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Xu JP, Zeng RX, Mai XY, Pan WJ, Zhang YZ, Zhang MZ. How does HbA1c predict mortality and readmission in patients with heart failure? A protocol for systematic review and meta-analysis. Syst Rev 2023; 12:35. [PMID: 36899409 PMCID: PMC10007851 DOI: 10.1186/s13643-023-02179-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 01/26/2023] [Indexed: 03/12/2023] Open
Abstract
BACKGROUND Accumulating evidence suggests that HbA1c levels, a common clinical indicator of chronic glucose metabolism over the preceding 2-3 months, are independent risk factors for cardiovascular disease, including heart failure. However, conflicting evidence obscures clear cutoffs of HbA1c levels in various heart failure populations. The aim of this review is to assess the possible predictive value and optimal range of HbA1c on mortality and readmission in patients with heart failure. METHODS A systematic and comprehensive search will be performed using PubMed, Embase, CINAHL, Scopus, and the Cochrane Library databases before December 2022 to identify relevant studies. All-cause mortality is the prespecified primary endpoint. Cardiovascular death and heart failure readmission are secondary endpoints of interest. We will only include prospective and retrospective cohort studies and place no restrictions on the language, race, region, or publication period. The ROBINS-I tool will be used to assess the quality of each included research. If there were sufficient studies, we will conduct a meta-analysis with pooled relative risks and corresponding 95% confidence intervals to evaluate the possible predictive value of HbA1c for mortality and readmission. Otherwise, we will undertake a narrative synthesis. Heterogeneity and publication bias will be assessed. If heterogeneity was significant among included studies, a sensitivity analysis or subgroup analysis will be used to explore the source of heterogeneity, such as diverse types of heart failure or patients with diabetes and non-diabetes. Additionally, we will conduct meta-regression to examine the time-effect and treatment-effect modifiers on all-cause mortality compared between different quantile of HbA1c levels. Finally, a restricted cubic spline model may be used to explore the dose-response relationship between HbA1c and adverse outcomes. DISCUSSION This planned analysis is anticipated to identify the predictive value of HbA1c for mortality and readmission in patients with heart failure. Improved understanding of different HbA1c levels and their specific effect on diverse types of heart failure or patients with diabetes and non-diabetes is expected to be figured out. Importantly, a dose-response relationship or optimal range of HbA1c will be determined to instruct clinicians and patients. SYSTEMATIC REVIEW REGISTRATION PROSPERO registration details: CRD42021276067.
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Affiliation(s)
- Jun-Peng Xu
- The Second Clinical College of Guangzhou University of Chinese Medicine, Guangzhou, 510405, China.,The Guangzhou University of Chinese Medicine, Guangzhou, 510405, China.,Department of Critical Care Medicine, Guangdong Provincial Hospital of Chinese Medicine, 111 Dade Road, Yuexiu District, Guangzhou, 510120, Guangdong Province, China
| | - Rui-Xiang Zeng
- The Second Clinical College of Guangzhou University of Chinese Medicine, Guangzhou, 510405, China.,Department of Critical Care Medicine, Guangdong Provincial Hospital of Chinese Medicine, 111 Dade Road, Yuexiu District, Guangzhou, 510120, Guangdong Province, China
| | - Xiao-Yi Mai
- The Second Clinical College of Guangzhou University of Chinese Medicine, Guangzhou, 510405, China.,Department of Critical Care Medicine, Guangdong Provincial Hospital of Chinese Medicine, 111 Dade Road, Yuexiu District, Guangzhou, 510120, Guangdong Province, China
| | - Wen-Jun Pan
- The Guangzhou University of Chinese Medicine, Guangzhou, 510405, China
| | - Yu-Zhuo Zhang
- The Second Clinical College of Guangzhou University of Chinese Medicine, Guangzhou, 510405, China.,The Guangzhou University of Chinese Medicine, Guangzhou, 510405, China.,Department of Critical Care Medicine, Guangdong Provincial Hospital of Chinese Medicine, 111 Dade Road, Yuexiu District, Guangzhou, 510120, Guangdong Province, China
| | - Min-Zhou Zhang
- The Second Clinical College of Guangzhou University of Chinese Medicine, Guangzhou, 510405, China. .,Department of Critical Care Medicine, Guangdong Provincial Hospital of Chinese Medicine, 111 Dade Road, Yuexiu District, Guangzhou, 510120, Guangdong Province, China.
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2
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Cunha FM, Carreira M, Ferreira I, Bettencourt P, Lourenço P. Low stress hyperglycemia ratio predicts worse prognosis in diabetic acute heart failure patients. Rev Port Cardiol 2023; 42:433-441. [PMID: 36634761 DOI: 10.1016/j.repc.2022.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 02/09/2022] [Accepted: 02/23/2022] [Indexed: 01/11/2023] Open
Abstract
INTRODUCTION Acute blood glucose but not glycated hemoglobin (HbA1c) predicts poor outcome in acute heart failure (HF). The stress hyperglycemia ratio (SHR) has been proposed as a prognostic predictor in various clinical settings. OBJECTIVES We assessed the prognostic implications of the SHR in acute HF patients with and without diabetes. METHODS We performed a retrospective analysis of an acute HF registry conducted between 2009 and 2010. Estimated average glucose (eAG) was calculated as (28.7×HbA1c)-46.7 and SHR as acute blood glucose divided by eAG. The primary endpoint was all-cause mortality. Follow-up was three months. Patients were grouped by SHR tertiles (≤0.88, 0.89-1.16, and >1.16). Cox regression analysis was used to test the association of SHR (cut-off 0.88) with all-cause mortality. Analysis was stratified according to the presence of diabetes. Multivariate models were built accounting for acute blood glucose and for eAG (models 1 and 2, respectively). RESULTS We studied 599 patients, mean age 76±12 years, of whom 62.1% had reduced ejection fraction and 50.9% had diabetes. Median acute blood glucose, eAG and SHR were 136 (107-182) mg/dl, 131 (117-151) mg/dl, and 1.02 (0.20-3.34), respectively. During follow-up 102 (17.0%) died. In patients with diabetes, those in the lowest SHR tertile had a hazard ratio (HR) of 2.24 (95% CI: 1.05-5.22) (model 1) and 2.34 (1.25-4.38) (model 2). In patients without diabetes, the HR of three-month death in the lowest SHR tertile was 0.71 (95% CI: 0.36-1.39) and 1.02 (0.58-1.81). Significant interaction was observed between diabetes and SHR. CONCLUSIONS In HF patients with diabetes, a SHR ≤0.88 was associated with a more than twofold higher three-month mortality risk. No such association was found in non-diabetic patients. The presence of diabetes influences the association of the SHR with mortality.
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Affiliation(s)
- Filipe M Cunha
- Endocrinology Department, Centro Hospitalar do Tâmega e Sousa, Penafiel, Portugal.
| | - Marta Carreira
- Internal Medicine Department, Centro Hospitalar de São João, Porto, Portugal
| | - Inês Ferreira
- Internal Medicine Department, Centro Hospitalar de São João, Porto, Portugal
| | - Paulo Bettencourt
- Internal Medicine Department, Hospital CUF Porto, Porto, Portugal; Porto Cardiovascular I&D Unit (UnIC), Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | - Patrícia Lourenço
- Internal Medicine Department, Centro Hospitalar de São João, Porto, Portugal; Porto Cardiovascular I&D Unit (UnIC), Faculdade de Medicina da Universidade do Porto, Porto, Portugal; Heart Failure Clinic of the Internal Medicine Department, Centro Hospitalar de São João, Porto, Portugal
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3
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Afghahi H, Nasic S, Rydell H, Svensson J, Peters B. The association between long-term glycemic control and all-cause mortality is different among older versus younger patients with diabetes mellitus and maintenance hemodialysis treatment. Diabetes Res Clin Pract 2022; 191:110033. [PMID: 35940301 DOI: 10.1016/j.diabres.2022.110033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Revised: 08/01/2022] [Accepted: 08/03/2022] [Indexed: 11/17/2022]
Abstract
AIMS Knowledge about association between glycated hemoglobin (HbA1c) and risk of all-cause mortality in patients with diabetes mellitus on maintenance hemodialysis (HD)-treatment is sparse. The study aims to investigate association between HbA1c and all-cause mortality in patients with diabetes and maintenance HD-treatment, separately for two age groups- above and below 75 years. METHODS 2487 patients (mean age 66 years, 66 % men) were separated in two age groups: ≤75 years (n = 1810) and > 75 years (n = 677) and followed up between 2008 and 2018. Hazard ratios (HR) and 95 % confidence intervals (CI) for associations between HbA1c and all-cause mortality were calculated using Cox-regression-models. RESULTS 1295 (52 %) patients died and 473 (70 %) among the patients above 75 years old. In the multivariate analysis, HbA1c5-6 % was used as reference. In patients ≤ 75 years old, only increased HbA1c > 9.7 %, HR2.03(CI1.43-2.89) was associated with increased risk of all-cause mortality. In patients > 75 years, HbA1c ≤ 5 %, HR1.67(CI1.16-2.40); HbA1c6.9-7.8 %, HR1.41(CI1.03-1.93) and HbA1c8.7-9.7 %, HR1.79 (CI1.08-2.96) were associated with increased risk of all-cause mortality. CONCLUSIONS We found a J-shaped association between HbA1c and mortality only in diabetic HD-patients > 75 years. This probably indicates that in an old population of diabetic HD-patients, both intensive glucose control and hyperglycemia could be harmful and associated with higher risk of death.
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Affiliation(s)
- Hanri Afghahi
- Department of Nephrology, Skaraborg Hospital, Skövde, Sweden; Department of Molecular and Clinical Medicine, Institute of Medicine, the Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Salmir Nasic
- Research and Development Centre at Skaraborg Hospital, Skövde, Sweden; Department of Molecular and Clinical Medicine, Institute of Medicine, the Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Helena Rydell
- Karolinska University Hospital, Stockholm Division of Renal Medicine, CLINTEC, Karolinska Institutet, Sweden
| | - Johan Svensson
- Research and Development Centre at Skaraborg Hospital, Skövde, Sweden; Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, the Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Björn Peters
- Department of Nephrology, Skaraborg Hospital, Skövde, Sweden; Department of Molecular and Clinical Medicine, Institute of Medicine, the Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden.
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4
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Kim DK, Ko GJ, Choi YJ, Jeong KH, Moon JY, Lee SH, Hwang HS. Glycated hemoglobin levels and risk of all-cause and cause-specific mortality in hemodialysis patients with diabetes. Diabetes Res Clin Pract 2022; 190:110016. [PMID: 35870571 DOI: 10.1016/j.diabres.2022.110016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 07/04/2022] [Accepted: 07/18/2022] [Indexed: 11/03/2022]
Abstract
AIM Adequate glycemic control is fundamental for improving clinical outcomes in hemodialysis patients with diabetes. However, the target for glycated hemoglobin (HbA1c) level and whether cause-specific mortality differs based on HbA1c levels remain unclear. METHODS A total of 24,243 HD patients with diabetes were enrolled from a multicenter, nationwide registry. We examined the association between HbA1c levels and the risk of all-cause and cause-specific mortality. RESULTS Compared to patients with HbA1c 6.5%-7.5%, patients with HbA1c 8.5-9.5% and ≥9.5% were associated with a 1.26-fold (95% CI, 1.12-1.42) and 1.56-fold (95% CI, 1.37-1.77) risk for all-cause mortality. The risk of all-cause mortality did not increase in patients with HbA1c < 5.5%. In cause-specific mortality, the risk of cardiovascular deaths significantly increased from small increase of HbA1c levels. However, the risk of other causes of death increased only in patients with HbA1c > 9.5%. The slope of HR increase with increasing HbA1c levels was significantly faster for cardiovascular causes than for other causes. CONCLUSIONS There was a linear relationship between HbA1c levels and risk of all-cause mortality in hemodialysis patients, and the risk of cardiovascular death increased earlier and more rapidly, with increasing HbA1c levels, compared with other causes of death.
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Affiliation(s)
- Dae Kyu Kim
- Division of Nephrology, Department of Internal Medicine, Kyung Hee University, Seoul, Republic of Korea
| | - Gang Jee Ko
- Division of Nephrology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Yun Jin Choi
- Biomedical Research Institute, Korea University College of Medicine, Seoul, Republic of Korea
| | - Kyung Hwan Jeong
- Division of Nephrology, Department of Internal Medicine, Kyung Hee University, Seoul, Republic of Korea
| | - Ju Young Moon
- Division of Nephrology, Department of Internal Medicine, Kyung Hee University, Seoul, Republic of Korea
| | - Sang Ho Lee
- Division of Nephrology, Department of Internal Medicine, Kyung Hee University, Seoul, Republic of Korea
| | - Hyeon Seok Hwang
- Division of Nephrology, Department of Internal Medicine, Kyung Hee University, Seoul, Republic of Korea.
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5
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Currie CJ. Scientific independence and objectivity: many questions linger about treatment of type 2 diabetes, such as scientific study design, optimal glucose control and the safety of injecting exogenous insulin. Postgrad Med 2020; 132:667-675. [PMID: 32559126 DOI: 10.1080/00325481.2020.1784562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Whilst clinical guidelines exist for the treatment of people with type 2 diabetes, many underlying assumptions are still not qualified by convincing evidence. In this commentary, it is argued that fundamental issues still cloud clinical practice, such as biases in the design of clinical studies, the association between glucose control & clinical outcomes, and the safety of exposure to exogenous insulin and other glucose-lowering drugs. Relevant scientific evidence and alternative opinions about important issues continue to be largely ignored, and no effort has been made to resolve these questions. This may have had serious consequences, such as stifling innovation because there are no further benefits to be achieved in relation to glucose control.
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Affiliation(s)
- Craig J Currie
- Division of Population Medicine, School of Medicine, Cardiff University , Cardiff, UK.,Global Epidemiology, Pharmatelligence , Cardiff, UK
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Seferović PM, Jhund PS. Physiological monitoring of the complex multimorbid heart failure patient - diabetes and monitoring glucose control. Eur Heart J Suppl 2020; 21:M20-M24. [PMID: 31908611 PMCID: PMC6937507 DOI: 10.1093/eurheartj/suz219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Heart failure (HF) is a global epidemic, particularly affecting the elderly and/or frail patients often with comorbidities. Amongst the comorbidities, type 2 diabetes mellitus (T2DM) is highly prevalent and associated with higher morbidity and mortality. We review the detection and treatment of T2DM in HF and the need to balance the risk of hypoglycaemia and overall glycaemic control. Despite large attributable risks, T2DM is often underdiagnosed in HF. Therefore there is a need for systematic monitoring (screening) for undetected T2DM in HF patients. Given that patients with HF are at greater risk for developing T2DM compared with the general population, an emphasis also has to be placed on regular reassessment of glycaemic status during follow-up. Therefore, glucose-lowering therapies (e.g. sodium-glucose cotransporter-2 inhibitors, SGLT-2 inhibitors) with a known benefit for the prevention or delay of HF hospitalization could be considered early in the course of T2DM, to optimise treatment and reduce cardiovascular (CV) risk. Although intensive glycaemic control has been shown to effectively reduce the risk of microvascular complications in T2DM, these same trials have shown either no reduction in CV outcomes, or even an increase in mortality with tight glycaemic control (i.e. targeting HbA1c levels <7.0%). More lenient glycaemic targets (e.g. HbA1c levels 7.0-8.0%) may be more appropriate for HF patients with T2DM. The 2016 ESC Guidelines for the diagnosis and treatment of HF proposed metformin as the first-line therapy, given its long-standing use and low risk of hypoglycaemia. More recently, several novel glucose lowering-medications have been introduced, including dipeptidyl peptidase-4 (DPP-4) inhibitors, glucagon-like peptide-1 receptor agonists (GLP-1 RA), and SGLT-2 inhibitors. The most consistent reduction in the risk of HF hospitalisation has been shown with the three SGLT-2 inhibitors (empagliflozin, canagliflozin and dapagliflozin) which now offer improved outcomes in patients with both HF and T2DM.
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Affiliation(s)
- Petar M Seferović
- University of Belgrade Faculty of Medicine, 8 Koste Todorovića, 11000 Belgrade, Serbia.,Serbian Academy of Sciences and Arts, Belgrade, Serbia
| | - Pardeep S Jhund
- British Heart Foundation Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, 126 University Place, Glasgow G12 8TA, UK
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7
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Forbes A. Reducing the Burden of Mortality in Older People With Diabetes: A Review of Current Research. Front Endocrinol (Lausanne) 2020; 11:133. [PMID: 32256448 PMCID: PMC7089919 DOI: 10.3389/fendo.2020.00133] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Accepted: 02/27/2020] [Indexed: 01/09/2023] Open
Abstract
This review considers the burden of mortality observed in the older population of people with diabetes and identifies the risk factors associated with mortality hazard in this population. The mortality gap between older people with and without diabetes is enduring, with excess mortality being 10% greater than in the general population. While early mortality in men with diabetes is significantly greater than females with diabetes, the relative mortality risk in females is much higher compared to women without diabetes. Older people who have developed diabetes in middle age have significantly higher mortality hazard compared to those who develop it in old age, emphasizing the continued importance of optimizing diabetes care in all ages. To minimize mortality hazard in older age it is important to address some of the factors that convey risk, these include: comorbidity; polypharmacy; physical and mental frailty; safe glycemic targets for older people; hypoglycemia; glycemic targets; and the hypoglycemic agents. While the data to determine optimal management approaches are limited, the overall need is for a more diligent approach in assessing the needs of older people with diabetes to inform individualized care strategies and therapy goals that minimize potential hazards.
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Šimić S, Svaguša T, Prkačin I, Bulum T. Relationship between hemoglobin A1c and serum troponin in patients with diabetes and cardiovascular events. J Diabetes Metab Disord 2020; 18:693-704. [PMID: 31890693 DOI: 10.1007/s40200-019-00460-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 10/24/2019] [Indexed: 12/11/2022]
Abstract
Objectives Diabetes mellitus is a group of metabolic disorders associated with high risk for cardiovascular disease. Although troponins are primarily clinically used for the diagnosis of acute coronary syndrome, they are also used in risk assessment in patients with acute coronary syndrome as well as in a number of other conditions. The aim of this review was to investigate the relationship between hemoglobin A1c and serum troponin in patients with diabetes and cardiovascular events. Methods Hemoglobin A1c has been chosen as the best clinical indicator of glucose control and risk of micro and macrovascular complications. We investigated cardiac troponins as a group of markers of muscle injury which includes troponin T, troponin I and troponin C. Troponin T and I are specific for myocardial injury, compared to C which is specific for skeletal muscle. Results In this review, we showed that there was a causal relation between hemoglobin A1c levels and serum troponin concentrations. Hemoglobin A1c has shown to be a positive predictive factor of incidence, mortality and morbidity of conditions such as acute coronary syndrome, arrhythmias, stroke, pulmonary embolism and other conditions that causes troponin elevation by its release in circulation. Conclusions Chronic hyperglycemia decreases glomerular filtration and consequently decreases troponin elimination and also by affecting the heart microcirculation it leads to microvascular damage and consequently to ischemia which contribute to troponin concentration elevation. Furthermore, correlation between hemoglobin A1c and troponin concentration manifests in their prognostic value for mortality.
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Affiliation(s)
- Stjepan Šimić
- 1School of Medicine, University of Zagreb, Šalata 3, 10000 Zagreb, Croatia
| | - Tomo Svaguša
- 1School of Medicine, University of Zagreb, Šalata 3, 10000 Zagreb, Croatia
- 2Department of Internal Medicine, Dubrava University Hospital, Zagreb, Croatia
| | - Ingrid Prkačin
- 1School of Medicine, University of Zagreb, Šalata 3, 10000 Zagreb, Croatia
- 3Department of Internal Medicine, Merkur University Hospital, Zagreb, Croatia
| | - Tomislav Bulum
- 1School of Medicine, University of Zagreb, Šalata 3, 10000 Zagreb, Croatia
- 4Vuk Vrhovac Clinic for Diabetes, Endocrinology and Metabolic Diseases, Merkur University Hospital, Zagreb, Croatia
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9
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Turgeon RD, Koshman SL, Youngson E, Pearson GJ. Association Between Hemoglobin A1c and Major Adverse Coronary Events in Patients with Diabetes Following Coronary Artery Bypass Surgery. Pharmacotherapy 2019; 40:116-124. [PMID: 31883378 DOI: 10.1002/phar.2359] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
INTRODUCTION Diabetes is associated with a higher risk of major adverse coronary events (MACE) following coronary artery bypass grafting (CABG). Guidelines recommend disparate targets for glycemic control of patients with diabetes who have undergone CABG, ranging from a target hemoglobin A1c (HbA1c) of < 7.0% to 7.1-8.5%, based on data from non-CABG patients. To date, no study has evaluated the long-term impact of HbA1c concentrations on MACE post-CABG. OBJECTIVE To evaluate the association between HbA1c and MACE in CABG patients with diabetes. METHODS A secondary analysis of the Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI2D) trial, which enrolled patients with type 2 diabetes and coronary artery disease, restricted to participants who underwent CABG with ≥ 1 HbA1c measurement post-CABG, was performed. The index date was date of first post-CABG HbA1c measurement. The primary outcome was MACE (composite of death, myocardial infarction, unstable angina, or repeat revascularization). Secondary outcomes included MACE components and heart failure. Cox proportional hazards models treating HbA1c as a time-dependent exposure (reference group: HbA1c 6.1-7.0%) were used to derive hazard ratios (HRs) with 95% confidence intervals adjusting for age, sex and baseline characteristics selected by stepwise regression. RESULTS A total of 549 patients were followed over a median 3.5 years. The median age of the cohort was 64 years, 25.1% were female, and median baseline HbA1c was 6.7%. Compared to achieving an HbA1c 6.1-7.0%, HbA1c > 8.0% was associated with an increased risk of MACE (HR 1.77, 1.01-3.10). This association was strongest for unstable angina (HR 5.21, 1.03-26.39). Achieving an HbA1c ≤ 6.0% was associated with an increased risk of death (HR 2.41, 1.01-5.74). Other comparisons were not statistically significant. CONCLUSION Among patients with type 2 diabetes who underwent CABG, achieving HbA1c 6.1-7.0% was associated with a lower risk of MACE and unstable angina versus achieving an HbA1c > 8.0% and lower risk of death versus achieving an HbA1c ≤ 6.0%.
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Affiliation(s)
- Ricky D Turgeon
- Department of Pharmacy, Vancouver General Hospital, Vancouver, British Columbia, Canada.,Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - Sheri L Koshman
- Department of Medicine (Division of Cardiology), University of Alberta, Edmonton, Alberta, Canada
| | - Erik Youngson
- Alberta SPOR Support Unit, University of Alberta, Edmonton, Alberta, Canada
| | - Glen J Pearson
- Department of Medicine (Division of Cardiology), University of Alberta, Edmonton, Alberta, Canada
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Seferović PM, Coats AJS, Ponikowski P, Filippatos G, Huelsmann M, Jhund PS, Polovina MM, Komajda M, Seferović J, Sari I, Cosentino F, Ambrosio G, Metra M, Piepoli M, Chioncel O, Lund LH, Thum T, De Boer RA, Mullens W, Lopatin Y, Volterrani M, Hill L, Bauersachs J, Lyon A, Petrie MC, Anker S, Rosano GMC. European Society of Cardiology/Heart Failure Association position paper on the role and safety of new glucose-lowering drugs in patients with heart failure. Eur J Heart Fail 2019; 22:196-213. [PMID: 31816162 DOI: 10.1002/ejhf.1673] [Citation(s) in RCA: 117] [Impact Index Per Article: 23.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 10/09/2019] [Accepted: 10/16/2019] [Indexed: 12/26/2022] Open
Abstract
Type 2 diabetes mellitus (T2DM) is common in patients with heart failure (HF) and associated with considerable morbidity and mortality. Significant advances have recently occurred in the treatment of T2DM, with evidence of several new glucose-lowering medications showing either neutral or beneficial cardiovascular effects. However, some of these agents have safety characteristics with strong practical implications in HF [i.e. dipeptidyl peptidase-4 (DPP-4) inhibitors, glucagon-like peptide-1 receptor agonists (GLP-1 RA), and sodium-glucose co-transporter type 2 (SGLT-2) inhibitors]. Regarding safety of DPP-4 inhibitors, saxagliptin is not recommended in HF because of a greater risk of HF hospitalisation. There is no compelling evidence of excess HF risk with the other DPP-4 inhibitors. GLP-1 RAs have an overall neutral effect on HF outcomes. However, a signal of harm suggested in two small trials of liraglutide in patients with reduced ejection fraction indicates that their role remains to be defined in established HF. SGLT-2 inhibitors (empagliflozin, canagliflozin and dapagliflozin) have shown a consistent reduction in the risk of HF hospitalisation regardless of baseline cardiovascular risk or history of HF. Accordingly, SGLT-2 inhibitors could be recommended to prevent HF hospitalisation in patients with T2DM and established cardiovascular disease or with multiple risk factors. The recently completed trial with dapagliflozin has shown a significant reduction in cardiovascular mortality and HF events in patients with HF and reduced ejection fraction, with or without T2DM. Several ongoing trials will assess whether the results observed with dapagliflozin could be extended to other SGLT-2 inhibitors in the treatment of HF, with either preserved or reduced ejection fraction, regardless of the presence of T2DM. This position paper aims to summarise relevant clinical trial evidence concerning the role and safety of new glucose-lowering therapies in patients with HF.
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Affiliation(s)
- Petar M Seferović
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia.,Serbian Academy of Sciences and Arts, Belgrade, Serbia
| | - Andrew J S Coats
- Pharmacology, Centre of Clinical and Experimental Medicine, IRCCS San Raffaele Pisana, Rome, Italy
| | - Piotr Ponikowski
- Centre for Heart Diseases, Wrocław Medical University, Wrocław, Poland
| | - Gerasimos Filippatos
- University of Cyprus Medical School, Nicosia, Cyprus.,Athens University Hospital Attikon, National and Kapodistrian University of Athens, Athens, Greece
| | - Martin Huelsmann
- Division of Cardiology, Department of Medicine II, Medical University of Vienna, Vienna, Austria
| | - Pardeep S Jhund
- British Heart Foundation, Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Marija M Polovina
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia.,Department of Cardiology, Clinical Centre of Serbia, Belgrade, Serbia
| | - Michel Komajda
- Institute of Cardiometabolism and Nutrition (ICAN), Pierre et Marie Curie University, Paris VI, La Pitié-Salpétrière Hospital, Paris, France
| | - Jelena Seferović
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia.,Clinic for Endocrinology, Diabetes and Metabolic Disorders, Clinical Centre, Belgrade, Serbia
| | - Ibrahim Sari
- Department of Cardiology, Faculty of Medicine, Marmara University, Istanbul, Turkey
| | - Francesco Cosentino
- Cardiology Unit, Department of Medicine, Karolinska Institute and Karolinska University Hospital, Stockholm, Sweden
| | | | - Marco Metra
- Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Massimo Piepoli
- Heart Failure Unit, Cardiology, G. da Saliceto Hospital, Piacenza, Italy
| | - Ovidiu Chioncel
- University of Medicine Carol Davila, Bucharest, Romania.,Emergency Institute for Cardiovascular Diseases, Bucharest, Romania
| | - Lars H Lund
- Department of Medicine, Karolinska Institutet, and Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Thomas Thum
- Hannover Medical School, Institute of Molecular and Translational Therapeutic Strategies, Hannover, Germany
| | - Rudolf A De Boer
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Wilfried Mullens
- Faculty of Medicine and Life Sciences, BIOMED - Biomedical Research Institute, Hasselt University, Diepenbeek, Belgium.,Department of Cardiology, Ziekenhuis Oost, Genk, Belgium
| | - Yuri Lopatin
- Regional Cardiology Centre Volgograd, Volgograd State Medical University, Volgograd, Russia
| | | | - Loreena Hill
- School of Nursing and Midwifery, Queen's University Belfast, Belfast, UK
| | - Johann Bauersachs
- Department of Cardiology and Angiology, Medical School Hannover, Hannover, Germany
| | - Alexander Lyon
- National Heart and Lung Institute, Imperial College London and Royal Brompton Hospital, London, UK
| | - Mark C Petrie
- Institute of Cardiovascular and Medical Sciences, British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Stefan Anker
- Department of Cardiology (CVK), Berlin Institute of Health Center for Regenerative Therapies (BCRT), German Centre for Cardiovascular Research (DZHK) partner site Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany
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11
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Dunning T, Martin P. Palliative and end of life care of people with diabetes: Issues, challenges and strategies. Diabetes Res Clin Pract 2018; 143:454-463. [PMID: 29097287 DOI: 10.1016/j.diabres.2017.09.018] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Revised: 09/18/2017] [Accepted: 09/21/2017] [Indexed: 01/21/2023]
Abstract
Palliative and end of life care are essential, but largely overlooked, aspects of comprehensive, personalised diabetes care. Life expectancy is lower in people with diabetes than in the general population due to complications and comorbidities, especially those associated with obesity such as cardiovascular disease, frailty and cancer. This paper makes the case for early initiation of palliative care and proactive planning for end of life. Early use of palliative care improves symptom management, comfort and quality of life, and often improves function. Significantly, it reduces disease burden and unnecessary treatment. Prognostication is challenging, but tools such as the Gold Standard Framework and diabetes-related indicators of reduced life expectancy can help identify those at high risk one year mortality. Skilled conversations, underpinned by an evidence-based framework, are a critical component in helping people with diabetes, and their families, discuss these complex issues and make appropriate advance care plans based on their values and preferences.
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Affiliation(s)
- Trisha Dunning
- Chair in Nursing, Centre for Quality and Patient Safety Research, Barwon Health Partnership, School of Nursing and Midwifery, Deakin University, Geelong, Australia.
| | - Peter Martin
- School of Medicine, Deakin University and Clinical Director Palliative Care Services Barwon Health, Geelong, Australia
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12
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Packer M. Higher mortality rate in patients with heart failure who are taking commonly prescribed antidiabetic medications and achieve recommended levels of glycaemic control. Diabetes Obes Metab 2018; 20:1766-1769. [PMID: 29469167 DOI: 10.1111/dom.13265] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2018] [Revised: 02/14/2018] [Accepted: 02/17/2018] [Indexed: 02/03/2023]
Abstract
Current guidelines for diabetes recommend that physicians attain a glycated haemoglobin (HbA1c) concentration ≤7.0%, but this target may not be applicable to those with heart failure. Fourteen studies in patients with chronic heart failure that examined the relationship between the level of HbA1c and risk of death specified whether HbA1c was influenced by treatment with antidiabetic medications. In patients with heart failure not receiving glucose-lowering drugs, the mortality rate was not higher among those with an HbA1c concentration <7.0%. By contrast, in patients who were treated with insulin, sulphonylureas and thiazolidinediones, an inverse or U-shaped relationship between HbA1c and the risk of death was generally observed, and mortality was lowest in patients with both heart failure and diabetes if the level of HbA1c was >7.0%. These studies suggest that patients with both heart failure and diabetes are at increased risk of death if they are prescribed certain glucose-lowering drugs to achieve levels of HbA1c <7.0%.
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Affiliation(s)
- Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, Texas
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13
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Forbes A, Murrells T, Mulnier H, Sinclair AJ. Mean HbA 1c, HbA 1c variability, and mortality in people with diabetes aged 70 years and older: a retrospective cohort study. Lancet Diabetes Endocrinol 2018; 6:476-486. [PMID: 29674135 DOI: 10.1016/s2213-8587(18)30048-2] [Citation(s) in RCA: 112] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Revised: 01/11/2018] [Accepted: 01/11/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND Glycaemic targets for older people have been revised in recent years because of concern that more stringent targets are associated with increased mortality. We aimed to investigate the association between glycaemic control (mean HbA1c) and variability (variability of HbA1c over time) and mortality in older people with diabetes. METHODS We did a 5-year retrospective cohort study using The Health Improvement Network database, which includes data from 587 UK primary care practices. We included patients of either sex who were aged 70 years and older with type 1 or type 2 diabetes. The primary outcome was time to all-cause mortality. Our primary exposure variables were mean HbA1c and variability of HbA1c over time. The observation included a 4-year run-in period (from 2003) as a baseline, with a 5-year follow-up (from 2007 to 2012). We assessed mean HbA1c in three models: a baseline mean HbA1c for 2003-06 (model 1), the mean across the whole follow-up period (model 2), and a time-varying yearly updated mean (model 3). A variability score (from 0 [low] to 100 [high]) was calculated on the basis of number of changes in HbA1c of 0·5% (5·5 mmol/mol) or more from 2003 to 2012 or to the point of mortality, based on changes in the annual mean as per each model with a minimum of six readings. FINDINGS The cohort consisted of 54 803 people, of whom 17 680 (8614 [30·7%] of 28 017 women and 9066 [33·8%] of 26 786 men) died during the observation period. The overall mortality rate was 77 per 1000 person-years (73 per 1000 person-years for women and 80 per 1000 person-years for men). The data showed a J-shaped distribution for mortality risk in both sexes, with significant increases with HbA1c values greater than 8% (64 mmol/mol) and less than 6% (42 mmol/mol), although excess mortality risk was non-significant in model 1 for men at HbA1c values of 8% (64 mmol/mol) to less than 8·5% (<69 mmol/mol) and in models 1 and 3 for both sexes assessed individually at HbA1c values less than 6% (42 mmol/mol). Mortality increased substantially with increasing HbA1c variability in all models (overall and for both sexes). For the model 2 HbA1c measure, the adjusted hazard ratios comparing patients with a glycaemic variability score of more than 80 to 100 with those with a score of 0 to 20 were 2·47 (95% CI 2·08-2·93) for women and 2·21 (1·87-2·61) for men. Fitting the mean HbA1c models with the glycaemic variability score altered the risk distribution; this observation was most marked in the model 2 analysis, in which a significant increased risk was only apparent with HbA1c values greater than 9·5% (80 mmol/mol) in women and 9% (75 mmol/mol) in men. INTERPRETATION Both low and high levels of glycaemic control were associated with an increased mortality risk, and the level of variability also seems to be an important factor, suggesting that a stable glycaemic level in the middle range is associated with lower risk. Glycaemic variability, as assessed by variability over time in HbA1c, might be an important factor in understanding mortality risk in older people with diabetes. FUNDING King's College London and Diabetes Frail.
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Affiliation(s)
- Angus Forbes
- Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK.
| | - Trevor Murrells
- Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK
| | - Henrietta Mulnier
- Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK
| | - Alan J Sinclair
- Foundation for Diabetes Research in Older People, Diabetes Frail, Luton, UK; Department of Pharmacy, University of Aston, Birmingham, UK
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14
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Currie CJ, Holden SE, Jenkins‐Jones S, Morgan CL, Voss B, Rajpathak SN, Alemayehu B, Peters JR, Engel SS. Impact of differing glucose-lowering regimens on the pattern of association between glucose control and survival. Diabetes Obes Metab 2018; 20:821-830. [PMID: 29119713 PMCID: PMC5888185 DOI: 10.1111/dom.13155] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Revised: 10/16/2017] [Accepted: 11/04/2017] [Indexed: 12/17/2022]
Abstract
AIMS To characterize survival in relation to achieved glycated haemoglobin (HbA1c) level within alternative glucose-lowering regimens with differing risks of hypoglycaemia. METHODS Data were extracted from the UK Clinical Practice Research Datalink and the corresponding Hospital Episode Statistics. Patients with type 2 diabetes prescribed glucose-lowering therapy in monotherapy or dual therapy with metformin between 2004 and 2013 were identified. Risk of all-cause mortality within treatment cohorts was evaluated using the Cox proportional hazards model, introducing mean HbA1c as a quarterly updated, time-dependent covariable. RESULTS There were 6646 deaths in a total follow-up period of 374 591 years. Survival for lower (<7%) vs moderate HbA1c levels (≥7%, <8.5%) differed by cohort: metformin, adjusted hazard ratio (aHR) 1.03 (95% confidence interval [CI] 0.95-1.12); sulphonylurea, aHR 1.11 (95% CI 0.99-1.25); insulin, aHR 1.47 (95% CI 1.25-1.72); combined regimens with low hypoglycaemia risk, aHR 1.02 (95% CI 0.94-1.10); and combined regimens with higher hypoglycaemia risk excluding insulin, aHR 1.24 (95% CI 1.13-1.35) and including insulin, aHR 1.28 (95% CI 1.18-1.37). Higher HbA1c levels were associated with increased mortality in regimens with low hypoglycaemia risk. Post hoc analysis by HbA1c deciles revealed an elevated risk of all-cause mortality for the lowest deciles across all cohorts, but particularly in those regimens associated with hypoglycaemia. High HbA1c was associated with no difference, or a small increase in mortality risk in regimens with increased risk of hypoglycaemia. CONCLUSIONS The pattern of mortality risk across the range of HbA1c differed by glucose-lowering regimen. Lower HbA1c was associated with increased mortality risk compared with moderate control, especially in those regimens associated with hypoglycaemia. High levels of HbA1c were associated with the expected elevated mortality risk in regimens with low hypoglycaemia risk.
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Affiliation(s)
- Craig J. Currie
- Institute of Population Medicine, School of MedicineCardiff UniversityCardiffUK
- Global Epidemiology, PharmatelligenceCardiffUK
| | | | | | | | | | | | | | - John R. Peters
- Diabetes and EndocrinologyUniversity Hospital of WalesCardiffUK
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15
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Forbes A, Murrells T, Sinclair AJ. Examining factors associated with excess mortality in older people (age ≥ 70 years) with diabetes - a 10-year cohort study of older people with and without diabetes. Diabet Med 2017; 34:387-395. [PMID: 27087619 DOI: 10.1111/dme.13132] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/11/2016] [Indexed: 12/28/2022]
Abstract
AIMS To compare all-cause mortality in older people with or without diabetes and consider the associated risk of comorbidity and polypharmacy. METHODS A 10-year cohort study using data from the Health Innovation Network database (2003-2013) comparing mortality in people aged ≥ 70 years with diabetes (DM cohort) (n = 35 717) and without diabetes (No DM cohort) (n = 307 918). RESULTS The mean age of the DM cohort was 78.1 ± 5.8 years vs. 79.0 ± 6.3 years in the No DM cohort. Mean diabetes duration was 8.2 ± 8.1 years, and 30% had diabetes for > 10 years. The DM cohort had a greater comorbidity load and people in this cohort were prescribed more therapies than the No DM cohort. The 5- and 10-year survival rates were lower in the DM cohort at 64% and 39%, respectively, compared with 72% and 50% in the No DM cohort. The excess mortality in the DM cohort was greatest in those aged < 75 years with longer duration diabetes, the relative hazard for mortality was higher in females. Although comorbidity and polypharmacy were associated with increased mortality risk in the DM cohort, this risk was lower compared with the No DM cohort. The hazard ratios (95% confidence interval) for comorbidities > 4 and medicines ≥ 7 were 1.29 (1.19 to 1.41) and 1.34 (1.25 to 1.43) in the DM cohort and 1.63 (1.57 to 1.70) and 1.48 (1.40 to 1.56) in the No DM cohort, respectively. CONCLUSIONS There is significant excess mortality in older people with diabetes, which is unexplained by comorbidity or polypharmacy. This excess is greatest in the younger old with longer disease duration, suggesting that it may be related to the effect of diabetes exposure.
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Affiliation(s)
- A Forbes
- Florence Nightingale Faculty of Nursing and Midwifery, King's College London, London
| | - T Murrells
- Florence Nightingale Faculty of Nursing and Midwifery, King's College London, London
| | - A J Sinclair
- Diabetes Frail and the University of Aston, Birmingham, UK
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16
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Grembowski D, Ralston JD, Anderson ML. Health Outcomes of Population-Based Pharmacy Outreach to Increase Statin Use for Prevention of Cardiovascular Disease in Patients with Diabetes. J Manag Care Spec Pharm 2016; 22:909-17. [PMID: 27459653 PMCID: PMC10397924 DOI: 10.18553/jmcp.2016.22.8.909] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND In 2003, Group Health implemented a pharmacy-based, systemwide outreach effort to increase the preventive use of statins and angiotensin-converting enzyme inhibitors in enrollees at risk for cardiovascular disease, including all enrollees with diabetes. OBJECTIVE To estimate the associations between the use of statins and major vascular events and the total costs in 2006-2010 for enrollees with diabetes, using a pharmacy-based, systemwide outreach. METHODS In a 14-year (1997-2010) longitudinal cohort study design, the study population consisted of 6,975 Group Health enrollees with type 1 or type 2 diabetes, who were enrolled continuously and had no statin use before the Group Health outreach in 1997-2002. Health outcomes were all-cause mortality, cardiovascular mortality, myocardial infarction, and stroke. Statin exposure was measured by cumulative statin use since 2003, weighted by the effect of the statin type and dose on the lowering of low-density lipoprotein levels. Regression models estimated associations between cumulative statin use, health outcomes, and total costs in 2006-2010. RESULTS Among enrollees with no statin use before outreach began in 2003, about half had no or low exposure to statins by the end of 2005. In 2006-2010, cumulative statin use was greater among enrollees with risk factors for cardiovascular disease. Greater statin use was related to lower cardiovascular deaths and incidence of stroke and myocardial infarction, greater but nonsignificant all-cause mortality, and unrelated to total costs. CONCLUSIONS Population-based pharmacy outreach increased statin use for eligible enrollees with diabetes, which was related to better cardiovascular outcomes. Generally, statin use was unrelated to all-cause mortality and total costs. DISCLOSURES This study was funded by Grant No. R21 HS019501 from the Agency for Healthcare Research and Quality (AHRQ) and was conducted as part of the AHRQ announcement Optimizing Prevention and Healthcare Management for the Complex Patient (R21; RFA-HS-10-009). Ralston and Anderson are employees of Group Health and the Group Health Research Institute, which provided the data for this study. Study concept and design were contributed by Grembowski, Ralston, and Anderson. Anderson assisted with data collection and analysis, and data interpretation was performed by Anderson, along with Grembowski and Ralston. The manuscript was prepared by Grembowski, along with Ralston and Anderson.
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Affiliation(s)
- David Grembowski
- 1 University of Washington School of Public Health, Seattle, Washington
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Engelmann J, Manuwald U, Rubach C, Kugler J, Birkenfeld AL, Hanefeld M, Rothe U. Determinants of mortality in patients with type 2 diabetes: a review. Rev Endocr Metab Disord 2016; 17:129-37. [PMID: 27068710 DOI: 10.1007/s11154-016-9349-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
UNLABELLED We aimed to review and summarize the evidence from accomplished trials analyzing factors influencing mortality in patients with T2DM and to provide some recommendations for targets and treatment in the European region. The following databases were searched for relevant trials: PubMed and the Cochrane Library. Of 3.806 citations, 134 trials met our inclusion criteria. RESULTS The reduction in lifetime for 65 + -years-old patients having less than 10 years T2DM amounts to 1.8 years. Having T2DM for more than 10 years lifetime will be reduced by 2.7 years. However, the lifetime shortening factor of T2DM will even be stronger for 40 + -years-old patients at onset. Males will lose 11.6 years of life and 18.6 QUALYs. T2DM among females will reduce life by 14 QUALYs by 22 years. From a statistical point of view, the highest mortality rate will occur in an over 55-years-old European smoking and non-compliant diabetic woman with alcohol abuse living in a rural area with a low level of education and a low socio-economic status. Furthermore, other co-morbidities such as cardiovascular diseases, gout, and depression affect mortality. Additionally, mortality will increase with a BMI over 35 and also with a BMI under 20-25. This refers to the obesity paradox indicating a higher mortality rate among normal weight patients with T2DM compared to overweight patients with T2DM. HbA1c-levels between 6.5 % and 7 % are associated with the lowest impact on mortality.
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Affiliation(s)
- Jana Engelmann
- Health Sciences/Public Health, Faculty of Medicine, TUD, Fetscherstraße 74, D-01307, Dresden, Germany
| | - Ulf Manuwald
- Health Sciences/Public Health, Faculty of Medicine, TUD, Fetscherstraße 74, D-01307, Dresden, Germany
| | - Constanze Rubach
- Health Sciences/Public Health, Faculty of Medicine, TUD, Fetscherstraße 74, D-01307, Dresden, Germany
| | - Joachim Kugler
- Health Sciences/Public Health, Faculty of Medicine, TUD, Fetscherstraße 74, D-01307, Dresden, Germany
| | - Andreas L Birkenfeld
- Medical Clinic III, University Clinic, Faculty of Medicine, TUD, Fetscherstraße 74, D-01307, Dresden, Germany
- Study Center Prof. Hanefeld, Research for Metabolic Vascular Syndrome, GWT-TUD GmbH, Fiedlerstraße 34, D-01307, Dresden, Germany
| | - Markolf Hanefeld
- Study Center Prof. Hanefeld, Research for Metabolic Vascular Syndrome, GWT-TUD GmbH, Fiedlerstraße 34, D-01307, Dresden, Germany
| | - Ulrike Rothe
- Health Sciences/Public Health, Faculty of Medicine, TUD, Fetscherstraße 74, D-01307, Dresden, Germany.
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