine the mortality of diabetic vs nondiabetic patients with anterior myocardial infarction (AMI) among the subsets of this population who did and did not develop cardiogenic shock. PATIENTS AND METHODS: The study population consisted of a consecutive series of 1263 Olmsted County, Minnesota, patients admitted to the coronary care unit at the Mayo Clinic in Rochester, Minn, between January 1, 1988, and July 31, 2000. Of these patients, 73 met the criteria for cardiogenic shock during their hospitalization. In-hospital and postadmission mortality were compared between diabetic and nondiabetic patients within the cardiogenic shock and nonshock patient groups, respectively. RESULTS: In patients with AMI and cardiogenic shock, diabetes was associated with a trend for increased in-hospital mortality (odds ratio, 2.82; 95% confidence interval [CI], 0.90-9.92; P = .08). In 73 patients with cardiogenic shock, estimated survival at 1, 3, and 5 years was 25%, 17%, and 17%, respectively, for diabetic patients, and 50%, 44%, and 36%, respectively, for nondiabetic patients (P = .046). The association between diabetic patients and increased long-term mortality was stronger in patients with cardiogenic shock than in patients without cardiogenic shock (adjusted relative risk, 2.08; 95% CI, 1.11-3.90; P = .02). In diabetic patients without cardiogenic shock, estimated survival at 1, 3, and 5 years was low, at 75%, 61%, and 45%, respectively, compared with 83%, 76%, and 69%, respectively, for nondiabetic patients (adjusted relative risk, 1.29; 95% CI, 1.02-1.62; P = .03). CONCLUSION: The presence of diabetes as a comorbidity in patients with AMI appears to be associated with increased mortality compared with nondiabetic patients, and this relationship may be potentially magnified in patients who develop cardiogenic shock.     

High risk of cardiovascular disease in patients with type 1 diabetes in the U.K.: a cohort study using the general practice research database

OBJECTIVE: To estimate the absolute and relative risk of cardiovascular disease (CVD) in patients with type 1 diabetes in the U.K. RESEARCH DESIGN AND METHODS: Subjects with type 1 diabetes (n = 7,479) and five age- and sex-matched subjects without diabetes (n = 38,116) and free of CVD at baseline were selected from the General Practice Research Database (GPRD), a large primary care database representative of the U.K. population. Incident major CVD events, comprising myocardial infarction, acute coronary heart disease death, coronary revascularizations, or stroke, were captured for the period 1992-1999. RESULTS: The hazard ratio (HR) for major CVD was 3.6 (95% CI 2.9-4.5) in type 1 diabetic men compared with those without diabetes and 7.7 (5.5-10.7) in women. Increased HRs were found for acute coronary events (3.0 and 7.6 in type 1 diabetic men and women, respectively, versus nondiabetic subjects), coronary revascularizations (5.0 in men, 16.8 in women), and for stroke (3.7 in men, 4.8 in women). Type 1 diabetic men aged 45-55 years had an absolute CVD risk similar to that of men in the general population 10-15 years older, with an even greater difference in women. CONCLUSIONS: Despite advances in care, these data show that absolute and relative risks of CVD remain extremely high in patients with type 1 diabetes. Women with type 1 diabetes continue to experience greater relative risks of CVD than men compared with those without diabetes.     

Time-Dependent Impact of Diabetes on Mortality in Patients With Stroke: Survival up to 5 years in a health insurance population cohort in Germany

OBJECTIVE To estimate the impact of diabetes on mortality in patients after first stroke event. RESEARCH DESIGN AND METHODS Using claims data from a nationwide statutory health insurance fund (Gmünder ErsatzKasse), we assessed all deaths in a cohort of 5,757 patients with a first stroke between 2005 and 2007 (69.3% male, mean age 68.1 years, 32.2% with diabetes) up to 2009. By use of Cox regression, we estimated time-dependent hazard ratios (HRs) to compare patients with and without diabetes stratified by sex. RESULTS The cumulative 5-year mortality was 40.0 and 54.2% in diabetic men and women, and 32.3 and 38.1% in their nondiabetic counterparts, respectively. In males, mortality was significantly lower in diabetic compared with nondiabetic patients in the first 30 days (multiple-adjusted HR 0.67 [95% CI 0.53-0.84]). After approximately a quarter of a year, the diabetes risk increased, yielding crossed survival curves. Later on, mortality risk tended to be similar in diabetic and nondiabetic men (1-2 years: 1.42 [1.09-1.85]; 3-5 years: 1.00 [0.67-1.41]; time dependency of diabetes, P = 0.008). In women, the pattern was similar; however, time dependency was not statistically significant (P = 0.89). Increasing age, hemorrhagic stroke, renal failure (only in men), levels of care dependency, and number of prescribed medications were significantly associated with mortality. CONCLUSIONS We found a time-dependent mortality risk of diabetes after first stroke in men. Possible explanations may be type of stroke or earlier and more intensive treatment of risk factors in diabetic patients.     

Insulin resistance,the metabolic syndrome,and risk of incident cardiovascular disease in nondiabetic american indians: the Strong Heart Study

OBJECTIVE: Insulin resistance (IR) and the metabolic syndrome (MS) are associated with type 2 diabetes and adverse cardiovascular disease (CVD) risk factor profiles. Whether IR and MS predict CVD independently of diabetes and other CVD risk factors is not known. This study examines whether IR and/or presence of MS are independently associated with CVD in nondiabetic American Indians (AI). RESEARCH DESIGN AND METHODS: We examined 2283 nondiabetic AI who were free of CVD at the baseline examination of the Strong Heart Study (SHS). CVD risk factors were measured, IR was quantified using the homeostasis model assessment (HOMA), and MS as defined by the National Cholesterol Education Program Adult Treatment Panel (ATP III) was assessed for each participant. Incident CVD and diabetes were ascertained during follow-up. RESULTS: MS was present in 798 individuals (35%), and 181 participants (7.9%) developed CVD over 7.6 +/- 1.8 years of follow-up. Age, BMI, waist circumference, and triglyceride levels increased and HDL cholesterol decreased across tertiles of HOMA-IR. Risk of diabetes increased as a function of baseline HOMA-IR (6.3, 14.6, and 30.1%; P < 0.001) and MS (12.8 vs. 24.5%). In Cox models adjusted for CVD risk factors, risk of CVD did not increase either as a function of baseline HOMA-IR or MS, but individual CVD risk factors predicted subsequent CVD. CONCLUSIONS: Among nondiabetic AI in the SHS, HOMA-IR and MS both predict diabetes, but neither predicts CVD independently of other established CVD risk factors.     

Enalapril prevents clinical proteinuria in diabetic patients with low ejection fraction

OBJECTIVE: Clinical proteinuria is a risk factor for both end-stage renal disease and cardiovascular disease. The prevalence of clinical proteinuria, its correlates and predictive value, and the effect of ACE inhibitors in preventing clinical proteinuria in diabetic and nondiabetic patients with left ventricular (LV) dysfunction are unknown. RESEARCH DESIGN AND METHODS: The Studies of Left Ventricular Dysfunction (SOLVD) trials were analyzed to determine the baseline distribution of clinical proteinuria and related cardiovascular risk factors, the effect of baseline proteinuria on the risk of hospitalization for congestive heart failure (CHF) and mortality, and the effect of enalapril in preventing new clinical proteinuria. RESULTS: A total of 5,487 out of 6,797 SOLVD participants (81%) were assessed for proteinuria at baseline. A total of 177 patients (3.2%) had baseline proteinuria. These patients had significantly higher systolic (137 vs. 125 mmHg, P < or = 0.001) and diastolic (83 vs. 77 mmHg, P < or = 0.001) blood pressure levels, a higher prevalence of diabetes (41 vs. 18%, P < or = 0.001), a lower ejection fraction (26.2 vs. 27.3%, P < or = 0.05), and greater degree of CHF (New York Heart Association [NYHA] class III/IV in 22 vs. 10%, P < or = 0.001) than patients without baseline proteinuria. Patients with baseline proteinuria also had higher rates of hospitalization for CHF (relative risk 1.81 [95% CI 1.37-2.41], P = 0.0001) and mortality (1.73 [1.34-2.24], P = 0.0001). Enalapril prevented clinical proteinuria in diabetic patients (0.38 [0.17-0.81], P = 0.0123) but not in nondiabetic patients (1.43 [0.77-2.63], P = 0.2622) without baseline proteinuria. CONCLUSIONS: Clinical proteinuria is an independent predictor of hospitalization for CHF and mortality in diabetic and nondiabetic patients with LV dysfunction. Enalapril significantly reduces the risk of clinical proteinuria in diabetic patients with LV dysfunction.     

Clinical Characteristics of Diabetic vs Nondiabetic Patients Who "Rule-in" for Acute Myocardial Infarction

OBJECTIVE: To compare the clinical characteristics of diabetic vs nondiabetic patients who present to the ED with acute myocardial infarction (AMI). METHODS: This was a prospective, observational study at a suburban, university hospital ED of patients presenting to the ED during study hours between December 1993 and October 1996 with typical and atypical symptoms consistent with cardiac ischemia. Diabetic and nondiabetic patients with AMI were compared. Demographic, historical, and clinical data were recorded by trained research assistants using a standardized, closed-question, data collection instrument. Final discharge diagnosis of AMI was assigned by WHO criteria. Continuous variables were analyzed by t-tests. Clinical variables were analyzed by chi-square tests. All tests were two-tailed with alpha preset at 0.05. RESULTS: There were 216 patients with AMI during the study period; 51 of these patients (24%) were diabetic. For diabetic vs nondiabetic patients with AMI, there was no significant difference in age (64.0 +/- 13 vs 60.0 +/- 14 years, p = 0.13), female gender (37% vs 26%, p = 0.13), and time to presentation from symptom onset (192 +/- 238 vs 251 +/- 456 minutes, p = 0.41). Hypertension was the only cardiac risk factor significantly more prevalent in diabetic vs nondiabetic patients with AMI (77% vs 50%, OR = 1.54, 95% CI = 1.24 to 1.91, p = 0.001), though elevated cholesterol (48% vs 33%, OR = 1.47, 95% CI = 1.02 to 2.12, p = 0.06) tended to be more prevalent in the diabetic group. There was no statistically significant difference between the two groups in terms of the frequency of chest pain (OR = 1.04, 95% CI = 0.95 to 1.14, p = 0.30), associated symptoms, and diagnostic ECGs (OR = 1.16, 95% CI = 0.76 to 1.79, p = 0.53). CONCLUSION: Diabetic patients with AMI may have similar symptoms upon presentation as do nondiabetic patients with AMI. Of the cardiac risk factors, hypertension is more prevalent in diabetic vs nondiabetic patients with AMI.     

Risk Factors for Cardiovascular and Cerebrovascular Death among African Americans and Hispanics in Los Angeles, California

OBJECTIVE: To describe the risk factors associated with cardiovascular mortality in the African American (AA) and Hispanic populations in Los Angeles County in an effort to define causes for the excess mortality seen in AAs. METHODS: This was a longitudinal analysis of all-cause, cardiovascular, and cerebrovascular mortality in a large, prospective multiethnic cohort of individuals aged 45-74 years. Death rates between AA and Hispanic men and women during the six-year period from 1993 to 1998 due to hypertension, cardiomyopathy, acute myocardial infarction (AMI), ischemic heart disease, and stroke were compared. RESULTS: There were 1,157 deaths due to cardiovascular disease (CVD) or cerebrovascular disease among the 71,798 eligible members of the cohort included in these analyses. Age-adjusted mortality rates were two to five times higher in AAs as compared with Hispanics (e.g., 373.15 in AAs for hypertensive disease vs 50.37 in Hispanics). A history of hypertension was the most common significant risk factor for CVD; other risk factors significantly associated with CVD mortality included cigarette smoking and a past history of diabetes and stroke. Adjusting for these factors did not remove the significance of AA ethnicity as a risk factor for CVD mortality in either subjects reporting or subjects not reporting hypertension at baseline. CONCLUSIONS: The evidence for both higher relative severity and higher incidence of hypertensive disease among AAs, and the consistency of the effect across gender, suggests that a major determinant of risk may be a gene environment interaction.     

Increased heat generation from atherosclerotic plaques in patients with type 2 diabetes: an increased local inflammatory activation

OBJECTIVE: Patients with coronary artery disease (CAD) and diabetes show increased inflammatory activation. Thermography detects local inflammatory involvement as heat generation. The aim of this study was to investigate whether patients with CAD and diabetes have increased local heat generation compared with nondiabetic patients. RESEARCH DESIGN AND METHODS: We enrolled patients undergoing percutaneous coronary interventions: 45 diabetic patients and 63 nondiabetic patients, serving as the control group, matched for age, type of clinical syndrome, statin and aspirin intake, and angiographic stenosis (%). Coronary thermography was performed, and temperature difference (DeltaT) between the atherosclerotic plaque and the proximal vessel wall was measured. RESULTS: Patients with diabetes had increased temperature difference compared with nondiabetic patients (DeltaT: 0.17 +/- 0.18 degrees C vs. 0.09 +/- 0.02 degrees C, P = 0.01). Twenty-one diabetic and 22 nondiabetic patients suffered from acute coronary syndromes (ACSs) (P = 0.22). Patients with diabetes and ACSs had increased temperature difference compared with nondiabetic patients with ACSs (DeltaT: 0.29 +/- 0.31 degrees C vs. 0.15 +/- 0.21 degrees C, P = 0.02), which is the same as patients with diabetes and chronic stable angina (DeltaT: 0.09 +/- 0.08 degrees C vs. 0.05 +/- 0.04 degrees C, P = 0.006). Twenty-three diabetic and 30 nondiabetic patients were under therapy with statins (P = 0.72). Patients with diabetes under statins had lower temperature difference compared with untreated patients (DeltaT: 0.11 +/- 0.12 degrees C vs. 0.22 +/- 0.21 degrees C, P = 0.02), which is the same as nondiabetic patients under statins (DeltaT: 0.05 +/- 0.04 degrees C vs. 0.13 +/- 0.18 degrees C, P = 0.01). CONCLUSIONS: Patients with diabetes have increased temperature difference compared with nondiabetic patients. Patients with diabetes under statins showed decreased temperature difference compared with untreated patients, suggesting that statins have a favorable effect in patients with diabetes and CAD.     

Impact of NIDDM on mortality and causes of death in Pima Indians.

OBJECTIVE--To compare overall and cause-specific death rates for diabetic and nondiabetic Pima Indians. RESEARCH DESIGN AND METHODS--This community-based study determined overall and cause-specific death rates in persons with and without NIDDM in the Pima population. Underlying causes of death for the 10-yr period from 1975 to 1984 were derived from review of death certificates and medical records. Diabetes diagnoses were based on an ongoing diabetes study initiated by the National Institutes of Health in 1965. RESULTS--Of the 512 deaths, 241 were in Pima Indians with NIDDM; 203 (84%) of the deaths in diabetic subjects were attributed to natural causes (46 diabetic nephropathy, 35 IHD, 29 infections, 20 malignant neoplasms, 20 alcoholic liver disease, 18 stroke, 35 other causes). For natural causes, the overall age-sex-adjusted death rate in diabetic subjects was 1.7 times (95% CI 1.4-2.2) that in nondiabetic subjects. Longer duration of diabetes was significantly related to mortality, an association that was stronger in women than in men. Rates of death from diabetic nephropathy, IHD, and infections (but not stroke) were each significantly related to longer diabetes duration. Together, diabetic nephropathy and IHD accounted for 90% of the excess death rate among diabetic, compared with nondiabetic, Pimas. CONCLUSIONS--In Pima Indians, NIDDM has a significant adverse effect on death rates that is directly related to diabetes duration, especially for deaths from diabetic nephropathy, IHD, or infections. Among the Pima, diabetic nephropathy is the leading cause of death, and IHD ranks second--a variation from other populations (in which IHD ranks first), probably partly attributable to a much younger age of onset of diabetes among the Pima than in the U.S. white population.     

Hypertension prevalence, awareness, treatment, and control in an adult type 1 diabetes population and a comparable general population

OBJECTIVE: To compare the prevalence, awareness, treatment, and control of hypertension in a population-representative sample of adults with type 1 diabetes and comparable nondiabetic control subjects. RESEARCH DESIGN AND METHODS: In 2000-2002, the Coronary Artery Calcification in Type 1 Diabetes Study enrolled 1,416 individuals aged 19-56 years with no known history of coronary artery disease: 652 type 1 diabetic patients (46% male, mean age 37 years) and 764 nondiabetic control subjects (50% male, mean age 39 years). Subjects were asked if they had been told by a physician that they had hypertension or were on a blood pressure medication. Blood pressure was measured using standardized Joint National Committee (JNC) protocol. RESULTS: Type 1 diabetic subjects, compared with nondiabetic subjects, had higher rates of hypertension prevalence (43 vs. 15%, P < 0.001), awareness (53 vs. 45%, P = 0.11), treatment (87 vs. 47%, P < 0.001), and control (55 vs. 32%, P < 0.001) for the JNC 6 goal (130/85 mmHg). Only 42% of all type 1 diabetic hypertensive subjects met the new JNC 7 goal (130/80 mmHg). Type 1 diabetic subjects had better blood pressure control (72 vs. 32%, P < 0.0001), using 140/90 mmHg as a common measure. The majority of treated subjects were on a single antihypertensive agent (75 vs. 64%). CONCLUSIONS: Subjects with type 1 diabetes have higher rates of hypertension prevalence, treatment, and control than nondiabetic subjects. However, hypertension remains largely uncontrolled, even if treated in high-risk populations, such as type 1 diabetic subjects and undiagnosed individuals in the general population. Achieving more stringent blood pressure goals will require increased attention and may necessitate the use of multiple antihypertensive agents.     

Peripheral arterial disease in diabetic and nondiabetic patients: a comparison of severity and outcome

OBJECTIVE: The aim of this study was to quantify the distribution of peripheral arterial disease in the diabetic and nondiabetic population attending for angiography and to compare severity and outcome between both groups of patients. RESEARCH DESIGN AND METHODS: Randomly selected lower-extremity angiograms were examined according to the Bollinger system. Patient demographics and medical history were recorded and case notes were examined to determine which patients later underwent a revascularization procedure or amputation and which patients had died. RESULTS: A total of 136 arteriograms obtained between 1992 and 1996 were analyzed. The age (mean +/- SD) of the patients was 64.7 +/- 10.8 years. Diabetic patients (43%) and nondiabetic patients were of similar age (63.9 +/- 10.4 vs. 65.3 +/- 11.1 years, P = 0.43), with a similar history of smoking (81.0 vs. 76.9%, P = 0.26), ischemic heart disease (41.4 vs. 37.2%, P = 0.54), and hypercholesterolemia (24.4 vs. 30.8%, P = 0.48). However, there were a greater proportion of hypertensive patients in the diabetic group (63.8 vs. 39.7%, P = 0.006). Diabetic patients had greater severity of arterial disease in the profunda femoris and all arterial segments below the knee (P = 0.02). A greater number of amputations occurred in the diabetic group: diabetic patients were five times more likely to have an amputation (41.4 vs. 11.5%, odds ratio [OR] 5.4, P < 0.0001). Mortality was higher in the diabetic group (51.7 vs. 25.6%, OR 3.1, P = 0.002), and diabetic patients who died were younger at presentation than nondiabetic patients (64.7 +/- 11.4 vs. 71.1 +/- 8.7 years, P = 0.04). CONCLUSIONS: In patients with peripheral arterial disease, diabetic patients have worse arterial disease and a poorer outcome than nondiabetic patients.     

Processes and outcomes of care for diabetic acute myocardial infarction patients in Ontario: do physicians undertreat?

OBJECTIVE: To compare the health service utilization and long-term outcomes of acute myocardial infarction (AMI) patients with and without diabetes in Ontario. RESEARCH DESIGN AND METHODS: We examined 25,697 patients from Ontario (6,052 and 19,645 patients with and without diabetes, respectively) who were hospitalized because of AMI between 1 April 1992 and 31 December 1993. Using linked administrative databases, we determined the use of invasive cardiac procedures at 1 year as well as the intensity of specialty follow-up care and use of evidence-based pharmacotherapies (among elderly individuals) within the first 90 days of hospital discharge. Outcomes examined included mortality and recurrent cardiac admissions at 30 days and 5 years post AMI. Multivariable analyses adjusted for sociodemographic and case-mix characteristics, attending physician specialty, and admitting hospital characteristics. RESULTS: Despite being at significantly higher risk for death at baseline, diabetic patients were less likely to be followed-up by a cardiologist (22.2 vs. 25.6%, P < 0.001), to receive myocardial revascularization (12.6 vs. 14.9%, P < 0.001), to receive beta-blockers (34.2 vs. 44.0%, P < 0.001), and to receive aspirin therapy (59.7 vs. 63.5%, P < 0.001) after AMI than their nondiabetic counterparts. Diabetes was an important independent predictor of 5-year morbidity (adjusted hazard ratio 1.52, 95% CI 1.45-1.59) and 5-year mortality outcomes (1.57, 1.50-1.63). Variations in processes of care were marginally associated with higher nonfatal complication rates for diabetic patients. CONCLUSIONS: When managing AMI patients with diabetes in Ontario, physician treatment aggressiveness does not correspond appropriately to the baseline risk of patients.     

Insulin resistance associated with lower rates of weight gain in Pima Indians.

Insulin resistance is commonly associated with obesity and noninsulin-dependent diabetes. Whereas it predicts the development of diabetes, its effect on body weight change is unknown. We measured glucose disposal rates at submaximally- and maximally-stimulating insulin concentrations in 192 nondiabetic Pima Indians and followed their weight change over 3.5 +/- 1.8 y (mean +/- SD). Results: (a) Insulin-resistant subjects gained less weight than insulin-sensitive subjects (3.1 vs. 7.6 kg, P less than 0.0001). (b) The percent weight change per year correlated with glucose disposal at submaximally-(r = 0.19, P less than 0.01) and maximally-stimulating (r = 0.34, P less than 0.0001) insulin concentrations independent of sex, age, initial weight, and 24-h energy expenditure; the correlations were stronger for glucose oxidation than for glucose storage. (c) Weight gain was associated with an increase in insulin resistance more than four times that predicted from the cross-sectional data. We conclude that insulin resistance is associated with a reduced risk of weight gain in nondiabetic Pima Indians.     

Diagnosis of type 2 diabetes at an older age: effect on mortality in men and women

OBJECTIVE: To compare the mortality of people who were diagnosed with type 2 diabetes over 65 years of age with that of nondiabetic individuals. RESEARCH DESIGN AND METHODS: Using a population-based diabetes information system for an observational cohort study in Tayside, Scotland, people who were diagnosed with type 2 diabetes over the age of 65 years between 1993 and 2002 were identified. Nondiabetic comparators, matched for age and sex, were identified from the nondiabetic population. The two cohorts were followed up for mortality and cardiovascular mortality according to death certification records. RESULTS: There were 3,594 people with type 2 diabetes (48% male) and 7,188 matched comparators identified in the study. Over a mean follow-up period of 4.6 +/- 2.9 years for 3,594 people with type 2 diabetes and 7,188 comparators, 909 (25.3%) patients in the diabetic cohort and 1,651 (23.0%) in the nondiabetic cohort died. The adjusted relative risk for mortality in the diabetic cohort compared with the nondiabetic cohort was 1.06 (95% CI 0.94-1.19) for men and 1.29 (1.15-1.45) for women. Cardiovascular deaths accounted for 49.4% of the deaths in people with and 45.2% in those without diabetes (adjusted relative risk 1.01 [0.93-1.10]). CONCLUSIONS: Men diagnosed with type 2 diabetes over the age of 65 years have no excess mortality compared with their nondiabetic counterparts, a finding that was not replicated for women.     

Adiponectin in a native Canadian population experiencing rapid epidemiological transition

OBJECTIVE: Adiponectin is emerging as an important protein in the etiology of obesity and related metabolic disorders. The objectives of this study were to determine cross-sectional and prospective associations of adiponectin concentration with adiposity, type 2 diabetes, and cardiovascular disease (CVD) risk factors in a population-based study of Native Canadians, a group experiencing dramatic increases in diabetes and CVD. RESEARCH DESIGN AND METHODS: During the 1993-1995 baseline survey, samples for glucose, insulin, adiponectin, and lipids were collected after an overnight fast. Waist circumference and percent body fat were measured, and a 75-g oral glucose tolerance test was administered: n = 505 with normal glucose tolerance (NGT), 74 with impaired glucose tolerance (IGT), and 149 with diabetes. In 1998, 95 high-risk subjects, defined as those who, at baseline, had either IGT or NGT with an elevated 2-h glucose concentration (>/==" BORDER="0">7.0 mmol/l), participated in a follow-up examination using the protocol used at baseline. RESULTS: After adjustment for covariates including percent body fat and homeostasis model assessment of insulin resistance (HOMA-IR), adiponectin concentrations were significantly lower among men versus women (10.8 vs. 15.0 micro g/ml, P < 0.0001) and among diabetic versus NGT subjects (11.1 vs. 13.1 micro g/ml, P < 0.05). Adiponectin was inversely correlated with percent body fat, waist circumference, HOMA-IR, and triglyceride and positively correlated with HDL (r = |0.30|-|0.44|, all P < 0.0001). In multivariate linear regression analysis in nondiabetic subjects, HDL and percent body fat were significantly related to adiponectin variation among both men and women (R(2) = 28-29%). Factor analysis returned three underlying factors among these variables, with adiponectin loading on the second factor along with insulin, waist circumference, triglyceride, and HDL. In the follow-up study, higher adiponectin at baseline was significantly associated with increases in HDL (r = 0.24, P = 0.03) and decreases in HOMA-IR (r = -0.29, P = 0.009) after adjustment for covariates, including age, adiposity, and diabetes status at baseline and follow-up. CONCLUSIONS: These population-based findings support the hypothesis that low circulating levels of adiponectin are an important determinant of risk of CVD.     

Prevalence and mortality of acute myocardial infarction in patients with diabetes

The purpose of this study was to investigate if insulin-dependent diabetes mellitus (IDDM) and non-insulin-dependent diabetes mellitus (NIDDM) predispose to the development of acute myocardial infarction (AMI) and modify the prognosis. The study includes 832 AMI patients consecutively hospitalized over a 3-yr period. The prevalence of diabetes mellitus among the AMI patients was 9.7% and is significantly higher than in an age-matched population, where it is 6.1% (P less than 0.001). The prevalence of diabetes was higher for women than for men (14.9% versus 7.6%). The risk of AMI was found to be twice as high among IDDM than among nondiabetic patients (P less than 0.001). Men with NIDDM were not found to have a significantly higher risk of AMI (P greater than 0.1), but the risk of AMI in women with NIDDM was approximately doubled (P less than 0.01). During the first month following AMI the mortality rate for nondiabetic patients was 20.2% compared with 42.0% for diabetic patients (P less than 0.001). Insulin treatment in NIDDM was associated with a reduced mortality rate compared with treatment with oral agents (P less than 0.05). The mortality rate was significantly higher in patients with poor metabolic control compared with patients in good control, whether before AMI or at the time of hospitalization. Diabetic patients had a higher risk of developing cardiogenic shock and conduction disorders than nondiabetic patients. We conclude that diabetes mellitus disposes to AMI and that the mortality rate of AMI is significantly increased among diabetic patients. Poor metabolic regulation of the diabetes may aggravate the prognosis for AMI.     

Preventable Major Cardiovascular Events Associated With Uncontrolled Glucose,Blood Pressure,and Lipids and Active Smoking in Adults With Diabetes With and Without Cardiovascular Disease: A Contemporary Analysis

OBJECTIVEThe objective of this study was to assess the incidence of major cardiovascular (CV) hospitalization events and all-cause deaths among adults with diabetes with or without CV disease (CVD) associated with inadequately controlled glycated hemoglobin (A1C), high LDL cholesterol (LDL-C), high blood pressure (BP), and current smoking.RESULTSMean (SD) age at baseline was 59 (14) years; 48% of subjects were female, 45% were white, and 31% had CVD. Mean follow-up was 59 months. Event rates per 100 person-years for adults with diabetes and CVD versus those without CVD were 6.0 vs. 1.7 for MI/ACS, 5.3 vs. 1.5 for stroke, 8.4 vs. 1.2 for HF, 18.1 vs. 40 for all CV events, and 23.5 vs. 5.0 for all-cause mortality. The percentages of CV events and deaths associated with inadequate risk factor control were 11% and 3%, respectively, for those with CVD and 34% and 7%, respectively, for those without CVD.CONCLUSIONSAdditional attention to traditional CV risk factors could yield further substantive reductions in CV events and mortality in adults with diabetes.     

Cardiovascular and All-Cause Mortality Over a 23-Year Period Among Chinese With Newly Diagnosed Diabetes in the Da Qing IGT and Diabetes Study

OBJECTIVE

Despite its growing prevalence in China, the extent to which diabetes leads to excess cardiovascular disease (CVD) mortality and all-cause mortality is unclear.

RESEARCH DESIGN AND METHODS

We compared death rates and causes of death among 630 people with newly diagnosed diabetes (NDD) and 519 with normal glucose tolerance (NGT) who, in 1986, were identified as a result of screening 110,660 adults aged 25–74 years for diabetes in Da Qing, China.

RESULTS

During 23 years of follow-up, 338 (56.5%) participants with NDD and 100 (20.3%) with NGT died. CVD was the predominant cause of death in those with diabetes (47.5% in men and 49.7% in women), almost half of which was due to stroke (52.3% in men and 42.3% in women). The age-standardized incidence of all-cause death was three times as high in those with NDD as in those with NGT with incidences (per 1,000 person-years) of 36.9 (95% CI 31.5–42.3) vs. 13.3 (10.2–16.5) in men (P < 0.0001) and 27.1 (22.9–31.4) vs. 9.2 (7.8–10.6) in women (P < 0.0001). The incidence of CVD deaths in men and women with NDD (17.5 [13.8–21.2] vs. 13.5 [10.5–16.5]) did not differ significantly. Significantly higher death rates attributable to renal disease and infection were also found in the NDD group.

CONCLUSIONS

Diabetes is associated with a substantially increased risk of death in Chinese adults, especially from CVD, almost half of which is due to stroke.