Baseline characteristics of the diabetic participants in the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT)

OBJECTIVE

Hypertension (HTN) is a major risk factor for cardiovascular disease (CVD) in the setting of diabetes. There is no consensus on how best to treat hypertension among those with diabetes. Here we describe the characteristics of a cohort of hypertensive adults with diabetes who are part of a large prospective blood pressure study. This study will help clarify the treatment of HTN in the setting of diabetes.

RESEARCH DESIGN AND METHODS

The Antihypertensive and Lipid-Lowering high-risk hypertensive participants, ages > or = 55 years, designed to determine whether the incidence of fatal and nonfatal coronary heart disease (CHD) and combined cardiovascular events (fatal and nonfatal CHD, revascularization surgery, angina pectoris, congestive heart failure, and stroke) differs between diuretic (chlorthalidone) treatment and three alternative antihypertensive therapies: a calcium channel blocker (amlodipine), an ACE inhibitor (lisinopril), and an alpha-adrenergic blocker (doxazosin). The planned follow-up is an average of 6 years, to be completed March 2002.

RESULTS

There are 15,297 diabetic individuals in the ALLHAT study (36.0% of the entire cohort). Of these individuals, 50.2% are male, 39.4% are African-American, and 17.7% are Hispanic. Demographic and laboratory characteristics of the cohort are similar to those of other studies of the U.S. elderly population with HTN. The sample size has 42 and 93% confidence, treatments for the two study outcomes.

CONCLUSIONS

The diabetic cohort in ALLHAT wil be able to provide valuable information about the treatment of hypertension in older diabetic patients at risk for incident CVD.

The role of personal health concerns and knowledge of the health effects of hormone replacement therapy (HRT) on the ever use of HRT by menopausal women, aged 50-54 years

Previous studies of factors important in a woman's decision to use hormone replacement therapy (HRT) infrequently have simultaneously considered the effects of personal concern for chronic medical disorders that begin at the time of the menopause (such as osteoporosis and heart disease) and knowledge of the beneficial and adverse effects of HRT on these conditions (increased risk of uterine and breast cancers). Moreover, few studies have been performed in broad-based populations that have included black women. This study was undertaken to determine the cross-sectional association of concern for chronic medical disorders that begin at the time of the menopause and knowledge of the effects of HRT on these disorders on the ever use of HRT in a biracial cohort of postmenopausal women. Two hundred eight-eight women, aged 50-54 years, who were members of an HMO, who reported their last menstrual period to be more than 1 year ago, and who were aware of HRT, were examined by questionnaire. Of the cohort, 21.2% were black. Concern for chronic medical disorders that begin at the time of the menopause was modest (approximately 50%). Knowledge of the effects of HRT on breast cancer, uterine cancer, and heart disease was low (approximately 30%). Only for osteoporosis was knowledge high (approximately 65%). On adjusted analysis, concern for heart disease was weakly associated with ever use of HRT, but only for white women. The factors most strongly associated with initiating HRT were a doctor's recommendation to use HRT and satisfaction with a doctor's counseling. Having menopausal symptoms was associated with ever use of HRT in black women. Black women were only 30% as likely as white women to ever use HRT after adjustment for baseline differences.

CONCLUSION

In this study, personal concerns for medical conditions that begin at the time of the menopause and knowledge of the effects of HRT on these conditions were low. Only personal concern for heart disease among white women was independently, but weakly, associated with ever use of HRT. Black women were less likely than white women to ever use HRT, even after adjustment for baseline differences between them.

Hormone replacement therapy awareness in a biracial cohort of women aged 50-54 years

OBJECTIVES

Previous studies of hormone replacement therapy (HRT) among women have focused on factors associated with the use of such therapy. Most of the studies involved populations of white women. Consequently, little is known about HRT awareness among the general population of women, and particularly among black women. The present study focused on factors associated with HRT awareness among a cohort of black and white women aged 50-54 years.

DESIGN

Of more than 2,700 women, aged 50-54 years, who were members of a health maintenance organization, 700 were randomly selected and mailed a questionnaire addressing their awareness of HRT, as well as their menopausal status, medical history, and sources of information on HRT.

RESULTS

Of the 700 women, 479 (68.4%) responded to the questionnaire. After exclusions, 421 (88%) were analyzed. On adjusted analysis, the factors most strongly associated with HRT awareness were a higher educational level, the perception of going or having gone through menopause, the presence of menopausal symptoms, and having undergone a bilateral oophorectomy. Black race (independent of educational level) was associated with a lower likelihood of HRT awareness. The most common source of information on HRT for women in this cohort was the physician, followed by the media.

CONCLUSIONS

HRT awareness among women is strongly influenced by race, educational level, and the perception of going or having gone through menopause. Public health efforts to encourage wider use of HRT among older women should focus on increasing HRT awareness among black women and women with a lower educational level.

Cardiovascular disease in older adults with glucose disorders: comparison of American Diabetes Association criteria for diabetes mellitus with WHO criteria

BACKGROUND

The new fasting American Diabetes Association (ADA) criteria for the diagnosis of diabetes mellitus rely mainly on fasting blood glucose concentrations and use a lower cut-off value for diagnosis than the WHO criteria. We aimed to assess the sensitivity of these criteria for the detection of cardiovascular disease, the main complication of diabetes mellitus in the elderly.

METHODS

We did a cross-sectional and prospective analysis of 4515 participants of the Cardiovascular Health Study, an 8 year longitudinal study designed to identify factors related to the onset and course of cardiovascular disease in adults aged at least 65 years. We calculated the prevalence and incidence of cardiovascular disease for the ADA and WHO criteria.

FINDINGS

There was a higher prevalence of cardiovascular disease among individuals with impaired glucose or newly diagnosed diabetes by both criteria than among those with normal glucose concentrations. However, because fewer individuals had abnormal glucose states by the fasting ADA criteria (22.3%) than by the WHO criteria (46.8%), the number of cases of cardiovascular disease attributable to abnormal glucose states was a third of that attributable by the WHO criteria (53 vs 159 cases per 10,000). For the two sets of criteria, the relative risk for incident cardiovascular disease (mean follow-up 5.9 years) was higher in individuals with impaired glucose and newly diagnosed diabetes than in those with normal glucose. Individuals classified as normal by the fasting ADA criteria had a higher absolute number of incident events (455 of 581 events) than those classified as normal by the WHO criteria (269 of 581 events). Fasting ADA criteria were therefore less sensitive than the WHO criteria for predicting cardiovascular disease among individuals with abnormal glucose (sensitivity, 28% vs 54%).

INTERPRETATION

The new fasting ADA criteria seem to be less predictive than the WHO criteria for the burden of cardiovascular disease associated with abnormal glucose in the elderly.

Antidiabetic treatment trends in a cohort of elderly people with diabetes. The cardiovascular health study, 1989-1997

OBJECTIVE

This study characterizes the pharmaceutical treatment of type 2 diabetes from 1989-1990 to 1996-1997 in an elderly cohort.

RESEARCH DESIGN AND METHODS

A total of 5,888 adults aged > or = 65 years were recruited and attended a baseline clinic visit in 1989-1990 (n = 5,201, original cohort) or 1992-1993 (n = 687. African-American [new] cohort) as participants of the Cardiovascular Health Study. Fasting serum glucose (FSG) was measured at baseline. Medication use was ascertained by drug inventory at all annual clinic visits. Diabetes was defined at baseline as insulin or oral hypoglycemic agent (OHA) use or as having an FSG > or = 7.0 mmol/l (126 mg/dl), the current consensus definition of diabetes.

RESULTS

A total of 387 (7%) original (FSG = 9.8 mmol/l [177 mg/dl]) and 115 (17%) new (FSG = 10.6 mmol/l [191 mg/dl]) cohort members had pharmacologically treated diabetes at baseline. Among those in the original and in the new cohorts who survived follow-up, respectively, OHA use decreased from 80 to 48% (P < 0.001) and from 67 to 50% (P < 0.003) and insulin use increased from 20 to 33% (P = 0.001) and from 33 to 37% (P = 0.603). There were 396 (8%) original (FSG = 8.8 mmol/l [159 mg/dl]) and 45 (7%) new (FSG = 10.0 mmol/l [181 mg/dl]) cohort members with diabetes untreated at baseline. Among them, respectively, OHA use reached 38 and 30% and insulin use reached 6 and 16% in 1996-1997.

CONCLUSIONS

Diabetes was common in this elderly cohort, and > 80% of treated patients with diabetes at baseline were not achieving fasting glucose goals of < or = 6.7 mmol/l (120 mg/dl). Many untreated at baseline remained untreated after 7 years of follow-up.

Coronary artery disease in diabetic and nondiabetic patients with lower extremity arterial disease: A report from the Coronary Artery Surgery Study Registry

OBJECTIVE

Patients with lower extremity arterial disease (LEAD) are at an increased risk of having coronary artery disease (CAD). Diabetics are at especially high risk for having LEAD with concomitant CAD. This study was undertaken (1) to define the clinical and arteriographic features associated with CAD among diabetics and nondiabetics with LEAD and (2) to determine the long-term survival and predictors of mortality of diabetics and nondiabetics with LEAD and CAD.

RESEARCH DESIGN AND METHODS

Two hundred sixty-three diabetics and 1137 nondiabetics from the Coronary Artery Surgery Study who had evidence of LEAD, who were 50 years and older, and who had arteriographically proven CAD were monitored for a mean of 12.8 years.

RESULTS

Among all the subjects with LEAD there was a high prevalence of current and past smoking, history of previous myocardial infarction, systemic hypertension, congestive heart failure, high degrees of angina pectoris and unstable angina pectoris, and use of beta-blockers. On arteriographic evaluation a high prevalence of three-vessel epicardial coronary disease and involvement of multiple coronary segments with > or =50% diameter narrowing was found. Multivariate analysis showed the number of coronary segments with >50% occlusion, the presence of cerebrovascular disease, the use of digitalis, and elevated systolic blood pressure were independently associated with diabetes. On follow-up diabetics had a significantly higher mortality rate (mostly cardiac) than nondiabetics: median survival, 8.1 years and 12.7 years, respectively. At 15 years the mortality rates were 77.1% and 62.0%, respectively. On multivariate analysis, age, number of coronary occlusions, number of significantly narrowed epicardial arteries, diminished myocardial contractility, hypertension, and smoking were significant predictors of mortality in the total group and in each subgroup. Coronary artery bypass grafting surgery was protective. The presence of diabetes was an independent risk factor for mortality.

CONCLUSIONS

The presence of LEAD is associated with multivessel epicardial and multiple coronary segment occlusion. On long-term follow-up there is a high mortality rate. In patients with LEAD and diabetes, CAD is especially severe and prognosis is poor.

Coronary artery disease in diabetic patients with lower-extremity arterial disease: disease characteristics and survival. A report from the Coronary Artery Surgery Study (CASS) registry

OBJECTIVE

Patients who have diabetes and lower-extremity arterial disease (LEAD) are at an increased risk of dying from coronary artery disease (CAD). This study was undertaken to: 1) define the clinical and arteriographic factors associated with LEAD among diabetic patients; 2) determine the long-term survival and predictors of mortality of diabetic patients with LEAD, compared to those without LEAD; and 3) determine if the presence of LEAD is an independent risk factor for mortality among diabetic patients with CAD.

RESEARCH DESIGN AND METHODS

A total of 263 diabetic patients from the Coronary Artery Surgery Study (CASS) registry with LEAD, who were > or = 50 years of age, and who had arteriographically proven CAD, were identified and followed for a mean of 12.8 years. A total of 1,349 comparably aged diabetic patients from the CASS registry with CAD and no evidence of LEAD were followed for an equivalent period of time.

RESULTS

Compared with diabetic patients without LEAD, diabetic patients with LEAD were characterized by the presence of cerebrovascular disease, a high rate of current smoking, elevated systolic blood pressure, high grades of angina pectoris, and digitalis use. Severity of epicardial CAD and extent of CAD were not independent predictors of the presence of LEAD. On follow-up, diabetic patients with LEAD had significantly higher mortality (mostly cardiovascular) than diabetic patients without LEAD, with a median survival of 8.1 and 10.9 years, respectively. On multivariate analysis, age, the number of significantly narrowed coronary arteries, and the presence of left ventricular dysfunction predicted mortality in both subsets of diabetic patients. Among all the diabetic patients with CAD, the presence of LEAD was an independent risk factor for mortality.

CONCLUSIONS

Diabetic patients with LEAD have a higher mortality rate (mostly cardiovascular) than diabetic patients without LEAD, despite no apparent anatomic differences in the severity and extent of CAD. This suggests that factors associated with the presence of LEAD, other than the anatomy of the coronary circulation, may play a role in determining survival among diabetic patients with LEAD and CAD.

Coronary artery disease and coronary artery bypass grafting in diabetic patients aged > or = 65 years (report from the Coronary Artery Surgery Study [CASS] Registry)

A cohort of 317 diabetic patients, aged > or = 65 years, with angiographically proven coronary artery disease, was analyzed and followed for a mean of 12.8 years. Compared with 1,843 age-matched nondiabetic patients, diabetic patients were more likely to (1) have a higher number of coronary occlusions, (2) not be current smokers, (3) have higher systolic but lower diastolic blood pressures, (4) have evidence of peripheral vascular disease, and (5) be women. They did not differ significantly with respect to total cholesterol, family history of coronary artery disease, history of hypertension, or left ventricular hypertrophy. In the total elderly cohort, diabetes was found to be an independent predictor of mortality, conferring a 57.0% increased risk of death. Survival analysis showed that diabetic subjects consistently had higher mortality than nondiabetics. However, the relative survival benefit of coronary artery bypass graft surgery versus medical therapy was comparable in diabetic and nondiabetic patients. Surgical therapy conferred a reduction in mortality of 44%.

Adrenocortical carcinoma

In reviewing the experience of a number of authors and investigators, it is clear that early diagnosis of adrenocortical carcinoma is essential for cure. Of all the modalities of therapy currently available, surgical resection holds the most promise for cure or prolonged survival. Treatment for extensive local disease or metastatic disease has been discouraging, and the prognosis for reasonable, comfortable survival is poor. Unfortunately, the toxicity of mitotane, an adrenolytic agent and currently the most effective drug available, is often unacceptable and may militate against its use. Because many of the debilitating side effects of these tumors are related to hormone production, newer drugs that result in hormonal blockade may add considerably to the comfort of the patient. The development of less toxic chemotherapeutic agents presents a challenge for both the oncologist and the endocrinologist.