Risk factors, mortality, and cardiovascular outcomes in patients with type 2 diabetes

Background: Patients with diabetes are at higher risk for death and cardiovascular outcomes than the general population. We investigated whether the excess risk of death and cardiovascular events among patients with type 2 diabetes could be reduced or eliminated. Methods: In a cohort study, we included 271,174 patients with type 2 diabetes who were registered in the Swedish National Diabetes Register and matched them with 1,355,870 controls on the basis of age, sex, and county. We assessed patients with diabetes according to age categories and according to the presence of five risk factors (elevated glycated hemoglobin level, elevated low-density lipoprotein cholesterol level, albuminuria, smoking, and elevated blood pressure). Cox regression was used to study the excess risk of outcomes (death, acute myocardial infarction, stroke, and hospitalization for heart failure) associated with smoking and the number of variables outside target ranges. We also examined the relationship between various risk factors and cardiovascular outcomes. Results: The median follow-up among all the study participants was 5.7 years, during which 175,345 deaths occurred. Among patients with type 2 diabetes, the excess risk of outcomes decreased stepwise for each risk-factor variable within the target range. Among patients with diabetes who had all five variables within target ranges, the hazard ratio for death from any cause, as compared with controls, was 1.06 (95% confidence interval [CI], 1.00 to 1.12), the hazard ratio for acute myocardial infarction was 0.84 (95% CI, 0.75 to 0.93), and the hazard ratio for stroke was 0.95 (95% CI, 0.84 to 1.07). The risk of hospitalization for heart failure was consistently higher among patients with diabetes than among controls (hazard ratio, 1.45; 95% CI, 1.34 to 1.57). In patients with type 2 diabetes, a glycated hemoglobin level outside the target range was the strongest predictor of stroke and acute myocardial infarction; smoking was the strongest predictor of death. Conclusions: Patients with type 2 diabetes who had five risk-factor variables within the target ranges appeared to have little or no excess risk of death, myocardial infarction, or stroke, as compared with the general population. (Funded by the Swedish Association of Local Authorities and Regions and others.)

Range of risk factor levels: control, mortality and cardiovascular outcomes in type 1 diabetes mellitus

Background—Individuals with type 1 diabetes have high risk of cardiovascular complications, but it is unknown to what extent fulfilling all cardiovascular treatment goals is associated with residual risk of mortality and cardiovascular outcomes in type 1 diabetes compared with the general population. Methods—We included all patients with type 1 diabetes aged >=18 years registered in the Swedish National Diabetes Register from January 1, 1998 - December 31, 2014, in all 33,333 patients, each matched for age and sex with 5 controls without diabetes randomly selected from the population. Patients with type 1 diabetes were categorized according to number of risk factors not at target: glycated hemoglobin, blood pressure, albuminuria, smoking and LDL cholesterol. Risk of all-cause mortality, acute myocardial infarction (AMI), heart failure hospitalization (HF) and stroke was examined in relation to the number of risk factors at target.Results—The mean follow-up was 10.4 years in the diabetes group. Overall, 2074 of 33,333 patients with diabetes and 4141 of 166,529 controls died. Risk for all outcomes increased stepwise for each additional risk factor not at target. Adjusted hazard ratios (HR) for patients achieving all risk factor targets compared with controls were 1.31 (95% CI 0.93-1.85) for all-cause mortality; 1.82 (95% CI 1.15-2.88) for AMI; 1.97 (95% CI 1.04-3.73) for HF; and 1.17 (95% CI 0.51-2.68) for stroke. HR for patients versus controls with none of the risk factors meeting target was 7.33 (95% CI 5.08-10.57) for all-cause mortality; 12.34 (95% CI 7.91-19.48) for AMI: 15.09 (95% CI 9.87-23.09) for HF; and 12.02 (95% CI 7.66-18.85) for stroke.Conclusions—A steep graded association exists between decreasing number of CV risk factors at target and major adverse CV outcomes among patients with T1DM. However, risks for all outcomes were numerically higher for T1DM patients compared with controls, even when all risk factors were at target, with risk for AMI and HF statistically significantly so

Potential effects of bariatric surgery on the incidence of heart failure and atrial fibrillation in patients with type 2 diabetes mellitus and obesity and on mortality in patients with preexisting heart failure: a nationwide, matched, observational cohort study

Background: Obesity and diabetes mellitus are strongly associated with heart failure (HF) and atrial fibrillation (AF). The benefits of bariatric surgery on cardiovascular outcomes are known in people with or without diabetes mellitus. Surgical treatment of obesity might also reduce the incidence of HF and AF in individuals with obesity and type 2 diabetes mellitus (T2DM). Methods and Results: In this register‐based nationwide cohort study we compared individuals with T2DM and obesity who underwent Roux‐en‐Y gastric bypass surgery with matched individuals not treated with surgery. The main outcome measures were hospitalization for HF and/or AF and mortality in patients with preexisting HF. We identified 5321 individuals with T2DM and obesity who had undergone Roux‐en‐Y gastric bypass surgery between January 2007 and December 2013 and 5321 matched controls. The individuals included were 18 to 65 years old and had a body mass index >27.5 kg/m2. The follow‐up time for hospitalization was until the end of 2015 (mean 4.5 years) and the end of 2016 for death. Our results show a 73% lower risk for HF (hazard ratio [HR], 0.27; CI, 0.19–0.38), 41% for AF (HR, 0.59; CI, 0.44–0.78), and 77% for concomitant AF and HF (HR, 0.23; CI, 0.12–0.46) in the surgically treated group. In patients with preexisting HF we observed significantly lower mortality in the group who underwent surgery (HR, 0.23; 95% CI, 0.12–0.43). Conclusions: Bariatric surgery may reduce risk for HF and AF in patients with T2DM and obesity, speculatively via positive cardiovascular and renal effects. Obesity treatment with surgery may also be a valuable alternative in selected patients with T2DM and HF

Clinical Use and Effectiveness of Lipid Lowering Therapies in Diabetes Mellitus—An Observational Study from the Swedish National Diabetes Register

OBJECTIVES: To describe the use and evaluate the effectiveness of different lipid lowering therapies in unselected patients with type 1 and type 2 diabetes in clinical practice. DESIGN: Observational population-based study using the personal identification number to link information from the National Diabetes Register, the Prescribed Drug Register and the Patient register in Sweden. All patients in the NDR aged 18-75 years with diabetes more than one year were eligible, but only patients starting any lipid lowering treatment with at least three prescriptions 1 July 2006-30 June 2007 were included (n = 37,182). The mean blood lipid levels in 2008 and reductions in LDL cholesterol were examined. RESULTS: Blood lipid levels were similar in patients treated with simvastatin, atorvastatin and rosuvastatin, showing similar lipid lowering effect as currently used. Users of pravastatin, fluvastatin, ezetimib and fibrate more seldom reach treatment goals. Moderate daily doses of the statins were used, with 76% of simvastatin users taking 20 mg or less, 48% of atorvastatin users taking 10 mg, 55% of pravastatin users taking 20 mg, and 76% of rosuvastatin users taking 5 or 10 mg. CONCLUSIONS: This observational study shows that the LDL-C levels in patients taking simvastatin, atorvastatin or rosuvastatin are very similar as currently used, as well as their LDL-C lowering abilities. There is potential to intensify lipid lowering treatment to reduce the remaining high residual risk and achieve better fulfilment of treatment goals, since the commonly used doses are only low to moderate

Estimación del riesgo cardiovascular en pacientes con diabetes mellitus tipo 2 en un consultorio médico

Introduction: traumatic injuries are the leading cause of death in young people, ages under 45, and brain injuries have a high incidence of death in more than half of those suffering from these injuries.Objective: to characterize patients with severe cranioencephalic trauma in the Intensive Care Unit at Arnaldo Milián Castro General Teaching Hospital during the year 2018.Methods: an observational, descriptive and retrospective study was conducted in 38 patients with the diagnosis of severe head trauma from January 1, 2018 to January 1, 2019. Medical records were reviewed; variables such as age, cause of trauma, type of injury, complications and hospital staying were collected. Results: male patients predominated (92,11%), ages between 36 and 64 years (50 %); 50 % of traumas were due to traffic accidents. Subdural hematoma represented 52,63 % of lesions and pneumonia the most common complication (65,79 %). Patients admitted for more than 9 days predominated (44,74%); 73,68 % of patients were admitted alive; 65.79 % of patients underwent surgery. Severe cerebral edema was found among the causes of death (70 %).Conclusions: male patients after the third decade of life are prone to severe cranioencephalic trauma. Intervention on primary lesions avoids complications, where ventilation and prolonged hospital staying can trigger sepsis and act as factors affecting survival.Introducción: la diabetes mellitus es una enfermedad crónica no transmisible en aumento, y que, a la vez, representa un factor de riesgo para el desarrollo de enfermedades cardiovasculares. Objetivo: determinar el riesgo cardiovascular existente en los pacientes con diabetes mellitus tipo 2 pertenecientes al Consultorio Médico 15 del Policlínico Universitario “Federico Capdevila”.Método: Se realizó un estudio observacional, descriptivo, longitudinal con carácter retrospectivo, en el periodo comprendido entre septiembre de 2018 y febrero de 2019. La población estuvo constituida por los 87 pacientes con diagnóstico de diabetes mellitus tipo 2, trabajándose con la totalidad. Los datos fueron obtenidos mediante la entrevista, las historias clínicas individuales, y de salud familiar. Se cumplieron los principios de bioética.Resultados: se identificó riesgo cardiovascular en el sexo femenino (58,62 %), y en el grupo etario de 70 a 79 años de edad (28,73 %); así como en pacientes con obesidad (65,51 %); donde el 68,97 % de los pacientes sufrió de alguna enfermedad cardiovascular; entre ellas la hipertensión arterial (67,82 %). Predominó el riesgo cardiovascular leve (25,30 %). Se encontró relación entre la presencia de hipertensión arterial descompensada y un riesgo cardiovascular alto/muy alto (p<0,05).Conclusiones: las féminas que sufrían de diabetes mellitus tipo 2, que sobrepasaban la séptima década de vida y que sufrían de obesidad he hipertensión arterial presentaron riesgo cardiovascular, en su mayoría con riesgo leve. La hipertensión arterial descompensada se relacionó a un mayor riesgo cardiovascula

Clinical effects, cardiovascular and renal outcomes associated with rapid-acting insulin analogs among individuals with type 2 diabetes: a nation-wide observational cohort study

Abstract Background Rapid-acting insulin analogs (RAIs) have not been examined for long-term safety in randomized clinical trials. We performed a nationwide longitudinal cohort study among individuals with type 2 diabetes (T2DM) to address cardiovascular safety and mortality among users of lispro, aspart and glulisine insulins. Methods We used four national registers, following patients previously not treated with RAI but with continuous use of RAIs in 2005-2014 up to 6.4 years, to examine HbA1c and weight, and the occurrence of severe hyperglycemia or hypoglycemia, renal failure, cardiovascular events or death. The treatment groups were compared using a weighted Cox proportional hazards model. Results We included 17,620 patients, mean age slightly higher than 60 years, diabetes duration 9.9–11.7 years, mean BMI 30.5 kg/m2, HbA1c around 70 mmol/mol (8.6% NGSP), and 40.9–54.0% of the patients exhibiting eGFR <60 ml/min/1.73 m2 in the three groups. Around 95% of the patients also used another insulin, and 24.2–24.7% had a history of cardiovascular disease (CVD). Mean HbA1c and weight levels were stable and similar. Incidence rates of death were 234.4, 284.9 and 156.7 per 1000 person-years among users of lispro, aspart, and glulisine; incidence rates of all cardiovascular events were 668.4, 622.4, and 699.5 per 1000 person-years, respectively. There were no differences in mortality, CVD, renal failure or severe hypoglycemia or hyperglycemia, although a lower mortality risk in patients on glulisine compared with aspart, and lower risk of stroke in users of glulisine was suggested. The risk of severe hyperglycemia was higher with lispro than aspart, and lower of severe hypoglycemia than aspart or glulisine among the older age group. Conclusions Overall, there do not appear to be any major important differences in effects on hypoglycemia, hyperglycemia, weight or long-term safety between the three available RAIs among insulin-naive individuals with T2DM in clinical practice

Prescription of lipid-lowering medications for patients with type 2 diabetes mellitus and risk-associated LDL cholesterol: a nationwide study of guideline adherence from the Swedish National Diabetes Register

Abstract Background Management of type 2 diabetes mellitus (T2DM) encompasses intensive glycaemic control, along with treatment of comorbidities and complications to handle the increased risk of cardiovascular disease (CVD). Improved control of LDL-cholesterol (LDL-C) with lipid-lowering medications is associated with reduced CVD risk in T2DM patients. Thus, treatment guidelines recommend lipid-lowering medications for T2DM patients with LDL-C above risk-associated thresholds. This study aimed to assess healthcare provider adherence to guidelines regarding lipid-lowering medication prescription among T2DM patients and to analyse factors associated with lipid-lowering medication prescription. Methods Observations in 2007 − 2014 for T2DM patients age ≥ 18 were collected from the Swedish National Diabetes Register. Observations were excluded if they lacked information about LDL-C, lipid-lowering medication prescription or CVD. Observations with established CVD were attributed to secondary prevention; remaining observations were attributed to primary prevention. The analyses included primary and secondary prevention observations with LDL-C above risk-associated thresholds (LDL-C ≥ 2.5 mmol/l and LDL-C ≥ 1.8 mmol/l respectively). Guideline adherence was analysed as the probability of prescribing lipid-lowering medications using mixed-effect model regression adjusted for potential confounders. Factors associated with prescribing lipid-lowering medications were analysed for patient and healthcare provider characteristics using mixed-effect model regression and odds ratio. Results A total of 1,204,376 observations from 322,046 patients reported by 1352 healthcare providers were included. Primary prevention accounted for 63%; 52% were men, mean age was 64 and mean LDL-C was 3.4 mmol/l. For secondary prevention, 60% were men, mean age was 72 and mean LDL-C was 2.7 mmol/l. During 2007–2014, guideline adherence ranged from 36 to 47% for primary prevention and 59 to 69% for secondary prevention. In general, concomitant prescription of diabetes medications, antiplatelets and antihypertensives along with smoking and specialised care were associated with higher prescription of lipid-lowering medications. Patients age ≥ 80 were associated with lower prescription of lipid-lowering medications. Higher prescription was associated with longer diabetes duration in primary prevention and men in secondary prevention. Conclusions Adherence to treatment guidelines levelled off after an initial increase in both prevention groups. Lipid-lowering medication prescription was based on individualised CVD risk

Diabetes mellitus was not associated with lower amputation-free survival after open revascularization for chronic limb-threatening ischemia : A nationwide propensity score adjusted analysis

The risk of major amputation is higher after urgently planned endovascular therapy for chronic limb-threatening ischemia (CLTI) in patients with diabetes mellitus (DM). The aim of this nationwide cohort study was to compare outcomes between patients with and without DM following urgently planned open revascularization for CLTI from 2010 to 2014. Out of 1537 individuals registered in the Swedish Vascular Registry, 569 were registered in the National Diabetes Register. A propensity score adjusted Cox regression analysis was conducted to compare outcome between the groups with and without DM. Median follow-up was 4.3 years and 4.5 years for patients with and without DM, respectively. Patients with DM more often had foot ulcers (p = 0.034) and had undergone more previous amputations (p = 0.001) at baseline. No differences in mortality, cardiovascular death, major adverse cardiovascular events (MACE), or major amputation were observed between groups. The incidence rate of stroke was 70% higher (95% CI: 1.11-2.59; p = 0.0137) and the incidence rate of acute myocardial infarction (AMI) 39% higher (95% CI: 1.00-1.92; p = 0.0472) among patients with DM in comparison to those without. Open vascular surgery remains a first-line option for a substantial number of patients with CLTI, especially for limb salvage in patients with DM. The higher incidence rates of stroke and AMI among patients with DM following open vascular surgery for infrainguinal CLTI require specific consideration preoperatively with the aim of optimizing medical treatment to improve cardiovascular outcome postoperatively

Long-term Survival and Cardiovascular Morbidity after Elective Open Aortic Aneurysm Repair in Patients with and without Type 2 Diabetes : A Nationwide Propensity-Adjusted Analysis

Background: Epidemiological data indicate decreased risk for development and growth of abdominal aortic aneurysm (AAA)among patients with diabetes mellitus (DM), but DM also goes with increased cardiovascular (CV)morbidity and mortality. We evaluated the effects of DM on mortality and CV morbidity after elective open AAA repair. Methods: This is a nationwide observational cohort study of patients registered in the Swedish Vascular Registry and the Swedish National Diabetes Register. Comparison of mortality and CV morbidity after elective open AAA repair in 397 patients with and 1709 without DM with propensity score–adjusted analysis, during median 4.51 years of follow-up for patients with DM and 4.59 years for those without. Results: In adjusted analysis, diabetic patients showed higher rates of acute myocardial infarction (AMI)(relative risk [RR]1.57, 95% confidence interval [CI]1.04–2.36; P = 0.03)and major adverse cardiovascular events (MACEs, RR 1.28, CI 1.04–1.58; P = 0.02)during follow-up, whereas there were no differences in total (RR 0.98, CI 0.75–1.29; P = 0.91)or CV (RR 0.30, CI 0.07–1.26; P = 0.10)mortality or stroke (RR 1.06, CI 0.67–1.67; P = 0.80). Among diabetic patients, higher HbA1c was related to a higher risk for AMI during follow-up (RR 1.04, CI 1.01–1.08; P = 0.02). Conclusions: Patients with DM had higher rates of AMI and MACE after elective open AAA repair than those without DM, whereas neither total nor CV mortality differed between groups. Putative beneficial effects of DM on the aortic wall might not be relevant after open surgery including thrombus removal and aneurysmorrhaphy