Evaluation of the association between diabetic retinopathy and the incidence of atrial fibrillation: A nationwide population-based study

Systemic sclerosis is a risk factor of incident psoriasis: results from a nationwide cohort study

Objective

Although the co-existence of systemic sclerosis (SSc) and psoriasis (PsO) has been reported, the risk relationship between the two diseases remains unclear. We aimed to assess whether SSc is associated with the risk of incident PsO.

Methods

From the Korean National Health Insurance Service database, 4,933 patients with SSc and 24,665 age- and sex-matched controls were selected. Hazard ratios (HRs) and 95% confidence intervals (CIs) for incident PsO were estimated using multivariable Cox proportional hazard models adjusted for known risk factors of PsO. Further, we selected individuals whose health check-up data were available (2,355 patients with SSc and 11,775 age- and sex-matched controls). In this population, we further adjusted for additional risk factors of PsO using the health check-up data.

Results

In the analysis of 4,933 patients with SSc and 24,665 age- and sex-matched controls, incidence rates of PsO in patients with SSc and controls were 10.26 and 3.20 per 1,000 person-years, respectively. After adjusting for risk factors of PsO, patients with SSc had a significantly higher risk of incident PsO (adjusted HR: 3.055 [95% CI: 2.597, 3.594]). Moreover, in the analysis of individuals who had health check-up data, additional risk factors of PsO were further adjusted; the result also showed that patients with SSc have a significantly higher risk of incident PsO (adjusted HR: 2.820 [95% CI: 2.207, 3.603]).

Conclusion

Patients with SSc had a 3-fold higher risk of developing incident PsO than controls, independent of known risk factors of PsO.

Association Between Atrial Fibrillation and Diabetes-Related Complications: A Nationwide Cohort Study

OBJECTIVE

This study aimed to investigate the associations between concurrent atrial fibrillation and diabetes-related complications among patients with diabetes.

RESEARCH DESIGN AND METHODS

This nationwide observational cohort study used the health checkup database from the Korean National Health Insurance Service. Patients diagnosed with diabetes who underwent health checkups between 2009 and 2012 were investigated. The patients with atrial fibrillation were matched in a 1:5 ratio with those without atrial fibrillation using propensity scores. Study outcomes included macrovascular, microvascular (diabetic retinopathy and diabetic nephropathy), and diabetic foot complications. The risks of clinical outcomes were measured using hazard ratios (HRs) with 95% CIs.

RESULTS

A total of 65,760 patients with diabetes were analyzed (54,800 without atrial fibrillation and 10,960 with atrial fibrillation). After well-balanced propensity score matching, atrial fibrillation was associated with significantly higher risks of macrovascular complications (HR 1.12, 95% CI 1.09-1.16), diabetic nephropathy (HR 1.23, 95% CI 1.16-1.30), and diabetic foot complications (HR 1.13, 95% CI 1.09-1.17) compared with no atrial fibrillation, while the risk of diabetic retinopathy was comparable (HR 0.99, 95% CI 0.96-1.03). Patients with atrial fibrillation had a significantly higher risk of diabetic foot amputation (HR 4.12, 95% CI 1.98-8.56).

CONCLUSIONS

Among patients with diabetes, concurrent atrial fibrillation was associated with increased risks for diabetes-related macrovascular complications, diabetic nephropathy, and diabetic foot. Such patients require holistic management to reduce the risk of adverse outcomes.

Type 2 Diabetes and Atrial Fibrillation: Evaluating Causal and Pleiotropic Pathways Using Mendelian Randomization

Background Observational associations between type 2 diabetes (T2D) and atrial fibrillation (AF) have been established, but causality remains undetermined. We performed Mendelian randomization (MR) to study causal effects of genetically predicted T2D on AF risk, independent of cardiometabolic risk factors. Methods and Results Instrumental variables included 182 uncorrelated single nucleotide polymorphisms associated with T2D at genome-wide significance (P <5×10-8). Genetic association estimates for cardiometabolic exposures were obtained from genome-wide association studies including 188 577 individuals for low-density lipoprotein-C, 694 649 individuals for body mass index, and 757 601 for systolic blood pressure. Two-sample, inverse-variance weighted MR formed the primary analyses. The MR-TRYX approach was used to dissect potential pleiotropic pathways, with multivariable MR performed to investigate cardiometabolic mediation. Genetically predicted T2D associated with increased AF liability in univariable MR (odds ratio [OR], 1.08 [95% CI, 1.02-1.13], P=0.003). Sensitivity analyses indicated potential pleiotropy, with radial MR identifying 4 outlier single nucleotide polymorphisms that were likely contributors. Phenomic scanning on MR-base and subsequent least absolute shrinkage and selection operator regression allowed prioritization of 7 candidate traits. The outlier-adjusted effect estimate remained consistent with the original inverse-variance weighted estimate (OR, 1.07 [95% CI, 1.02-1.12], P=0.008). On multivariable MR, T2D remained associated with increased AF liability after adjustment for low-density lipoprotein-C and body mass index. Following adjustment for systolic blood pressure, the relationship between T2D and AF became nonsignificant (OR, 1.04 [95% CI, 0.95-1.13], P=0.40). Conclusions These data provide novel genetic evidence that while T2D likely causally associates with AF, mediation via systolic blood pressure exists. Endeavoring to lower systolic blood pressure alongside achieving normoglycemia may provide particular benefit on AF risk in patients with T2D.

Incidence and adverse clinical events of primary sclerosing cholangitis with ulcerative colitis

PURPOSE

The aim of this study was to conduct a nationwide population-based study to estimate the incidence of primary sclerosing cholangitis in patients with ulcerative colitis (UC-PSC) and investigate healthcare use, medication use, surgery, cancer, and death as adverse clinical events of UC-PSC.

METHODS

We identified incident cases of UC with (UC-PSC) or without PSC (UC-alone) between 2008 and 2018 using health insurance claims data in Korea. Univariate (crude hazard ratio (HR)) and multivariate analyses were performed to compare the risk of adverse clinical events between groups.

RESULTS

A total of 14,406 patients with UC using population-based claims data were detected in the cohort. Overall, 3.38% (487/14,406) of patients developed UC-PSC. During a mean follow-up duration of approximately 5.92 years, the incidence of PSC in patients with UC was 185 per 100,000 person-years. The UC-PSC group showed statistically more frequent healthcare use (hospitalization and emergency department visits: HRs, 5.986 and 9.302, respectively; P < .001), higher immunomodulator and biologic use (azathioprine, infliximab, and adalimumab: HRs, 2.061, 3.457, and 3.170, respectively; P < .001), and higher surgery rate (operation for intestinal obstruction, and colectomy: HRs, 9.728 and 2.940, respectively; P < .001) than did the UC-alone group. The UC-PSC group also showed significantly higher colorectal cancer and biliary tract cancer (HRs, 2.799 and 36.343, respectively; P < .001) and mortality (HR, 4.257) rates than did the UC-alone group.

CONCLUSION

Patients with UC-PSC have higher risks of colorectal cancer, biliary tract cancer, and death than do patients with UC-alone. Although considered a rare disease, managing this complex and costly disease requires recognition of the impact of increased burden on healthcare services.

Risk of optic neuritis in type 2 diabetes mellitus: A nationwide cohort study

BACKGROUND/PURPOSE

This study aimed to investigate the association between the time course of type 2 diabetes mellitus (DM) and the development of optic neuritis (ON) in the Korean population aged 20 years and older.

METHODS

A total of 10,069,044 subjects were included in this study, which utilized stratified random sampling from the national cohort. The hazard ratios (HRs) for incident ON were compared between subjects with normal fasting glucose (NFG) levels, impaired fasting glucose (IFG) levels, patients with new-onset DM, diabetes duration of fewer than 5 years (early DM), and diabetes duration of 5 years or more (late DM). In addition, the HR for incident ON was assessed and stratified into 20 fasting glucose levels.

RESULTS

The cumulative incidence and HR for ON demonstrated a significant increase across the time course of diabetes (adjusted hazard ratio [aHR] = 1.05, 95% confidence interval [CI]: 1.00 to 1.10 for IFG; aHR = 1.31, 95% CI: 1.19 to 1.44 for new-onset DM; aHR = 1.46, 95% CI: 1.32 to 1.60 for early DM; and aHR = 1.92, 95% CI: 1.77 to 2.08 for late DM). Moreover, the HR for ON was 1.71-fold higher in individuals with fasting glucose levels of 132 mg/dL or more compared to those with levels below 75 mg/dL.

CONCLUSION

In this nationwide cohort study, the risk of ON was found to increase with the time course of diabetes and elevated glucose levels. These results suggest that efforts to regulate glucose levels and prevent DM progression could reduce the risk of ON.

Association of immune-mediated inflammatory diseases with depression and anxiety in patients with type 2 diabetes: A nationwide population-based study

Objective

Patients with type 2 diabetes (T2DM) are at a high risk of developing depression and anxiety. To better stratify the risk, we aimed to assess whether the presence of immune-mediated inflammatory diseases (IMIDs) confers a higher risk of depression and anxiety in these patients.

Methods

Patients with T2DM without prior depression or anxiety who underwent national health examination between 2009 and 2012 (n = 1,612,705) were enrolled from the nationwide health check-up data from Korean National Health Insurance Service. The outcome events were incident depression and anxiety, defined as International Classification of Diseases, 10th Revision codes F32-F33 and F40-F41, respectively. Multivariable Cox proportional hazard regression analyses were conducted to estimate the adjusted hazard ratio (aHR) and 95% confidence interval (CI) according to the existence of IMIDs.

Results

Over an average follow-up time of 6.4 years, existence of gut IMIDs was associated with a higher risk of depression (aHR: 1.28 [95% CI: 1.08-1.53]) and anxiety (1.22 [1.06-1.42]). Existence of joint IMIDs was associated with a higher risk of depression (1.34 [1.31-1.37]) and anxiety (1.31 [1.29-1.34]). Existence of skin IMID was associated with a higher risk of depression (1.18 [1.14-1.23]) and anxiety (1.13 [1.09-1.16]). The effect sizes of IMIDs on depression and anxiety were larger in those with ≥ 2 IMIDs (1.42 [1.19-1.69] and 1.49 [1.29-1.72], respectively) than in those with one IMID (1.30 [1.27-1.32] and 1.26 [1.24-1.28], respectively).

Conclusion

In patients with T2DM, presence of IMIDs was associated with a higher risk of depression and anxiety. More stringent attention and screening for anxiety and depression should be encouraged in patients with T2DM and comorbid IMIDs due to clinical implications of psychological distress on patient-reported outcomes and prognosis.

The impact of socioeconomic deprivation on the risk of atrial fibrillation in patients with diabetes mellitus: A nationwide population-based study

Objective

To evaluate the relationship between socioeconomic status and the risk of atrial fibrillation (AF) in patients with diabetes mellitus (DM).

Research design and methods

From the National Health Insurance Service (NHIS) database, we identified 2,429,610 diabetic patients who underwent national health check-ups between 2009 and 2012. Tracing back the subjects for 5 years from the date of health check-up, we determined the subjects’ income and whether they received medical aid (MA) during the past 5 years. Subjects were divided into six groups according to the number of years of receiving (MA groups 0 through 5) and into four groups according to socioeconomic status change during the past 5 years. We estimated the risk of AF for each group using the Cox proportional-hazards model.

Results

During a median follow-up of 7.2 ± 1.7 years, 80,257 were newly identified as AF. The MA groups showed a higher risk of AF than the non-MA group with the hazard ratios (HRs) and 95% confidence interval (CI) 1.32 (1.2–1.44), 1.33 (1.22–1.45), 1.23 (1.13–1.34), 1.28 (1.16–1.4), and 1.50 (1.39–1.63) for MA groups 1 through 5, respectively. Dividing subjects according to socioeconomic condition change, those who experienced worsening socioeconomic status (non-MA to MA) showed higher risk compared to the persistent non-MA group (HR 1.54; 95% CI 1.38–1.73).

Conclusion

Low socioeconomic status was associated with the risk of AF in patients with diabetes. More attention should be directed at alleviating health inequalities, targeting individuals with socioeconomic deprivation to provide timely management for AF.

Depression in patients with inflammatory bowel disease is associated with increased risk of dementia and Parkinson's disease: A nationwide, population-based study

Background

Inflammatory bowel disease (IBD) may be associated with depression which is considered an important cause of dementia and Parkinson's disease (PD). In the present study, the effects of depression on the development of dementia and/or PD in patients with IBD were evaluated.

Materials and methods

A nationwide population-based cohort study was conducted using claims data from the Health Insurance Review and Assessment Service in Korea. The incidence of dementia and PD were analyzed based on the presence of depression in patients with IBD.

Results

During a mean follow-up of 8 years, IBD patients with depression experienced dementia (6.7 vs. 2.0%; p < 0.001) and PD (1.1 vs. 0.3%; p < 0.001) significantly more than IBD patients without depression. Compared with IBD patients without depression, the risk of developing dementia was significantly higher in IBD patients with depression [adjusted hazard ratio (aHR) for IBD, Crohn's disease (CD), and ulcerative colitis (UC), 2.03, p < 0.001; 1.68, p = 0.033; 2.13, p < 0.001, respectively]. Compared with IBD patients without depression, the risk of developing PD was significantly higher in IBD patients with depression (aHR for IBD, CD, and UC, 2.54, p < 0.001; 1.93, p = 0.470; 2.75, p < 0.001, respectively). The cumulative incidence of dementia and PD in IBD patients with depression was significantly higher than in IBD patients without depression and showed a steady increase after a diagnosis of depression.

Conclusion

The risk of dementia and/or PD increased after a diagnosis of depression in patients with IBD.

Burden of Microvascular Disease and Risk of Atrial Fibrillation in Adults with Type 2 Diabetes

BACKGROUND

Epidemiological data on the associations of microvascular disease with atrial fibrillation are scarce. We evaluated the associations of diabetes-related microvascular disease in multiple vascular beds and its burden with incident atrial fibrillation among adults with type 2 diabetes.

METHODS

A total of 7603 participants with type 2 diabetes and without atrial fibrillation were assessed for diabetic kidney disease, retinopathy, or neuropathy at baseline in the Action to Control Cardiovascular Risk in Diabetes (ACCORD) study. Incident atrial fibrillation events were adjudicated using follow-up electrocardiograms. Modified Poisson regression was used to generate risk ratios (RRs) and 95% confidence intervals (CIs) for atrial fibrillation.

RESULTS

Of the 7603 participants (mean age 62.5 years, 38.0% women, 63.4% white), 63.3% (n = 4816) had microvascular disease-defined as the presence of ≥1 of: diabetic kidney disease, retinopathy, or neuropathy at baseline. Over a median of 7 years, there were 137 atrial fibrillation events (1.8%). Participants with microvascular disease had a 1.9-fold higher risk of incident atrial fibrillation compared with those without microvascular disease (RR 1.88; 95% CI, 1.20-2.95). Compared with no microvascular disease, the RRs for atrial fibrillation were 1.62 (95% CI, 1.01-2.61) and 2.47 (95% CI, 1.46-4.16) for those with 1 and ≥2 microvascular territories affected, respectively. The RRs for atrial fibrillation by type of microvascular disease were 1.57 (95% CI, 1.09-2.26), 0.95 (95% CI, 0.53-1.70), and 1.67 (95% CI, 1.15-2.44) for neuropathy, retinopathy, and diabetic kidney disease, respectively.

CONCLUSIONS

In a large cohort of adults with type 2 diabetes, the presence of microvascular disease and its burden were independently associated with higher risk of incident atrial fibrillation.

The complex interplay between diabetes mellitus and atrial fibrillation

INTRODUCTION

: A growing body of evidence suggests that diabetes mellitus (DM) is associated with an increased risk of new-onset atrial fibrillation (AF) and contributes to suboptimal arrhythmia control and poor prognosis in patients with AF. The high prevalence of AF among patients with DM is primarily attributed to common risk factors, shared pathophysiological mechanisms, and associated atrial remodeling and autonomic dysfunction.

AREAS COVERED

: This comprehensive review covers the current data on the role of DM in the development and prognosis of AF. In addition, we review the impact of anti-DM medications on AF prevention and the role of anticoagulation in patients with coexisting DM and AF.

EXPERT OPINION

: DM is independently associated with new-onset AF, and the coexistence of these two conditions contributes to poor outcomes, from reduced quality of life to increased risks of thromboembolic events, heart failure, and mortality. Despite this strong link, the current evidence is insufficient to recommend routine screening for AF in patients with DM. Although some observations exist on preventing AF with anti-DM medications, randomized controlled trials are warranted to explore the proposed benefits of novel anti-DM medicines in reducing the risk of incident AF.

Weight change and the risk of hip fractures in patients with type 2 diabetes: a nationwide cohort study

Both weight gain and weight loss in type 2 diabetic population were associated with increased risk of hip fracture, while maintaining weight lowered the risk of hip fracture. Regarding the risk of hip fracture, we can propose active monitoring to maintain the weight of type 2 diabetes patients.

INTRODUCTION

In type 2 diabetes, patients are often asked to control their weight in order to reduce their diabetic morbidity. The American Diabetes Association recommends that diabetic patients conduct high-intensity interventions for regulating diet, physical activity, and behavior to reduce weight, followed by long-term comprehensive weight maintenance programs. Although such weight control attempts are required in diabetic patients, there are few studies on the effect of weight change on hip fracture in this population. We aim to investigate the association between body weight change and the incidence of hip fracture in subjects with type 2 diabetes using large-scale, nationwide cohort data on the Korean population.

MATERIALS AND METHODS

A total of 1,447,579 subjects (894,204 men and 553,375 women) > 40 years of age, who were diagnosed with type 2 diabetes, were enrolled in this study. Weight change within 2 years was divided into five categories: from weight loss ≥ 10% to weight gain ≥ 10%. The hazard ratios (HRs) and 95% confidence intervals for the incidence of hip fracture were analyzed, compared with the reference of the stable weight group (weight change < 5%).

RESULTS

Among 5 weight change groups, more than 10% weight loss showed the highest HR (HR, 1.605; 95% CI, 1.493 to 1.725), followed by more than 10% weight gain (HR, 1.457; 95% CI, 1.318 to 1.612). The effect of weight change on hip fracture risk was greater in males than in females, and those under 65 years of age were greater than those over 65 years of age. Baseline BMI did not play a role of weight change affecting the risk of hip fracture. The HR for hip fracture of subjects with regular exercise was lower than those without regular exercise.

CONCLUSIONS

In the type 2 diabetes population, both weight gain and weight loss were significantly associated with a higher risk of hip fracture, whereas maintaining body weight reduced the risk of hip fracture the most.

The Connubium among diabetes, chronic kidney disease and atrial fibrillation

The burden of cardiovascular comorbid conditions was significantly higher in patients with Atrial Fibrillation (AF); most of them are affected by hypertension, Chronic Kidney Disease (CKD) and/or Diabetes Mellitus (DM). DM represents a well-known risk factor for the development and maintenance of AF; the coexistence of DM and AF is also associated with an increased risk of mortality and stroke. Moreover, DM is currently the main cause of renal impairment and the leading cause of dialysis in the world. The hyperglycemia is responsible for inducing redox imbalance and both systemic and intrarenal inflammation, playing a critical role in the pathogenesis of diabetic kidney disease. Long-term thromboembolic preventive therapy in AF patients with DM and CKD may be more challenging because both DM and CKD have been independently associated with an increased thromboembolic and bleeding risk, which results from the prothrombotic and pro-inflammatory status. Vitamin K Antagonists (VKAs) are characterized by numerous critical issues such as a narrow therapeutic window, increased tissue calcification and an unfavourable risk/benefit ratio with low stroke prevention effect and augmented risk of major bleeding. On the other hand, Direct Oral Anticoagulants (DOACs) are currently contraindicated in dialysis patients even if mounting evidence suggests that they may have a nephroprotective role in AF patients with DM and CKD. Consequently, the choice of anticoagulant therapy in this setting of patient seems to be very challenging. The aim of this review is to investigate the role of DOACs in diabetic patients and its nephroprotective role by reviewing the current literature.

Medical therapies for prevention of cardiovascular and renal events in patients with atrial fibrillation and diabetes mellitus

Atrial fibrillation (AF), type 2 diabetes mellitus (DM), and chronic kidney disease (CKD) are three global epidemics with significant effects on morbidity and mortality. Diabetes is a risk factor for AF, and a risk factor for thromboembolism, comorbidity, and mortality when AF is present. The pathophysiology of diabetes-related AF and interrelationships with cardiovascular events and renal events is not fully understood but is in part related to structural, electrical, electromechanical, and autonomic remodelling. The current practice guidelines offer limited recommendations on the management of patients with AF (or risk of AF) and diabetes with its own heterogeneity for the prevention of cardiovascular and renal events. This document discusses possible clinical approaches for these patients. In the last decade, there have been major improvements for the prevention of stroke in AF patients with direct oral anticoagulants, which are preferable to vitamin K antagonists for stroke prevention in DM. Because of the increased risk rate for several cardiovascular adverse events in diabetic patients, a similar relative risk reduction generally translates into greater absolute risk reduction in the diabetic population. Recent trials with non-insulin diabetes drugs using glucagon-like peptide-1 agonists and sodium-glucose cotransporter-2 inhibitors showed a significant reduction for the risk of major adverse cardiovascular events in patients with type 2 DM. Sodium-glucose cotransporter-2 inhibitors also showed a large reduction in hospitalization for heart failure and renal events, which need to be more completely evaluated in patients with AF. Mechanisms, risks, and optimal management of AF patients with DM who have or are under risk of developing heart failure or CKD are also discussed in this document. The benefits of medical therapies for these patients still need to be put into perspective, and gaps in evidence on some of these issues are likely to be addressed in future years.

Acromegaly and cardiovascular outcomes: a cohort study

AIMS

Cardiovascular disease is a common complication in acromegaly. We investigated the risk of cardiovascular disease and mortality in patients with acromegaly in a large-scale population using nationwide data in Korea.

METHODS AND RESULTS

We performed a nationwide, retrospective, observational, cohort study of patients with acromegaly (n = 1874) and age- and sex-matched subjects without acromegaly (n = 9370) for a mean follow-up of 7.5 ± 3.2 years. The study outcomes were myocardial infarction, stroke, atrial fibrillation, congestive heart failure, and all-cause death. All outcomes were analysed by Cox proportional hazards regression analysis while controlling for age, sex, household income, place, Type 2 diabetes, hypertension, and dyslipidaemia. The incidence (per 1000 person-years) of atrial fibrillation (3.06 vs. 1.70; P = 0.001), congestive heart failure (3.11 vs. 1.63; P < 0.001), and all-cause mortality (6.31 vs. 4.03; P < 0.001) in patients with acromegaly was higher than in controls. However, the incidence of myocardial infarction and stroke did not differ between groups. After adjustment for covariates, the risk for atrial fibrillation [hazard ratio (HR): 1.59; 95% confidence interval (CI): 1.09-2.31], congestive heart failure (HR: 1.54; 95% CI: 1.06-2.25), and all-cause mortality (HR: 1.31; 95% CI: 1.01-1.69) was significantly higher in patients with acromegaly. In time lag sensitivity analysis, a higher risk for atrial fibrillation was observed only in the first 4 years after diagnosis in acromegaly patients compared with controls (HR: 3.05; 95% CI: 1.94-4.79).

CONCLUSION

Patients with acromegaly were at higher risk for atrial fibrillation, congestive heart failure, and all-cause death. The risk of atrial fibrillation had a time-dependent association with acromegaly.

Comparison of fracture risk between type 1 and type 2 diabetes: a comprehensive real-world data

Population-based cohort study of 6,548,784 Korean subjects demonstrates that the risk of fracture was higher in patients with diabetes than in nondiabetic subjects. Furthermore, patients with type 1 diabetes were associated with a higher risk of fracture than patients with type 2 diabetes for all measurement sites.

INTRODUCTION

Diabetes mellitus is associated with increased fracture risk. Although the pathophysiologic effect on bone metabolism differs according to the type of diabetes, a higher risk of fracture in patients with diabetes than in nondiabetic patients has been consistently demonstrated. Considering the ever-increasing number of patients with diabetes, we aimed to provide updated information on whether this phenomenon remains valid in real-world settings by using large-scale population datasets.

METHODS

We conducted a retrospective longitudinal study using data from the Korean National Health Insurance Service dataset of preventive health check-ups between January 2009 and December 2016. The hazard ratios were calculated for any fracture, vertebral fracture, and hip fracture and were analyzed according to the presence and type of diabetes. Among 10,585,818 subjects, 6,548,784 were eligible for the analysis (2418 patients with type 1 diabetes mellitus [T1DM] and 506,208 patients with type 2 diabetes mellitus [T2DM]).

RESULTS

The mean follow-up duration (in years) was 7.0 ± 1.3 for subjects without diabetes, 6.4 ± 2.0 for those with T1DM, and 6.7 ± 1.7 for T2DM. Patients with T1DM had a higher incidence rate for all types of fractures per 1000 person-years. The fully adjusted hazard ratios (HRs) for any fracture, vertebral fracture, and hip fracture were higher in T1DM than in T2DM (1.37 [95% confidence interval (CI): 1.23-1.52] for any fracture, 1.33 [95% CI: 1.09-1.63] for vertebral fracture, and 1.99 [95% CI: 1.56-2.53] for hip fracture).

CONCLUSIONS

In this large-scale population analysis, diabetes was associated with a higher risk of all types of fractures. Patients with T1DM had a higher risk of fracture than those with T2DM for all measurement sites, and hip fractures had the highest risk. Therefore, fracture prevention training for patients with diabetes is advisable.

Statin use for primary prevention in patients with type 2 diabetes: Can it benefit all ages? - A nationwide propensity-matched cohort study

AIMS

This study aims to investigate whether statin use is associated with a reduction in CVD and mortality in patients with type 2 diabetes without pre-existing CVD.

METHODS

A propensity score-matched cohort analysis using retrospective data was created. Statin users received at least a 90-day prescription, and never used statin before initiation of the study. Statin non-users never received statin throughout the study. Primary outcome was a composite of myocardial infarction (MI), stroke, and all-cause death, and secondary outcome was an individual event.

RESULTS

The propensity score matched cohort included 168,045 statin users and 168,045 non-users (mean age 57 years; median follow-up 5.0 years). Compared to statin non-users, the hazard ratio (HR) was 0.72 (95% confidence interval [CI] 0.70-0.73; P < 0.001) for composite outcomes, 0.80 (0.76-0.84; P < 0.001) for MI, 0.74 (0.71-0.76; P < 0.001) for stroke, and 0.68 (0.66-0.70; P < 0.001) for all-cause death in statin users. The risk reduction was most prominent in subjects aged 40-74 years, attenuated but significant in those aged ≥75 years, and not significant in those aged <40 years.

CONCLUSIONS

Statin showed a protective effect against CVD and all-cause death in type 2 diabetes; this effect was reduced beyond the age of 75 years and disappeared in young patients aged <40 years.

Association between diabetes status and subsequent onset of glaucoma in postmenopausal women

The purpose of this study was to analyze the risk of glaucoma based on diabetes status using a large nationwide longitudinal cohort of postmenopausal women. This study included 1,372,240 postmenopausal women aged ≥ 40 years who underwent National Health Screening Program in 2009. Subjects were classified into the following 5 categories based on diabetes status: no diabetes, impaired fasting glucose (IFG), new onset diabetes, diabetes treated with oral hypoglycemic medication, and diabetes treated with insulin. Subjects were followed from 2005 through 2018, and hazard ratios of glaucoma onset were calculated for each group. Subgroup analyses of subjects stratified by age, smoking, drinking, hypertension, and dyslipidemia were performed. During the follow up period, 42,058 subjects developed glaucoma. The adjusted hazard ratio was 1.061 (95% CI, 1.036–1.086) in the IFG group, 1.151 (95% CI, 1.086–1.220) in the new onset diabetes group, 1.449 (95% CI, 1.406–1.493) in the diabetes treated with oral hypoglycemic medication group, and 1.884(95% CI, 1.777–1.999) in the diabetes treated with insulin group compared to the no diabetes group. The results were consistent in subgroup analyses after stratifying by age, lifestyle factors (smoking and drinking), and comorbidities (hypertension and dyslipidemia). Diabetes status is associated with increased risk of glaucoma development in postmenopausal women.

Association of proteinuria and incident atrial fibrillation in patients with diabetes mellitus: a population-based senior cohort study

Diabetes mellitus (DM) is considered an independent risk factor for atrial fibrillation (AF). The excess risk in relation to the presence of proteinuria has not been well elucidated. Our aim was to determine the association between the incidence of AF and proteinuria in diabetic population. A total of 240,499 individuals aged ≥ 60 years from the Korea National Health Insurance Service-Senior cohort from 2004 to 2014 were included. 4.2% of individuals with DM and 3.7% of controls were diagnosed with AF during a median follow-up period of 7.2 years. Amongst controls (participants without proteinuria and DM), DM only, proteinuria only, and DM with proteinuria groups, the crude incidences of AF were 0.58, 0.70, 0.96, 1.24 per 100 person-years respectively. Compared with controls, the weighted risk of AF was increased by 11% (hazard ratio = 1.11, 95% confidence interval = 1.02-1.20, P = .001), 48% (hazard ratio = 1.48, 95% confidence interval = 1.30-1.69, P < .001), and 66% (hazard ratio = 1.66, 95% confidence interval = 1.26-2.18, P < .001) in the DM only, proteinuria only, and DM with proteinuria groups, respectively (P for trend < .001). Degree of proteinuria in diabetic patients was associated with a significantly higher rate of incident AF in dose dependent manner. Thus, assessing proteinuria by a simple urine dipstick test could provide a useful adjunct to risk assessment for AF in elderly population with DM.

Trends of age-related non-communicable diseases in people living with HIV and comparison with uninfected controls: A nationwide population-based study in South Korea

OBJECTIVES

We aim to compare the trends of non-communicable diseases (NCDs) and death among people living with HIV (PLWH) and uninfected controls in South Korea.

METHODS

We identified PLWH from a nationwide database of all Korean citizens enrolled from 1 January 2004 to 31 December 2016. A control cohort was randomly selected for PLWH by frequency matching for age and sex in a 20:1 ratio. To compare NCD trends between the groups, adjusted incidence rate ratios for outcomes across ages, calendar years and times after HIV diagnosis were calculated.

RESULTS

We included 14 134 PLWH and 282 039 controls in this study; 58.5% of PLWH and 36.4% of the controls were diagnosed with at least one NCD. The incidence rates of cancers, chronic kidney disease, depression, osteoporosis, diabetes and dyslipidaemia were higher in PLWH than in the controls, whereas those of cardiovascular disease, heart failure, ischaemic stroke and hypertension were lower in PLWH. Relative risks (RRs) for NCDs in PLWH were higher than controls in younger age groups. Trends in the RRs of NCDs tended to increase with the calendar year for PLWH vs. controls and either stabilized or decreased with time after HIV diagnosis. The RR of death from PLWH has decreased with the calendar year, but showed a tendency to rise again after 2014 and was significant at the early stage of HIV diagnosis.

CONCLUSIONS

Although the RR of each NCD in PLWH showed variable trends compared with that in controls, NCDs in PLWH have been increasingly prevalent.

Hypertension Burden and the Risk of New-Onset Atrial Fibrillation: A Nationwide Population-Based Study

The association between the cumulative hypertension burden and the development of atrial fibrillation (AF) is unclear. We aimed to investigate the relationship between hypertension burden and the development of incident AF. Using the Korean National Health Insurance Service database, we identified 3 726 172 subjects who underwent 4 consecutive annual health checkups between 2009 and 2013, with no history of AF. During the median follow-up of 5.2 years, AF was newly diagnosed in 22 012 patients (0.59% of the total study population; 1.168 per 1000 person-years). Using the blood pressure (BP) values at each health checkup, we determined the burden of hypertension (systolic BP ≥130 mm Hg or diastolic BP ≥80 mm Hg), stratified as 0 to 4 per the hypertension criteria. The subjects were grouped according to hypertension burden scale 1 to 4: 20% (n=742 806), 19% (n=704 623), 19% (n=713 258), 21% (n=766 204), and 21% (n=799 281). Compared with normal people, subjects with hypertension burdens of 1, 2, 3, and 4 were associated with an 8%, 18%, 26%, and 27% increased risk of incident AF, respectively. On semiquantitative analyses with further stratification of stage 1 (systolic BP of 130-139 mm Hg or diastolic BP of 80-89 mm Hg) and stage 2 (systolic BP ≥140 mm Hg or diastolic BP ≥90 mm Hg) hypertension, the risk of AF increased with the hypertension burden by up to 71%. In this study, both a sustained exposure and the degree of increased BP were associated with an increased risk of incident AF. Tailored BP management should be emphasized to reduce the risk of AF.

Sex, age, type of diabetes and incidence of atrial fibrillation in patients with diabetes mellitus: a nationwide analysis

BACKGROUND

There remain uncertainties regarding diabetes mellitus and the incidence of atrial fibrillation (AF), in relation to type of diabetes, and the interactions with sex and age. We investigated whether diabetes confers higher relative rates of AF in women compared to men, and whether these sex-differences depend on type of diabetes and age.

METHODS

All patients aged ≥ 18 seen in French hospitals in 2013 with at least 5 years of follow-up without a history of AF were identified and categorized by their diabetes status. We calculated overall and age-dependent incidence rates, hazard ratios, and women-to-men ratios for incidence of AF in patients with type 1 and type 2 diabetes (compared to no diabetes).

RESULTS

In 2,921,407 patients with no history of AF (55% women), 45,389 had prevalent type 1 diabetes and 345,499 had prevalent type 2 diabetes. The incidence rates (IRs) of AF were higher in type 1 or type 2 diabetic patients than in non-diabetics, and increased with advancing age. Among individuals with diabetes, the absolute rate of AF was higher in men than in women. When comparing individuals with and without diabetes, women had a higher adjusted hazard ratio (HR) of AF than men: adjusted HR 1.32 (95% confidence interval 1.27-1.37) in women vs. 1.12(1.08-1.16) in men for type 1 diabetes, adjusted HR 1.17(1.16-1.19) in women vs. 1.10(1.09-1.12) in men for type 2 diabetes.

CONCLUSION

Although men have higher absolute rates for incidence of AF, the relative rates of incident AF associated with diabetes are higher in women than in men for both type 1 and type 2 diabetes.

Increased atrial fibrillation risk in Parkinson's disease: A nationwide population-based study

OBJECTIVE

Parkinson's disease (PD) is the second most common neurodegenerative disorder associated with various morbidities. Although the relationship between cardiovascular disease and PD has been studied, a paucity of information on PD and atrial fibrillation (AF) association exists. Thus, we aimed to investigate whether patients with PD have an increased risk of AF.

METHODS

This study included 57,585 patients with newly diagnosed PD (≥40-year-old, mean age 69.7 years, men 40.2%) and without a history of AF from the Korean National Health Insurance Service (NHIS) database between 2010 and 2015. Furthermore, an equal number of age- and sex-matched subjects without PD were selected for comparison. The primary outcome was new-onset AF.

RESULTS

During the mean follow-up period of 3.4 ± 1.8 years, AF was newly diagnosed in 3,665 patients. A significantly higher incidence rate of AF was noted among patients with PD than among patients without PD (10.75 and 7.86 per 1000 person-year, respectively). Multivariate Cox-regression analysis revealed that PD was an independent risk factor for AF (hazard ratio [HR]: 1.27, 95% confidence interval [CI]: 1.18-1.36). Furthermore, subgroup analyses revealed that AF risk was higher in the younger age subgroups, and compared with the non-PD group, the youngest PD group (age: 40-49 years) had a threefold increased risk of AF (HR: 3.06, 95% CI: 1.20-7.77).

INTERPRETATION

Patients with PD, especially the younger age subgroups, have an increased risk of AF. Active surveillance and management of AF should be considered to prevent further complications.

Outcomes in relation to antithrombotic therapy among patients with atrial fibrillation after percutaneous coronary intervention

BACKGROUNDS

We investigated the prognostic impact of antithrombotic regimens at 1-year after percutaneous coronary intervention (PCI) among patients with atrial fibrillation (AF).

METHOD AND RESULTS

A total of 13,278 AF patients who underwent PCI from 2009 to 2013 were selected from Korean National Health Insurance Service database. Patients were categorized by antithrombotic regimens at 1-year after PCI: (1) OAC with or without single antiplatelet (OAC±SAPT); (2) triple therapy (TT) and (3) antiplatelets (APT) only. After propensity score matching, composite ischaemia (death, myocardial infarction, and stroke), composite bleeding (intracranial hemorrhage and gastrointestinal bleeding), and a composite clinical outcome (composite ischaemia and bleeding) were compared. Of total population, 1,100 (8.3%), 746 (5.6%), and 11,432 (86.1%) were treated with OAC±SAPT, TT, and APT only, respectively. Compared to OAC±SAPT group, the TT group had significantly higher risk of the composite clinical outcome (hazard ratio [HR] 1.46, 95% confidence interval [CI] 1.00-2.13) attributed to a higher trend in both ischaemia (HR 1.63, 95% CI 0.99-2.67) and bleeding (HR 1.22, 95% CI 0.69-2.13). The APT only group showed a higher risk of ischaemia (HR 1.85, 95% CI 1.25-2.74), despite a lower risk of bleeding (HR 0.55, 95% CI 0.32-0.94) compared to OAC±SAPT group.

CONCLUSIONS

OAC±SAPT was associated with better clinical outcomes compared to TT or APT only treatments, beyond 1-year after PCI among Asians with AF.

The Impact of Korean Medicine Treatment on the Incidence of Parkinson's Disease in Patients with Inflammatory Bowel Disease: A Nationwide Population-Based Cohort Study in South Korea

We aimed to investigate the association between Korean medicine (KM) treatment and the risk of Parkinson's Disease (PD) in patients with inflammatory bowel disease (IBD) in South Korea. This study analyzed data from the National Health Insurance Service-Senior cohort in South Korea. The 1816 IBD patients enrolled in the analysis comprised 411 who received only conventional treatment (monotherapy group) and 1405 who received both conventional and KM treatments (integrative therapy group). The risk of PD in patients with IBD was significantly lower in the integrative therapy group than in the monotherapy group after adjusting for confounding variables (adjusted hazard ratio (HR), 0.56; 95% confidence interval (CI) = 0.34-0.92). In the mild Charlson Comorbidity Index (CCI) group, the risk of PD in patients with IBD in the integrative therapy group was 0.39 times lower (adjusted HR, 95% CI = 0.20-0.77) than that in the monotherapy group. However, there was no significant difference in the risk of PD in patients with IBD between the integrative therapy and monotherapy groups among individuals with severe CCI (adjusted HR, 0.90; 95% CI = 0.41-1.96). IBD patients are at a decreased risk of PD when they receive integrative therapy. KM treatment may prevent PD in IBD patients.

Association of Retinal Microvascular Signs with Incident Atrial Fibrillation: The Multi-Ethnic Study of Atherosclerosis

PURPOSE

Microvascular diseases may contribute to the occurrence of atrial fibrillation (AF). Retinal microvascular signs that are similar to other microvasculature in the body and can be visualized directly via ophthalmoscopy may provide insights into such a relationship.

DESIGN

Prospective, longitudinal, multiethnic study.

PARTICIPANTS

We examined the association between retinal microvascular signs and incident AF in 4994 participants 47 to 86 years of age and free of prior AF who underwent fundus photography from 2002 through 2004 and were followed up through 2015 in the Multi-Ethnic Study of Atherosclerosis (MESA).

METHODS

Retinal microvascular signs evaluated include central retinal arteriolar equivalent and central retinal venular equivalent (CRVE) and presence of any retinopathy signs (e.g., retinal microaneurysms or hemorrhages). A multivariate Cox regression analysis was used to determine the relationship while adjusting for traditional risk factors, alcohol intake, body mass index, diabetes status, chronic kidney disease status, hemoglobin A1c level, C-reactive protein level, medications, and prevalent cardiovascular diseases or heart failure.

MAIN OUTCOME AND MEASURES

Incident AF events were identified using 12-lead electrocardiographic findings, hospital discharge records, and Medicare claims data.

RESULTS

During a median follow-up of 14.1 years, 643 AF events were identified. No association was found between any retinal microvascular signs and incident AF except for retinal focal arteriolar narrowing (hazard ratio, 1.75; 95% confidence interval, 1.06-2.87) in the overall population. However, in the subgroup analyses by gender, wider CRVE was associated with a higher risk of incident AF in women, but not in men (hazard ratio for every 10-μm increase in CRVE, 1.08 [95% confidence interval, 1.01-1.15] and 0.97 [95% confidence interval, 0.92-1.03], respectively; P = 0.041 for interaction).

CONCLUSIONS

No consistent pattern of association was found between retinal microvascular signs and incident AF. We observed an association in women, but not in men, of wider retinal venular calibers with incidence of AF. The reasons for a possible interaction are incompletely understood.

Increased risk of idiopathic pulmonary fibrosis in inflammatory bowel disease: A nationwide study

BACKGROUND AND AIM

The relationship between inflammatory bowel disease (IBD) and idiopathic pulmonary fibrosis (IPF) remains unclear. We evaluated the risk for developing IPF in patients with IBD using a nationwide population-based study.

METHODS

Using claims data from the National Health Insurance service in Korea, patients with IBD, including Crohn's disease (CD) and ulcerative colitis (UC), were identified through both the 10th revision of the International Statistical Classification of Diseases and Related Health Problems and rare and intractable disease program codes from January 2010 to December 2013. We compared 38 921 IBD patients with age-matched and sex-matched individuals without IBD in a ratio of 1:3. Patients with newly diagnosed IPF were identified by both the 10th revision of the International Statistical Classification of Diseases and Related Health Problems and rare and intractable disease registration codes.

RESULTS

During a mean 4.9-year follow-up, the incidence of IPF in patients with IBD was 33.21 per 100 000 person-years. The overall risk of IPF was significantly higher in IBD patients than in non-IBD controls (hazard ratio [HR], 1.62; 95% confidence interval [CI], 1.20-2.20; P = 0.003). In patients with CD, the incidence (per 100 000 person-years) of IPF was 26.04; in controls, the incidence was 9.15 (HR, 2.89; 95% CI, 1.46-5.72; P = 0.002). The incidence of IPF in patients with UC tended to be higher than in controls (36.66 vs 26.54 per 100 000 person-years; 95% CI, 0.99-1.99; HR, 1.41; P = 0.066). The risk of developing IPF in patients with IBD was higher in male patients than in female patients (P = 0.093 in CD; P = 0.147 in UC by interaction analysis).

CONCLUSIONS

Patients with IBD, especially CD, have an increased risk of developing IPF.

Risk of Atrial Fibrillation in Relation to the Time Course of Type 2 Diabetes Mellitus and Fasting Blood Glucose

The relation of progression of type 2 diabetes and detailed fasting glucose level with risk of atrial fibrillation (AF) is not well known. A total of 6,199,629 subjects not diagnosed with AF who underwent health check-up in 2009 were included from the Korean National Health Insurance Service database. Risk of AF was compared among subjects with normal fasting glucose (NFG), subjects with impaired fasting glucose (IFG), patients with diabetes duration <5 years (early diabetes mellitus [DM]), and patients with diabetes duration ≥5 years (late DM). Next, risk of AF stratified by fasting glucose level per 10 mg/dL was assessed. During a mean follow-up of 7.2 years, the risk of AF significantly increased across the time course of type 2 diabetes (adjusted hazard ratio (aHR) 1.04, 95% confidence interval (CI) 1.02 to 1.05 for IFG; aHR 1.06, 95% CI 1.04 to 1.08 for early DM; aHR 1.09, 95% CI 1.07 to 1.11 for late DM). The risk of AF was significantly higher in subjects who progressed to type 2 diabetes in the IFG group. Risk of AF increased with a 10 mg/dL increment of fasting blood glucose (p-for-trend <0.0001). However, there was a U-shape relationship between fasting blood glucose and risk of AF in those who received antidiabetic medication. In conclusion, the risk of AF increased with the time course of type 2 diabetes. However, low blood glucose in antidiabetic medication user was associated with an increased risk of AF.

Validation of diagnostic codes of major clinical outcomes in a National Health Insurance database

Background and objectives

The Korean National Health Insurance Service (NHIS) database has been widely used for cardiovascular research. We validated the primary diagnostic codes of major clinical outcomes, including acute myocardial infarction (AMI), gastrointestinal bleeding (GIB), stroke, and intracranial hemorrhage (ICH) used for Korea NHIS claims.

Subjects and methods

From 2016 to 2017, 800 patients with primary diagnostic codes of AMI, GIB, stroke, or ICH at discharge were randomly selected from a single tertiary medical center in Korea (200 patients per each diagnosis). The positive predictive value (PPV), sensitivity, and specificity of the primary diagnostic codes were calculated using hospital medical record review as the gold standard. Further improvement in the diagnostic validity of the codes was assessed by combining clinical information such as duration of hospitalization, blood transfusion, brain imaging studies, or prescription records of antithrombotic agents.

Results

Among 200 patients with AMI as the primary discharge diagnosis, 184 patients were clinically confirmed (PPV of 92.0%). For GIB, 184 (92.0%) patients with the primary discharge diagnosis were verified to have true GIB events, showing PPV of 92%. For stroke, 181 (90.5%) patients were clinically confirmed with true stroke events. For ICH, 143 (71.5%) patients were verified to be true ICH events. In stroke and ICH, the PPV and specificity improved after combining with the hospitalization duration, imaging studies, and prescription of antithrombotic agents.

Conclusions

For major clinical outcomes in the NHIS database, the primary diagnostic codes showed favorable reliability. For stroke and ICH, considerations of relevant clinical information could improve the accuracy of diagnosis.

Risk of early mortality and cardiovascular disease in type 1 diabetes: a comparison with type 2 diabetes, a nationwide study

Background

Both type 1 and type 2 diabetes are well-established risk factors for cardiovascular disease and early mortality. However, few studies have directly compared the hazards of cardiovascular outcomes and premature death among people with type 1 diabetes to those among people with type 2 diabetes and subjects without diabetes. Furthermore, information about the hazard of cardiovascular disease and early mortality among Asians with type 1 diabetes is sparse, although the clinical and epidemiological characteristics of Asians with type 1 diabetes are unlike those of Europeans. We estimated the hazard of myocardial infarction (MI), hospitalization for heart failure (HF), atrial fibrillation (AF), and mortality during follow-up in Korean adults with type 1 diabetes compared with those without diabetes and those with type 2 diabetes.

Methods

We used Korean National Health Insurance Service datasets of preventive health check-ups from 2009 to 2016 in this retrospective longitudinal study. The hazard ratios of MI, HF, AF, and mortality during follow-up were analyzed using the Cox regression analyses according to the presence and type of diabetes in ≥ 20-year-old individuals without baseline cardiovascular disease (N = 20,423,051). The presence and type of diabetes was determined based on the presence of type 1 or type 2 diabetes at baseline.

Results

During more than 93,300,000 person-years of follow-up, there were 116,649 MIs, 135,532 AF cases, 125,997 hospitalizations for HF, and 344,516 deaths. The fully-adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) for incident MI, hospitalized HF, AF, and all-cause death within the mean follow-up of 4.6 years were higher in the type 1 diabetes group than the type 2 diabetes [HR (95% CI) 1.679 (1.490–1.893) for MI; 2.105 (1.901–2.330) for HF; 1.608 (1.411–1.833) for AF; 1.884 (1.762–2.013) for death] and non-diabetes groups [HR (95% CI) 2.411 (2.138–2.718) for MI; 3.024 (2.730–3.350) for HF; 1.748 (1.534–1.993) for AF; 2.874 (2.689–3.073) for death].

Conclusions

In Korea, the presence of diabetes was associated with a higher hazard of cardiovascular disease and all-cause death. Specifically, people with type 1 diabetes had a higher hazard of cardiovascular disease and all-cause mortality compared to people with type 2 diabetes.

Risk of end-stage renal disease from chronic kidney disease defined by decreased glomerular filtration rate in type 1 diabetes: A comparison with type 2 diabetes and the effect of metabolic syndrome

BACKGROUND

We estimated the end-stage renal disease (ESRD) risk of chronic kidney disease (CKD) in patients with type 1 diabetes (T1D). The ESRD risk of CKD in patients with T1D was compared with that of CKD in patients without diabetes and with type 2 diabetes (T2D). We also evaluated the predictive value of metabolic syndrome (MetS) for ESRD development in CKD patients with T1D.

MATERIALS AND METHODS

The Korean National Health Insurance Service datasets of preventive health check-ups from 2009 to 2016 were used. The risk of incident ESRD was analysed according to the presence and type of diabetes in CKD (defined as an estimated glomerular filtration rate < 60 mL/min/1.73 m² ) patients aged 20 years or older. Incident ESRD risk according to the presence of MetS was calculated among adult patients with CKD and T1D.

RESULTS

During 10 701 375.84 person-years of follow-up, 43 693 cases of ESRD developed. Hazard ratios (HRs) for incident ESRD from CKD in the T1D group were 2.580 (95% confidence interval [CI], 2.336-2.849) and 9.267 (95% CI, 8.378-10.251) compared with T2D and nondiabetes groups, respectively. In CKD patients with T1D, the presence of MetS increased incident ESRD risk by an HR of 2.023 (95% CI, 1.501-2.727).

CONCLUSIONS

The presence of diabetes increases the risk for ESRD development from CKD. Furthermore, patients with T1D have a higher risk for ESRD incidence from CKD than do patients with T2D in a Korean population. MetS may be a useful predictor for ESRD in CKD patients with T1D.

Obstructive sleep apnea as a risk factor for incident end stage renal disease: a nationwide population-based cohort study from Korea

BACKGROUND

Obstructive sleep apnea (OSA) is known to be associated with metabolic dysregulation and incident cardiovascular diseases. However, its association with end-stage renal disease (ESRD) has not been clarified. This study aimed to evaluate longitudinally whether OSA is an independent risk factor for ESRD.

METHODS

This retrospective nationwide population-based cohort study included data on 67,359 patients with OSA and 336,795 age-, sex- and years of the enrollment-matched controls without OSA obtained from the Korean National Health Insurance Service database from 2009 to 2014. The study population was followed up from baseline to the date of ESRD diagnosis or until 2016. A Cox proportional-hazards model with multivariable adjustment was used to evaluate the association between OSA and incident ESRD.

RESULTS

A significantly higher incident ESRD risk (adjusted hazard ratio: 1.29, 95% confidence interval 1.02-1.62) was observed for patients older than 40 years with OSA than for matched controls, when adjusted for age, sex, income status, smoking, alcohol consumption, body mass index, diabetes, hypertension, dyslipidemia, estimated glomerular filtration rate, and proteinuria. The OSA group remained predictive of higher risk of ESRD incidence in subgroups of age ≥ 65 years, female sex, hypertension, dyslipidemia, proteinuria, and chronic kidney disease.

CONCLUSION

OSA was associated with a higher risk of incident ESRD. Understanding the association between OSA and ESRD might provide further insights to establish national health care policy.

Patients with Inflammatory Bowel Disease Are at an Increased Risk of Parkinson's Disease: A South Korean Nationwide Population-Based Study

Background and Aims: It is not known whether inflammatory bowel disease (IBD) enhances the risk of Parkinson’s disease (PD) or whether PD diagnosis is the result of increased health care use. We determined the risk of developing PD among patients with IBD in terms of health care and medication use. Methods: A nationwide population-based study was conducted using claims data from the Korean National Health care Insurance service. From 2010 to 2013, patients with Crohn’s disease (CD) and ulcerative colitis (UC) were identified through both International Classification of Disease, Tenth Revision (ICD-10) and national rare intractable disease (RID) registration program codes. We compared 38,861 IBD patients with age and sex-matched non-IBD individuals at a ratio of 1:3. Patients with newly diagnosed PD were identified through both ICD-10 and RID codes. Results: The incidence of PD among patients with IBD was 49 per 100,000 person-years. The risk of developing PD in patients with IBD was significantly higher than controls even after adjustment for health care use (adjusted hazard ratio (aHR), 1.87; P < 0.001). Compared to controls, the risk of PD was significantly higher in patients with CD (aHR, 2.23; P = 0.023) and UC (aHR, 1.85; P < 0.001). Corticosteroid use showed a preventive effect on developing PD in patients with CD (aHR 0.08; P < 0.001), but not UC (aHR, 0.75; P = 0.213). Among 2110 patients receiving anti-tumor necrosis factor (anti-TNF), none of the treated patients experienced PD during 9950 person-years. Conclusion: Patients with IBD are at an increased risk of PD, regardless of health care use. Corticosteroid and anti-TNF use may prevent PD in patients with IBD.

The risk of end-stage renal disease in systemic lupus erythematosus: A nationwide population-based study in Korea

Systemic lupus erythematosus (SLE) is known to be one of the leading causes of end-stage renal disease (ESRD). The aim of this study was to estimate the incidence rate of ESRD and the risk for progression to ESRD in SLE patients compared to the general population.A total of 21,253 SLE patients were extracted from the Korean National Health Insurance Service database between 2008 and 2013. Age-and sex-matched controls (n = 106,265) were randomly sampled in a 5:1 ratio from non-SLE individuals. Both cohorts were followed up for development of ESRD until 2015.During the median 7.53 years of follow-up, 533 (2.51%) cases of ESRD were newly developed in SLE patients and 145 (0.14%) cases in matched controls (incidence rate: 4.075 and 0.219 per 1000 person-year, respectively). SLE patients were at higher risk for ESRD development compared to matched controls (hazard ratio [HR], 9.84; 95% confidence interval [CI] 8.10-11.96) after multivariate adjustment. In subgroup analysis, the risk for ESRD was higher in male (HR, 7.76; 95% CI 5.07-11.90) and female patients with SLE (HR, 10.48; 95% CI 8.41-13.07) than in matched controls. When analyzed by age group, the younger the age, the higher the risk of ESRD versus non-SLE matched controls; this result was also significant after adjustment. In subgroup analysis according to comorbidities, the SLE group had a significantly higher risk of ESRD than the non-SLE group in almost all subgroups.SLE was associated with an increased incidence of ESRD.

Increased risk of atrial fibrillation in patients with Behçet's disease: A nationwide population-based study

BACKGROUND

Chronic inflammation plays a role in the pathophysiology of atrial fibrillation (AF). However, there is a paucity of information about whether Behçet's disease (BD) is associated with an increased risk of AF. This population-based study aimed to determine the risk of AF in patients with BD.

METHODS

A total of 6636 newly diagnosed BD patients without a history of AF were included from the Korean National Health Insurance Service database between 2010 and 2014. Newly diagnosed non-valvular AF was identified using the claims data. An age- and sex-matched non-BD subjects were extracted at a ratio of 1:5 (n = 31,040). The incidence and risk of AF were compared between groups.

RESULTS

During a mean follow-up of 3.6 ± 1.5 years, AF was newly diagnosed in 173 patients (51 in the BD group, 122 in the control group). The incidence was 2.3 and 1.1 per 1000 person-years, respectively. After adjustment, the BD group showed a 1.8-fold higher risk of AF compared to the control group. Patients with BD aged ≤40 years had a higher risk of AF, while patients aged ≥65 years showed a similar risk. Men with BD had a 2.5-fold increased risk of AF, whereas women with BD did not. Severe BD had a higher risk for AF compared to non-severe BD and controls.

CONCLUSIONS

BD was associated with an increased risk of AF, particularly in men and young patients. Active surveillance and treatment are needed in BD patients and those with arrhythmic symptoms.

Antithrombotic Therapy in Patients With Atrial Fibrillation After Percutaneous Coronary Intervention During 2-Year Follow-Up, from a Nationwide Population Study

Patients with atrial fibrillation (AF) who underwent percutaneous coronary intervention (PCI) are recommended to receive oral anticoagulants (OAC) and concomitant antiplatelet agents followed by OAC monotherapy continued beyond a year after PCI. However, long-term prescription patterns of antithrombotic therapy in real-world clinical practice were not fully investigated. From the National Health Insurance Service database of Korea, we obtained records of patients with AF who underwent PCI between 2009 and 2013. Patients without repeated PCI or death within 2 years following the procedure were included. Prescription records of antithrombotic therapy including anticoagulants and antiplatelet agents were reviewed at 3-month intervals after discharge. We investigated 8,891 patients. At discharge, 76.1% of the patients received dual antiplatelet therapy (DAPT) and only 17.1% received OAC. Although the proportion of patients receiving DAPT gradually decreased, >70% of patients received only antiplatelet agents (DAPT or single antiplatelet therapy) a year after PCI. During the 2-year follow-up, the proportion of patients receiving OAC remained <20%, and only 1.5% of the patients received OAC monotherapy a year after PCI. Female gender, previous myocardial infarction, peripheral vascular disease, and prescription of DAPT at discharge were associated with underprescription of OAC a year after PCI. In conclusion, a significant proportion (76%) of patients with AF who underwent PCI were not prescribed OAC at discharge despite the high risk of stroke contrary to the current guidelines. Most patients continued to receive antiplatelet agents without OAC beyond the 1-year time point after PCI.

Increased risk of atrial fibrillation in patients with inflammatory bowel disease: A nationwide population-based study

BACKGROUND

Inflammatory bowel disease (IBD), a chronic inflammatory disease of the gastrointestinal tract, could play a role in the pathophysiology of atrial fibrillation (AF).

AIM

To investigate the association between IBD and AF development.

METHODS

We performed a population-based cohort study using records in the Korean National Health Insurance Services database between 2010 and 2014. A total of 37696 patients with IBD (12349 with Crohn’s disease and 25397 with ulcerative colitis) were identified. The incidence rate of newly diagnosed AF in patients with IBD was compared with that in a 3 times larger cohort of 113088 age- and sex-matched controls without IBD.

RESULTS

During 4.9 ± 1.3 years of follow-up, 1120 patients newly diagnosed with AF (348 in the IBD group and 772 in controls) were identified. After adjustments using multivariable Cox proportional hazards, patients with IBD were at a 36% [95% confidence interval (CI) 20%-54%] higher risk of AF than controls. The association between IBD and the development of AF was stronger in younger than in older patients. Patients without cardiovascular risk factors showed a higher risk of AF primarily. Additionally, patients receiving immun-omodulators [Hazard ration (HR) 1.46, 95%CI 1.31-1.89], systemic corticosteroids (HR 1.37, 95%CI 1.10-1.71), or biologics agents (HR 2.38, 95%CI 1.51-3.75) were at higher risk of AF than patients without them.

CONCLUSION

IBD significantly increased the risk of AF, and the impact of IBD on developing AF was in patients with moderate to severe disease.

Risk of Anxiety and Depression in Patients with Inflammatory Bowel Disease: A Nationwide, Population-Based Study

Background and Aims: Inflammatory bowel disease (IBD) may be associated with anxiety and depression. The aim of this study was to evaluate the incidence of anxiety and depression in patients with IBD compared to the general population. Methods: A nationwide population-based cohort study was conducted using claims data from the National Healthcare Insurance service in Korea. We compared the incidence of anxiety and depression between 15,569 IBD patients and 46,707 non-IBD controls, age and sex matched at a ratio of 1:3. Results: During a mean follow-up of six years, IBD patients experienced significantly more anxiety (12.2% vs. 8.7%; p < 0.001) and depression (8.0% vs. 4.7%; p < 0.001) compared to controls. The curves showing cumulative incidences of anxiety and depression showed a steep rise within one year following a diagnosis of IBD, leading to lines with a constant slope. The hazard ratio (HR) for new onset anxiety following a diagnosis of Crohn’s disease (CD) and ulcerative colitis (UC) was 1.63 and 1.60, respectively, compared to controls (p < 0.001). Compared to controls, the HR for developing depression after a diagnosis of CD and UC was 2.09 and 2.00, respectively (p < 0.001). The risks of anxiety and depression in patients with IBD were higher compared to controls, except in those with diabetes mellitus, hypertension, and dyslipidemia, or who required immunomodulators and biologics within one year of the IBD diagnosis. Conclusions: The risk of anxiety and depression increased after a diagnosis of IBD compared to the general population.

Association between adult height, myocardial infarction, heart failure, stroke and death: a Korean nationwide population-based study

Background

The association between adult height and cardiovascular (CV) events and mortality has been suggested, albeit inconsistently. We sought to discover the comprehensive relationship between height, CV-related morbidity and all-cause death according to age.

Methods

We investigated the association between adult height and myocardial infarction (MI), heart failure (HF), stroke incidence and mortality in 16 528 128 Korean patients who underwent regular health check-ups (2005-08). Height was stratified by decile according to age (20-39 years, 40-59 years and ≥60 years) and gender.

Results

During a 9-year follow-up period, 590 346 participants died and 232 093 were admitted to hospital for MI, 201 411 for HF and 267 566 for stroke. An inverse relationship between height and MI, HF, stroke and all-cause death was observed in the overall cohort analysis. The association was unchanged after adjusting for CV risk and behavioural and adulthood socioeconomic factors. Both male and female sex showed an inverse relationship with height in adulthood, CV events and mortality. Adult height showed an inverse association in all CV events and mortality, especially in the older groups (≥40 years). In a subgroup analysis of body mass index, there was an inverse relationship between height, CV events and mortality in each group.

Conclusions

Shorter height in adulthood was strongly related to an increased risk of MI, HF, stroke and all-cause death. A suitable environment and appropriate nutrition early in life could influence adult height and eventually reduce the risk of CV events and mortality.

Temporal trends in prevalence and antithrombotic treatment among Asians with atrial fibrillation undergoing percutaneous coronary intervention: A nationwide Korean population-based study

Background

We investigated the recent 10-year trends in the number of patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI) in relation to prescription patterns of antithrombotic therapy.

Methods

We analyzed the annual prevalence of PCI and patterns of antithrombotic therapy after PCI, including antiplatelets and oral anticoagulants (vitamin K antagonists and non-vitamin K antagonist oral anticoagulants [NOACs]), in patients with AF between 2006 and 2015 by using the Korean National Health Insurance Service database. Independent factors associated with triple therapy (oral anticoagulant plus dual antiplatelet) prescription were assessed using multivariable logistic regression analysis.

Results

The number of patients with AF undergoing PCI increased gradually from 2006 (n = 2,140) to 2015 (n = 3,631) (p_trend<0.001). In 2006, only 22.7% of patients received triple therapy after PCI although 96.2% of them were indicated for anticoagulation (CHA₂DS₂-VASc score ≥2). The prescription rate of triple therapy increased to 38.3% in 2015 (p_trend<0.001), which was mainly attributed to a recent increment of NOAC-based triple therapy from 2013 (17.5% in 2015). Previous ischemic stroke or systemic embolism, old age, hypertension, and congestive heart failure were significantly associated with a higher triple therapy prescription rate, whereas previous myocardial infarction, PCI, and peripheral arterial disease were associated with triple therapy underuse.

Conclusions

From 2006 to 2015, the number of patients with AF undergoing PCI and the prescription rate of triple therapy increased gradually with a recent increment of NOAC-based antithrombotic therapy from 2013. Previous myocardial infarction, peripheral artery disease, and PCI were associated with underuse of triple therapy.

Mortality and causes of death in patients with atrial fibrillation: A nationwide population-based study

Background

Patients with atrial fibrillation are known to have a high risk of mortality. There is a paucity of population-based studies about the impact of atrial fibrillation on the mortality risk stratified by age, sex, and detailed causes of death.

Methods

A total of 15,411 patients with atrial fibrillation from the Korean National Health Insurance Service-National Sample Cohort were enrolled, and causes of death were identified according to codes of the 10th revision of the International Classification of Diseases.

Results

From 2002 to 2013, a total of 4,479 (29%) deaths were confirmed, and the crude mortality rate for all-cause death was 63.3 per 1,000 patient-years. Patients with atrial fibrillation had a 3.7-fold increased risk of all-cause death compared with the general population. The standardized mortality ratio for all-cause death was the highest in young patients and decreased with increasing age (standardized mortality ratio 21.93, 95% confidence interval 7.60–26.26 in patients aged <20 years; standardized mortality ratio 2.77, 95% confidence interval 2.63–2.91 in patients aged ≥80 years). Women with atrial fibrillation exhibited a greater excess mortality risk than men (standardized mortality ratio 3.81, 95% confidence interval 3.65–3.98 in women; standardized mortality ratio 3.35, 95% confidence interval 3.21–3.48 in men). Cardiovascular disease was the leading cause of death (38.5%), and cerebral infarction was the most common specific disease. Patients with atrial fibrillation had an about 5 times increased risk of death due to cardiovascular disease compared with the general population.

Conclusions

Patients with atrial fibrillation had a 4 times increased risk of mortality compared with the general population. However, the impact of atrial fibrillation on mortality decreased with age and in men. Cerebral infarction was the most common cause of death, and more attention should be paid to reducing the risk of stroke.

2018 Korean Guideline of Atrial Fibrillation Management

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia in the general population. The Korean Heart Rhythm Society organized a Korean AF Management Guideline Committee and analyzed all available studies regarding the management of AF, including studies on Korean patients. This guideline is based on recent data of the Korean population and the recent guidelines of the European Society of Cardiology, European Association for Cardio-Thoracic Surgery, American Heart Association, and Asia Pacific Heart Rhythm Society. Expert consensus or guidelines for the optimal management of Korean patients with AF were achieved after a systematic review with intensive discussion. This article provides general principles for appropriate risk stratification and selection of anticoagulation therapy in Korean patients with AF. This guideline deals with optimal stroke prevention, screening, rate and rhythm control, risk factor management, and integrated management of AF.

Ankylosing spondylitis: A novel risk factor for atrial fibrillation - A nationwide population-based study

BACKGROUND

Ankylosing spondylitis (AS) is a chronic inflammatory rheumatic disease, associated with a number of cardiovascular diseases. We sought to investigate whether AS increases the risk of atrial fibrillation (AF) in a nationwide population-based study.

METHODS

A total of 14,129 patients newly diagnosed with AS (mean age 41.8 ± 15.3 years, 72% male) were recruited from the Korean National Health Insurance Service database between 2010 and 2014 and followed up for new onset AF. Age- and sex-matched non-AS subjects (1:5, n = 70,645) were selected and compared with the AS patients.

RESULTS

During a mean follow-up of 3.5 years, AF was newly diagnosed in 486 patients (114 patients of the AS group). The AS patients developed AF more frequently than the non-AS subjects (2.32 vs. 1.51 per 1000 person-years). In multivariate Cox regression analysis, AS was an independent risk factor for AF (Hazard ratio [HR] 1.28, 95% confidence interval [1.03-1.58]). The AS with tumor necrosis factor inhibitor (TNFi) therapy group showed higher risk for AF (HR 1.60 [1.02-2.39]). In younger patients of the AS group (patients <40 years old), the risk for AF was three times higher than patients at same age in the non-AS group. AS was an independent risk factor for AF in men, but not in women (HR 1.53 [1.18-1.95]; HR 1.42 [0.94-2.08], respectively).

CONCLUSIONS

AS was an independent risk factor for AF, especially in those under 40 years of age and those administered TNFi. It would be reasonable to screen for AF and stroke prevention in these high-risk patients.

Risk factors for new-onset atrial fibrillation: A focus on Asian populations

The incidence of new-onset atrial fibrillation (NOAF) is increasing both in the Asian populations and Western countries. Several demographic and clinical risk factors were independently associated with NOAF, including ageing, male sex, obesity, obstructive sleep apnea syndrome, hypertension, coronary artery disease, renal dysfunction and heart failure. However, some differences in the incidence of NOAF, the prevalence of some risk factors and lifestyle or environmental conditions may exist between Asian and Western countries. Early recognition and holistic management of risk factors in an integrated manner may help reduce the burden of NOAF and its complications. While some risk scores have been developed to predict the risk of NOAF, thus far none are currently recommended or adequately validated to be used as a screening tool especially in the Asian population. The present semi-systematic review article aims to provide a comprehensive overview on the risk factors associated to NOAF, focusing on those explored in the Asian populations.

Psoriasis risk in patients with diabetic retinopathy: A nationwide population-based study

Psoriasis is a chronic cutaneous disease known to be related with systemic disease; however, the association between psoriasis and diabetic complications has not been previously reported. Diabetic microvascular complications include diabetic retinopathy (DR), nephropathy, and neuropathy, and overt diabetic nephropathy can lead to the end-stage renal disease (ESRD).The present study investigated the association between psoriasis and non-proliferative DR (NPDR) or proliferative DR (PDR) or ESRD. We analyzed the relationship between diabetic complication and psoriasis using data from the National Health Insurance Service between 2009 and 2015. During a mean follow-up of 5.18 years, 43,792 patients were newly diagnosed with psoriasis. In Cox proportional hazard models, patients with NPDR (hazard ratio [HR] 1.26) had a higher incidence of psoriasis and patients with PDR patients had a higher risk of psoriasis (HR 1.35). ESRD was defined by the ICD-10 code, including chronic kidney disease/renal failure, transplantation, and dialysis. The incidence of psoriasis increased in DR patients with ESRD (HR 2.99, 95% CI 2.49–3.59, p < 0.001) compared to non-DR patients without ESRD. This is the first association study between psoriasis and diabetic complications including DR and ESRD. DR and its severity were related to the onset of psoriasis. In addition, ESRD was related with an increased psoriasis in DR patients.

Increased Risk of Atrial Fibrillation in the Early Period after Herpes Zoster Infection: a Nationwide Population-based Case-control Study

BACKGROUND

Herpes zoster (HZ) is a chronic inflammatory disease that could result in autonomic dysfunction, often leading to atrial fibrillation (AF).

METHODS

From the Korean National Health Insurance Service database of 738,559 subjects, patients newly diagnosed with HZ (n = 30,685) between 2004 and 2011, with no history of HZ or AF were identified. For the non-HZ control group, 122,740 age- and sex-matched subjects were selected. AF development in the first two-years following HZ diagnosis, and during the overall follow-up period were compared among severe (requiring hospitalization, n = 2,213), mild (n = 28,472), and non-HZ (n = 122,740) groups.

RESULTS

There were 2,204 (1.4%) patients diagnosed with AF during follow-up, and 825 (0.5%) were diagnosed within the first two years after HZ. The severe HZ group showed higher rates of AF development (6.4 per 1,000 patient-years [PTPY]) compared to mild-HZ group (2.9 PTPY) and non-HZ group (2.7 PTPY). The risk of developing AF was higher in the first two-years after HZ diagnosis in the severe HZ group (10.6 PTPY vs. 2.7 PTPY in mild-HZ group and 2.6 PTPY in non-HZ group).

CONCLUSION

Severe HZ that requires hospitalization shows an increased risk of incident AF, and the risk is higher in the first two-years following HZ diagnosis.

Association between BMI and risk of severe hypoglycaemia in type 2 diabetes

AIM

This study aimed to assess the association between body mass index (BMI) and the development of severe hypoglycaemia in patients with type 2 diabetes (T2D), using nationwide data for the entire South Korean population.

METHODS

The association between BMI and severe hypoglycaemia was retrospectively examined from claims and National Health examination data registered between 2002 and 2015. A total of 1,366,692 subjects assigned clinical codes for T2D and prescribed antihypoglycaemic agents were included. The primary outcome was an episode of severe hypoglycaemia after the baseline health examination.

RESULTS

A total of 37,682 subjects (2.7%) experienced a new severe hypoglycaemic event during the follow-up period (mean: 8.6 years). An inverse J-shaped association was observed between BMI and severe hypoglycaemic events. The association between low BMI and high risk of severe hypoglycaemia was similar in subjects who had never smoked, did not consume alcohol, did not use insulin and had no major comorbidities, after adjusting for multiple confounding variables. This association was also found to be intensified in men, young people aged 30-49 years, those with major comorbidities and insulin users.

CONCLUSION

BMI and severe hypoglycaemia were found to be inversely associated. Thus, those who fall into the category of having low BMI and high risk of severe hypoglycaemia should be warned about the risk of having a hypoglycaemic event and be properly informed about hypoglycaemia to minimize the risk of fatal hypoglycaemia-related outcomes.

The Genetic and Environmental Factors of Primary Membranous Nephropathy: An Overview from China

Background

Primary membranous nephropathy (pMN) is the most common cause of nephrotic syndrome in adults. The discovery of the 2 autoantigens, M-type phospholipase A2 receptor (PLA2R) and thrombospondin type-1 domain-containing 7A (THSD7A), has defined pMN as an autoimmune disease. A remarkable increase in the frequency of pMN in primary glomerular disease was witnessed in China. The genetic and environmental contributors to disease susceptibility have been investigated in these patients.

Summary

We reviewed recent publications in genetic and environmental studies of pMN, focusing mainly on those undertaken in China. Following a genome-wide association study, the gene-gene interaction between the 2 most significant risk factors, PLA2R1 and DQA1, was validated in Chinese patients with MN. Fine mapping on human leukocyte antigen (HLA) locus found that DRB1*1501 and DRB1*0301 were risk alleles. Three amino acid residues on positions 13 and 71 of HLA-DRβ1 chain may confer the susceptibility to pMN by presenting T-cell epitopes on PLA2R. Another study found that DRB3*0202 was the most likely culprit allele for the signal at DRB1*0301. One environmental risk factor for pMN has been identified as the long-term exposure to high levels of PM_2.5 in Chinese patients with MN. Each 10 μg/m³ increase in PM_2.5 concentration was associated with 14% higher odds for pMN in the regions with PM_2.5 above 70 μg/m³.

Key Message

A gene-environment interaction is suspected as an underlying mechanism for the increasing trend of pMN in China.

Risk of ischemic stroke in metabolically healthy obesity: A nationwide population-based study

Background

Whether metabolically healthy obese (MHO) individuals are at increased risk of ischemic stroke is not well known. We investigated the association of the MHO phenotype with ischemic stroke.

Methods

A total of 354,083 adults (age 45.8 ± 14.2 years) from the Korean National Health Insurance Service–National Sample Cohort enrolled in 2004–2008 were followed-up for incident ischemic stroke until 2013. Subjects meeting none of the metabolic syndrome criteria were classified as ‘metabolically healthy’. The cohort was categorized into four groups according to obesity and metabolic status: metabolically healthy normal weight (MHNW), metabolically unhealthy normal weight (MUNW), MHO, and metabolically unhealthy obese (MUO).

Results

Ischemic stroke was newly diagnosed in 4,884 (1.4%) individuals during a mean follow-up of 7.4 ± 1.5 years. Stroke incidence rates for the MHNW, MUNW, MHO, and MUO groups were 0.56, 2.61, 0.61, and 2.76 per 1,000 person-years, respectively. While risk for stroke increased significantly in metabolically unhealthy groups, it was not increased in MHO compared to the MHNW group on multivariate analysis. In metabolically healthy individuals, obesity did not increase the risk for ischemic stroke, regardless of the severity of obesity. Meanwhile, in metabolically unhealthy individuals, being obese was significantly associated with increased risk of stroke.

Conclusions

MHO individuals were not at increased risk for ischemic stroke. However, obesity increased risk for ischemic stroke in persons with metabolic risk factors; therefore, maintaining normal weight may be more important for this population. Also, metabolic unhealthiness showed greater association than obesity with stroke.