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Tabesh M, Sacre JW, Mehta K, Chen L, Sajjadi SF, Magliano DJ, Shaw JE. The association of glycaemic risk factors and diabetes duration with risk of heart failure in people with type 2 diabetes: A systematic review and meta-analysis. Diabetes Obes Metab 2024. [PMID: 39268959 DOI: 10.1111/dom.15938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2024] [Revised: 08/20/2024] [Accepted: 08/26/2024] [Indexed: 09/15/2024]
Abstract
AIMS To conduct a systematic review in order to better understand the association of glycaemic risk factors and diabetes duration with risk of heart failure (HF) in individuals with type 2 diabetes (T2D). METHODS We identified longitudinal studies investigating the association of glycaemic factors (glycated haemoglobin [HbA1c], HbA1c variability, and hypoglycaemia) and diabetes duration with HF in individuals with T2D. Hazard ratios and odds ratios were extracted and meta-analysed using a random-effects model where appropriate. Risk of bias assessment was carried out using a modified Newcastle-Ottawa Scale. Egger's test along with the trim-and-fill method were used to assess and account for publication bias. RESULTS Forty studies representing 4 102 589 people met the inclusion criteria. The risk of developing HF significantly increased by 15% for each percentage point increase in HbA1c, by 2% for each additional year of diabetes duration, and by 43% for having a history of severe hypoglycaemia. Additionally, variability in HbA1c levels was associated with a 20%-26% increased risk of HF for each unit increase in the metrics of variability (HbA1c standard deviation, coefficient of variation, and average successive variability). All included studies scored high in the risk of bias assessment. Egger's test suggested publication bias, with trim-and-fill analyses revealing a significant 14% increased risk of HF per percentage point increase in HbA1c. CONCLUSIONS Glycaemic risk factors and diabetes duration significantly contribute to the heightened risk of HF among individuals with T2D. A reduction in risk of HF is anticipated with better management of glycaemic risk factors.
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Affiliation(s)
- Mahtab Tabesh
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
- Baker Department of Cardiovascular Research, Translation and Implementation, La Trobe University, Melbourne, Victoria, Australia
| | - Julian W Sacre
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Kanika Mehta
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Lei Chen
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Seyeddeh Forough Sajjadi
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Dianna J Magliano
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Jonathan E Shaw
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
- Baker Department of Cardiovascular Research, Translation and Implementation, La Trobe University, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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2
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Huang JY, Cai AP, Tsang CTW, Wu MZ, Gu WL, Guo R, Zhang JN, Zhu CY, Hung YM, Lip GYH, Yiu KH. The association of haemoglobin A1c variability with adverse outcomes in patients with atrial fibrillation prescribed anticoagulants. Eur J Prev Cardiol 2024:zwae249. [PMID: 39140113 DOI: 10.1093/eurjpc/zwae249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Revised: 05/20/2024] [Accepted: 07/17/2024] [Indexed: 08/15/2024]
Abstract
AIMS The association of haemoglobin A1c (HbA1c) variability with the risk of adverse outcomes in patients with atrial fibrillation (AF) prescribed anticoagulants remains unclear. This study aimed to evaluate the association of HbA1c variability with the risk of ischaemic stroke (IS)/systemic embolism (SE) and all-cause mortality among patients with non-valvular AF prescribed anticoagulants. METHODS AND RESULTS Patients newly diagnosed with AF from 2013 to 2018 were included. Variability in HbA1c, indexed by the coefficient of variation (CV), was determined for those with at least three HbA1c measurements available from the time of study enrolment to the end of follow-up. To evaluate whether prevalent diabetes would modify the relationship between HbA1c variability and outcomes, participants were divided into diabetes and non-diabetes groups. The study included 8790 patients (mean age 72.7% and 48.5% female). Over a median follow-up of 5.5 years (interquartile range 5.2, 5.8), the incident rate was 3.74 per 100 person-years for IS/SE and 4.89 for all-cause mortality in the diabetes group. The corresponding incident rates in the non-diabetes group were 2.41 and 2.42 per 100 person-years. In the diabetes group, after adjusting for covariates including mean HbA1c, greater HbA1c variability was significantly associated with increased risk of IS/SE [hazard ratio (HR) = 1.65, 95% confidence interval (CI): 1.27-2.13) and all-cause mortality (HR = 1.24, 95% CI: 1.05-1.47) compared with the lowest CV tertile. A similar pattern was evident in the non-diabetes group (IS/SE: HR = 1.58, 95% CI: 1.23-2.02; all-cause mortality: HR = 1.35, 95% CI: 1.10-1.64). CONCLUSION Greater HbA1c variability was independently associated with increased risk of IS/SE and all-cause mortality among patients with AF, regardless of diabetic status.
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Affiliation(s)
- Jia-Yi Huang
- Division of Cardiology, Department of Medicine, The University of Hong Kong-Shen Zhen Hospital, Shen Zhen, 518000, China
- Division of Cardiology, Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Room 1929B/K1931, Block K, Hong Kong, 999077, China
| | - An-Ping Cai
- Department of Cardiology, Hypertension Research Laboratory, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Southern Medical University, Guangzhou, 510080, China
| | - Christopher Tze Wei Tsang
- Division of Cardiology, Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Room 1929B/K1931, Block K, Hong Kong, 999077, China
| | - Mei-Zhen Wu
- Division of Cardiology, Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Room 1929B/K1931, Block K, Hong Kong, 999077, China
| | - Wen-Li Gu
- Division of Cardiology, Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Room 1929B/K1931, Block K, Hong Kong, 999077, China
| | - Ran Guo
- Division of Cardiology, Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Room 1929B/K1931, Block K, Hong Kong, 999077, China
| | - Jing-Nan Zhang
- Division of Cardiology, Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Room 1929B/K1931, Block K, Hong Kong, 999077, China
| | - Ching-Yan Zhu
- Division of Cardiology, Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Room 1929B/K1931, Block K, Hong Kong, 999077, China
| | - Yik-Ming Hung
- Division of Cardiology, Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Room 1929B/K1931, Block K, Hong Kong, 999077, China
| | - Gregory Y H Lip
- Department of Cardiology,Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, L14 3PE, UK
- Department of Clinical Medicine, Aalborg University, Aalborg, DK-9220, Denmark
| | - Kai-Hang Yiu
- Division of Cardiology, Department of Medicine, The University of Hong Kong-Shen Zhen Hospital, Shen Zhen, 518000, China
- Division of Cardiology, Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Room 1929B/K1931, Block K, Hong Kong, 999077, China
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Conlin PR, Burke BV, Hobbs C, Hurren KM, Lang AE, Morrison JW, Spacek L, Steil EN, Watts SA, Weinreb JE, Pogach LM. Management of Type 2 Diabetes Mellitus: Synopsis of the Department of Veterans Affairs and Department of Defense Clinical Practice Guideline. Mayo Clin Proc 2024; 99:S0025-6196(24)00210-6. [PMID: 39093266 DOI: 10.1016/j.mayocp.2024.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Revised: 04/16/2024] [Accepted: 04/23/2024] [Indexed: 08/04/2024]
Abstract
The US Department of Veterans Affairs (VA) and the US Department of Defense (DoD) approved a joint clinical practice guideline for the management of type 2 diabetes. This was the product of a multidisciplinary guideline development committee composed of clinicians from both the VA and the DoD and was overseen by the VA/DoD Evidence Based Practice Work Group. The development process conformed to the standards for trustworthy guidelines as established by the National Academy of Medicine. The guideline development committee developed 12 key questions to guide an evidence synthesis. An independent third party identified relevant randomized controlled trials and systematic reviews that were published from January 2016 through April 2022. This evidence synthesis served as the basis for drafting recommendations. Twenty-six recommendations were generated and rated by the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. Two algorithms were developed to guide clinical decision-making. This synopsis summarizes key aspects of the VA/DoD Clinical Practice Guideline for diabetes in 5 areas: prediabetes, screening for co-occurring conditions, diabetes self-management education and support, glycemic treatment goals, and pharmacotherapy. The guideline is designed to help clinicians and patients make informed treatment decisions to optimize health outcomes and quality of life and to align with patient-centered goals of care.
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Affiliation(s)
- Paul R Conlin
- Department of Veterans Affairs Boston Healthcare System, Boston, MA.
| | - Brian V Burke
- Department of Veterans Affairs Medical Center, Dayton, OH
| | | | - Kathryn M Hurren
- Department of Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI
| | - Adam Edward Lang
- Department of Primary Care, McDonald Army Health Center, Fort Eustis, VA
| | | | - Lance Spacek
- Department of Veterans Affairs South Texas Healthcare System, San Antonio, TX
| | - Evan N Steil
- Medical Readiness Command-Europe, Sembach, Germany
| | - Sharon A Watts
- Office of Nursing Service, Department of Veterans Affairs Long Beach Healthcare System, Long Beach, CA
| | - Jane E Weinreb
- Department of Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA
| | - Leonard M Pogach
- Specialty Care Program Office, Department of Veterans Affairs, Washington, DC
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Chen J, Yin D, Dou K. Intensified glycemic control by HbA1c for patients with coronary heart disease and Type 2 diabetes: a review of findings and conclusions. Cardiovasc Diabetol 2023; 22:146. [PMID: 37349787 PMCID: PMC10288803 DOI: 10.1186/s12933-023-01875-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 06/02/2023] [Indexed: 06/24/2023] Open
Abstract
The occurrence and development of coronary heart disease (CHD) are closely linked to fluctuations in blood glucose levels. While the efficacy of intensified treatment guided by HbA1c levels remains uncertain for individuals with diabetes and CHD, this review summarizes the findings and conclusions regarding HbA1c in the context of CHD. Our review showed a curvilinear correlation between regulated level of HbA1c and therapeutic effectiveness of intensified glycemic control among patients with type 2 diabetes and coronary heart disease. It is necessary to optimize the dynamic monitoring indicators of HbA1c, combine genetic profiles, haptoglobin phenotypes for example and select more suitable hypoglycemic drugs to establish more appropriate glucose-controlling guideline for patients with CHD at different stage of diabetes.
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Affiliation(s)
- Jingyang Chen
- Cardiometabolic Medicine Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037 China
| | - Dong Yin
- Cardiometabolic Medicine Center, Department of Cardiology, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037 China
| | - Kefei Dou
- Cardiometabolic Medicine Center, Department of Cardiology, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037 China
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Kandinata SG, Soelistijo SA, Pranoto A, Triyono EA. Random Blood Glucose, but Not HbA1c, Was Associated with Mortality in COVID-19 Patients with Type 2 Diabetes Mellitus—A Retrospective Study. PATHOPHYSIOLOGY 2023; 30:136-143. [PMID: 37092526 PMCID: PMC10123645 DOI: 10.3390/pathophysiology30020012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Revised: 03/05/2023] [Accepted: 04/03/2023] [Indexed: 04/08/2023] Open
Abstract
Previous studies have yielded inconsistent results on whether glycated hemoglobin (HbA1c) and random blood glucose (RBG) are associated with mortality of coronavirus disease 2019 (COVID-19) patients with type 2 diabetes mellitus (T2DM). This study aimed to assess the association of HbA1c and RBG with mortality among COVID-19 patients with T2DM. A retrospective study was conducted on 237 patients with COVID-19 and T2DM (survival (n = 169) and non-survival groups (n = 68)). Data on socio-demography, comorbidities, clinical symptoms, laboratory examination, and mortality were collected. Patients in the non-survival group had an older age range as compared with those in the survival group (60 (52.3–65.0) vs. 56.0 (48.5–61.5) years, p = 0.009). There was no statistical gender difference between the two groups. After matching was done, chronic kidney disease, NLR, d-dimer, procalcitonin, and random blood glucose were higher in the non-survival group compared to the survival group (p < 0.05). HbA1c levels were similar in survivors and non-survivors (8.7% vs. 8.9%, p=0.549). The level of RBG was independently associated with mortality of COVID-19 patients with T2DM (p = 0.003, adjusted OR per 1-SD increment 2.55, 95% CI: 1.36–4.76). In conclusion, RBG was associated with the mortality of COVID-19 patients with T2DM, but HbA1c was not.
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Affiliation(s)
- Stefanus Gunawan Kandinata
- Department of Internal Medicine, Dr. Soetomo General Academic Hospital—Faculty of Medicine, Airlangga University, Surabaya 60132, Indonesia
| | - Soebagijo Adi Soelistijo
- Endocrinology, Metabolism and Diabetes Unit, Department of Internal Medicine, Dr. Soetomo General Academic Hospital—Faculty of Medicine, Airlangga University, Surabaya 60132, Indonesia
| | - Agung Pranoto
- Endocrinology, Metabolism and Diabetes Unit, Department of Internal Medicine, Dr. Soetomo General Academic Hospital—Faculty of Medicine, Airlangga University, Surabaya 60132, Indonesia
| | - Erwin Astha Triyono
- Tropical and Infectious Disease Unit, Department of Internal Medicine, Dr. Soetomo General Academic Hospital—Faculty of Medicine, Airlangga University, Surabaya 60132, Indonesia
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Sartore G, Ragazzi E, Caprino R, Lapolla A. Long-term HbA1c variability and macro-/micro-vascular complications in type 2 diabetes mellitus: a meta-analysis update. Acta Diabetol 2023; 60:721-738. [PMID: 36715767 PMCID: PMC10148792 DOI: 10.1007/s00592-023-02037-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 01/17/2023] [Indexed: 01/31/2023]
Abstract
AIMS The aim of the present study was to evaluate, by means of a meta-analysis approach, whether new available data, appeared on qualified literature, can support the effectiveness of an association of HbA1c variability with the risk of macro- and/or micro-vascular complications in type 2 diabetes mellitus (T2DM). METHODS The meta-analysis was conducted according to PRISMA Statement guidelines and considered published studies on T2DM, presenting HbA1c variability as standard deviation (SD) or its derived coefficient of variation (CV). Literature search was performed on PubMed in the time range 2015-July 2022, with no restrictions of language. RESULTS Twenty-three selected studies fulfilled the aims of the present investigation. Overall, the analysis of the risk as hazard ratios (HR) indicated a significant association between the HbA1c variability, expressed either as SD or CV, and the complications, except for neuropathy. Macro-vascular complications were all significantly associated with HbA1c variability, with HR 1.40 (95%CI 1.31-1.50, p < 0.0001) for stroke, 1.30 (95%CI 1.25-1.36, p < 0.0001) for transient ischaemic attack/coronary heart disease/myocardial infarction, and 1.32 (95%CI 1.13-1.56, p = 0.0007) for peripheral arterial disease. Micro-vascular complications yielded HR 1.29 (95%CI 1.22-1.36, p < 0.0001) for nephropathy, 1.03 (95%CI 0.99-1.08, p = 0.14) for neuropathy, and 1.15 (95%CI 1.08-1.24, p < 0.0001) for retinopathy. For all-cause mortality, HR was 1.33 (95%CI 1.27-1.39, p < 0.0001), and for cardiovascular mortality 1.25 (95%CI 1.17-1.34, p < 0.0001). CONCLUSIONS Our meta-analysis on HbA1c variability performed on the most recent published data since 2015 indicates positive association between HbA1c variability and macro-/micro-vascular complications, as well as mortality events, in T2DM, suggesting that this long-term glycaemic parameter merits further attention as a predictive, independent risk factor for T2DM population.
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Affiliation(s)
- Giovanni Sartore
- Department of Medicine - DIMED, University of Padua, Padua, Italy
| | - Eugenio Ragazzi
- Department of Pharmaceutical and Pharmacological Sciences - DSF, University of Padua, Padua, Italy.
| | - Rosaria Caprino
- Department of Medicine - DIMED, University of Padua, Padua, Italy
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7
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Sun B, Gao Y, He F, Liu Z, Zhou J, Wang X, Zhang W. Association of visit-to-visit HbA1c variability with cardiovascular diseases in type 2 diabetes within or outside the target range of HbA1c. Front Public Health 2022; 10:1052485. [PMID: 36438253 PMCID: PMC9686379 DOI: 10.3389/fpubh.2022.1052485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Accepted: 10/27/2022] [Indexed: 11/11/2022] Open
Abstract
Background Although a growing attention has been recently paid to the role of HbA1c variability in the risk of diabetic complications, the impact of HbA1c variability on cardiovascular diseases (CVD) in type 2 diabetes is still debated. The aim of the study is to investigate the association of HbA1c variability with CVD in individuals within or outside the target range of HbA1c. Methods Using data from Action in Diabetes and Vascular disease: preterAx and diamicroN-MR Controlled Evaluation (ADVANCE), we enrolled 855 patients with type 2 diabetes in China. The primary outcomes included major macrovascular events and major microvascular events. Visit-to-visit HbA1c variability was expressed as the coefficient of variation (CV) of five measurements of HbA1c taken 3-24 months after treatment. Cox proportional hazard models were used to estimate adjusted hazard ratios (aHR). Results Among 855 patients in the intensive glucose treatment group, 563 and 292 patients were assigned to the group of "within the target range of HbA1c" (WTH) (updated mean HbA1c ≤ 7.0%) and "outside the target range of HbA1c" (OTH) (updated mean HbA1c > 7.0%), respectively. HbA1c variability was positively associated with the risk of major microvascular events in all patients and both the subgroups during a median follow-up period of 4.8 years. Particularly, the risk related to HbA1c variability was higher in patients in WTH group for the new or worsening nephropathy [aHR: 3.35; 95% confidence interval (CI): 1.05-10.74; P = 0.042]. Conclusions This retrospective cohort study confirmed the positive correlation between HbA1c variability and major microvascular events, especially in subjects in WTH or OTH.
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Affiliation(s)
- Bao Sun
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha, China,Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, China,Institute of Clinical Pharmacy, Central South University, Changsha, China
| | - Yongchao Gao
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha, China,Institute of Clinical Pharmacology, Central South University, Hunan Key Laboratory of Pharmacogenetics, Changsha, China,Engineering Research Center of Applied Technology of Pharmacogenomics, Ministry of Education, Changsha, China,National Clinical Research Center for Geriatric Disorders, Changsha, China
| | - Fazhong He
- Department of Pharmacy, Zhuhai People's Hospital (Zhuhai Hospital Affiliated With Jinan University), Zhuhai, China
| | - Zhaoqian Liu
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha, China,Institute of Clinical Pharmacology, Central South University, Hunan Key Laboratory of Pharmacogenetics, Changsha, China,Engineering Research Center of Applied Technology of Pharmacogenomics, Ministry of Education, Changsha, China,National Clinical Research Center for Geriatric Disorders, Changsha, China
| | - Jiecan Zhou
- The First Affiliated Hospital, Clinical Medical Research Center, Hengyang Medical School, University of South China, Hengyang, China,The First Affiliated Hospital, Hengyang Clinical Pharmacology Research Center, Hengyang Medical School, University of South China, Hengyang, China,Jiecan Zhou
| | - Xingyu Wang
- Beijing Hypertension League Institute, Beijing, China,Xingyu Wang
| | - Wei Zhang
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha, China,Institute of Clinical Pharmacology, Central South University, Hunan Key Laboratory of Pharmacogenetics, Changsha, China,Engineering Research Center of Applied Technology of Pharmacogenomics, Ministry of Education, Changsha, China,National Clinical Research Center for Geriatric Disorders, Changsha, China,*Correspondence: Wei Zhang
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Influence of Self-Practice Oriented Teaching plus Psychological Intervention on Blood Glucose Level and Psychological State in Patients with Type 2 Diabetes Mellitus on Insulin Therapy. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2022; 2022:5606697. [PMID: 35978998 PMCID: PMC9377873 DOI: 10.1155/2022/5606697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 07/02/2022] [Accepted: 07/07/2022] [Indexed: 11/17/2022]
Abstract
Background. The study aimed to examine the effect of self-practice oriented teaching plus psychological intervention on blood glucose level and psychological status of type 2 diabetic patients on first insulin therapy. Methods. A total of 80 patients with type 2 diabetes admitted from April 2020 to November 2020 were assessed for eligibility and included. They were then assigned to a control group and an observation group via the random number table method, with 40 cases in each group. In addition to insulin injection treatment in both groups prior to intervention, the control group received health education and psychological intervention, whereas the observation group adopted a self-practice oriented teaching strategy plus psychological intervention. Insulin injections, nursing satisfaction, blood glucose level, and disease awareness were compared between the two groups. The Exercise of Self-Care Agency (ESCA) scale was used to assess the patients’ self-care ability, the Generic Quality of Life Inventory-74 (GQOLI-74) scale was used to assess their quality of life, and the emotional state of patients was evaluated by the Hospital Anxiety and Depression (HAD) scale. Results. Patients in the observation group outperformed the control group in terms of insulin injection after intervention (
). Significantly higher nursing satisfaction and ESCA scores were observed after intervention (
). Self-practice oriented teaching plus psychological intervention resulted in remarkably lower postintervention glycemic indexes (
). Markedly higher disease knowledge scores and GQOLI-74 scores were witnessed in the observation group in contrast to those of the control group (
). The observation group patients showed lower HAD scores than those of the control group (
). Conclusion. Self-practice oriented teaching plus psychological intervention could effectively alleviate the negative emotions of type 2 diabetic patients on first insulin therapy, stabilize glycemic indexes, and improve quality of life, demonstrating good potential for clinical promotion.
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Park MJ, Choi KM. Association between Variability of Metabolic Risk Factors and Cardiometabolic Outcomes. Diabetes Metab J 2022; 46:49-62. [PMID: 35135078 PMCID: PMC8831817 DOI: 10.4093/dmj.2021.0316] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 12/07/2021] [Indexed: 11/10/2022] Open
Abstract
Despite strenuous efforts to reduce cardiovascular disease (CVD) risk by improving cardiometabolic risk factors, such as glucose and cholesterol levels, and blood pressure, there is still residual risk even in patients reaching treatment targets. Recently, researchers have begun to focus on the variability of metabolic variables to remove residual risks. Several clinical trials and cohort studies have reported a relationship between the variability of metabolic parameters and CVDs. Herein, we review the literature regarding the effect of metabolic factor variability and CVD risk, and describe possible mechanisms and potential treatment perspectives for reducing cardiometabolic risk factor variability.
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Affiliation(s)
- Min Jeong Park
- Division of Endocrinology & Metabolism, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Kyung Mook Choi
- Division of Endocrinology & Metabolism, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
- Corresponding author: Kyung Mook Choi https://orcid.org/0000-0001-6175-0225 Division of Endocrinology & Metabolism, Department of Internal Medicine, Korea University Guro Hospital, Korea University College of Medicine, 148 Gurodong-ro, Guro-gu, Seoul 08308, Korea E-mail:
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10
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Cahn A, Zuker I, Eilenberg R, Uziel M, Tsadok MA, Raz I, Lutski M. Machine learning based study of longitudinal HbA1c trends and their association with all-cause mortality: Analyses from a National Diabetes Registry. Diabetes Metab Res Rev 2022; 38:e3485. [PMID: 34233382 DOI: 10.1002/dmrr.3485] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 06/05/2021] [Accepted: 06/19/2021] [Indexed: 11/09/2022]
Abstract
OBJECTIVE The association of long-term HbA1c variability with mortality has been previously suggested. However, the significance of HbA1c variability and trends in different age and HbA1c categories is unclear. RESEARCH DESIGN AND METHODS Data on patients with diabetes listed in the Israeli National Diabetes Registry during years 2012-2016 (observation period) were collected. Patients with >4 HbA1c measurements, type 1 diabetes, eGFR < 30mg/ml/min, persistent HbA1c < 6% or malignancy were excluded. Utilizing machine learning methods, patients were classified into clusters according to their HbA1c trend (increasing, stable, decreasing). Mortality risk during 2017-2019 was calculated in subgroups defined by age (35-54, 55-69, 70-89 years) and last HbA1c (≤7% and >7%) at end of observation period. Models were adjusted for demographic, clinical and laboratory measurements including HbA1c, standard deviation (SD) of HbA1c and HbA1c trend. RESULTS This historical cohort study included 293,314 patients. Increased HbA1c variability (high SD) during the observation period was an independent predictor of mortality in patients aged more than 55 years (p < 0.01). The HbA1c trend was another independent predictor of mortality. Patients with a decreasing versus stable HbA1c trend had a greater mortality risk; this association persisted in all age groups in patients with HbA1c > 7% at the end of the observation period (p = 0.02 in age 35-54; p < 0.01 in aged >55). Patients with an increasing versus stable HbA1c trend had a greater mortality risk only in the elderly group (>70), yet in both HbA1c categories (p < 0.01). CONCLUSIONS HbA1c variability and trend are important determinants of mortality risk and should be considered when adjusting glycaemic targets.
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Affiliation(s)
- Avivit Cahn
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Hebrew University Hospital, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Inbar Zuker
- Israel Center for Disease Control, Ministry of Health, Ramat Gan, Israel
- Department of Epidemiology and Preventive Medicine, Sackler Faculty of Medicine, School of Public Health, Tel Aviv University, Tel-Aviv, Israel
| | - Roni Eilenberg
- TIMNA-Israel Ministry of Health's Big Data Platform, Ministry of Health, Jerusalem, Israel
| | - Moshe Uziel
- TIMNA-Israel Ministry of Health's Big Data Platform, Ministry of Health, Jerusalem, Israel
| | - Meytal Avgil Tsadok
- TIMNA-Israel Ministry of Health's Big Data Platform, Ministry of Health, Jerusalem, Israel
| | - Itamar Raz
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Hebrew University Hospital, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Miri Lutski
- Israel Center for Disease Control, Ministry of Health, Ramat Gan, Israel
- Department of Epidemiology and Preventive Medicine, Sackler Faculty of Medicine, School of Public Health, Tel Aviv University, Tel-Aviv, Israel
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Zhao Y, Malik S, Budoff MJ, Correa A, Ashley KE, Selvin E, Watson KE, Wong ND. Identification and Predictors for Cardiovascular Disease Risk Equivalents among Adults With Diabetes Mellitus. Diabetes Care 2021; 44:dc210431. [PMID: 34380703 DOI: 10.2337/dc21-0431] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 06/16/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE We examined diabetes mellitus (DM) as a cardiovascular disease (CVD) risk equivalent based on diabetes severity and other CVD risk factors. RESEARCH DESIGN AND METHODS We pooled 4 US cohorts (ARIC, JHS, MESA, FHS-Offspring) and classified subjects by baseline DM/CVD. CVD risks between DM+/CVD- vs. DM-/CVD+ were examined by diabetes severity and in subgroups of other CVD risk factors. We developed an algorithm to identify subjects with CVD risk equivalent diabetes by comparing the relative CVD risk of being DM+/CVD- vs. DM-/CVD+. RESULTS The pooled cohort included 27,730 subjects (mean age of 58.5 years, 44.6% male). CVD rates per 1000 person-years were 16.5, 33.4, 43.2 and 71.4 among those with DM-/CVD-, DM+/CVD-, DM-/CVD+ and DM+/CVD+, respectively. Compared with those with DM-/CVD+, CVD risks were similar or higher for those with HbA1c ≥ 7%, diabetes duration ≥10 years, or diabetes medication use while those with less severe diabetes had lower risks. Hazard ratios (95%CI) for DM+/CVD- vs. DM-/CVD+ were 0.96(0.86-1.07), 0.97(0.88-1.07), 0.96(0.82-1.13), 1.18(0.98-1.41), 0.93(0.85-1.02) and 1.00(0.89-1.13) among women, white race, age <55 years, triglycerides ≥2.26 mmol/L, hs-CRP ≥ 2 mg/L and eGFR<60 mL/min/1.73m2, respectively. In DM+/CVD- group, 19.1% had CVD risk equivalent diabetes with a lower risk score but a higher observed CVD risk. CONCLUSION Diabetes is a CVD risk equivalent in one-fifth of CVD-free adults living with diabetes. High HbA1c, long diabetes duration, and diabetes medication use were predictors of CVD risk equivalence. Diabetes is a CVD risk equivalent for women, white people, those of younger age, with higher triglycerides or CRP, or reduced kidney function.
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Affiliation(s)
- Yanglu Zhao
- Department of Epidemiology, University of California Los Angeles, Los Angeles, CA
- Heart Disease Prevention Program, Department of Medicine, University of California Irvine, Irvine, CA
| | - Shaista Malik
- Heart Disease Prevention Program, Department of Medicine, University of California Irvine, Irvine, CA
| | | | - Adolfo Correa
- Department of Medicine, University of Mississippi Medical Center, Jackson, MS
| | - Kellan E Ashley
- Department of Medicine, University of Mississippi Medical Center, Jackson, MS
| | - Elizabeth Selvin
- Department of Epidemiology, John Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Karol E Watson
- Department of Medicine, Ronald Reagan UCLA Medical Center, Los Angeles, CA
| | - Nathan D Wong
- Department of Epidemiology, University of California Los Angeles, Los Angeles, CA
- Heart Disease Prevention Program, Department of Medicine, University of California Irvine, Irvine, CA
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Lee S, Zhou J, Leung KSK, Wu WKK, Wong WT, Liu T, Wong ICK, Jeevaratnam K, Zhang Q, Tse G. Development of a predictive risk model for all-cause mortality in patients with diabetes in Hong Kong. BMJ Open Diabetes Res Care 2021; 9:9/1/e001950. [PMID: 34117050 PMCID: PMC8201981 DOI: 10.1136/bmjdrc-2020-001950] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 05/09/2021] [Indexed: 01/14/2023] Open
Abstract
INTRODUCTION Patients with diabetes mellitus are risk of premature death. In this study, we developed a machine learning-driven predictive risk model for all-cause mortality among patients with type 2 diabetes mellitus using multiparametric approach with data from different domains. RESEARCH DESIGN AND METHODS This study used territory-wide data of patients with type 2 diabetes attending public hospitals or their associated ambulatory/outpatient facilities in Hong Kong between January 1, 2009 and December 31, 2009. The primary outcome is all-cause mortality. The association of risk variables and all-cause mortality was assessed using Cox proportional hazards models. Machine and deep learning approaches were used to improve overall survival prediction and were evaluated with fivefold cross validation method. RESULTS A total of 273 678 patients (mean age: 65.4±12.7 years, male: 48.2%, median follow-up: 142 (IQR=106-142) months) were included, with 91 155 deaths occurring on follow-up (33.3%; annualized mortality rate: 3.4%/year; 2.7 million patient-years). Multivariate Cox regression found the following significant predictors of all-cause mortality: age, male gender, baseline comorbidities, anemia, mean values of neutrophil-to-lymphocyte ratio, high-density lipoprotein-cholesterol, total cholesterol, triglyceride, HbA1c and fasting blood glucose (FBG), measures of variability of both HbA1c and FBG. The above parameters were incorporated into a score-based predictive risk model that had a c-statistic of 0.73 (95% CI 0.66 to 0.77), which was improved to 0.86 (0.81 to 0.90) and 0.87 (0.84 to 0.91) using random survival forests and deep survival learning models, respectively. CONCLUSIONS A multiparametric model incorporating variables from different domains predicted all-cause mortality accurately in type 2 diabetes mellitus. The predictive and modeling capabilities of machine/deep learning survival analysis achieved more accurate predictions.
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Affiliation(s)
- Sharen Lee
- Cardiovascular Analytics Group, Laboratory of Cardiovascular Physiology, Hong Kong
| | - Jiandong Zhou
- School of Data Science, City University of Hong Kong, Kowloon, Hong Kong
| | | | - William Ka Kei Wu
- Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Wing Tak Wong
- School of Life Sciences, The Chinese University of Hong Kong, Hong Kong, China
| | - Tong Liu
- Department of Cardiology, The Second Hospital of Tianjin Medical University, Tianjin, China
| | - Ian Chi Kei Wong
- Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong, China
| | - Kamalan Jeevaratnam
- Faculty of Health and Medical Sciences, University of Surrey, Guildford, Surrey, UK
| | - Qingpeng Zhang
- School of Data Science, City University of Hong Kong, Kowloon, Hong Kong
| | - Gary Tse
- Cardiovascular Analytics Group, Laboratory of Cardiovascular Physiology, Hong Kong
- Department of Cardiology, The Second Hospital of Tianjin Medical University, Tianjin, China
- Faculty of Health and Medical Sciences, University of Surrey, Guildford, Surrey, UK
- Kent and Medway Medical School, Canterbury, UK
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New Insights into the Role of Visit-to-Visit Glycemic Variability and Blood Pressure Variability in Cardiovascular Disease Risk. Curr Cardiol Rep 2021; 23:25. [PMID: 33655430 DOI: 10.1007/s11886-021-01454-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/18/2021] [Indexed: 01/01/2023]
Abstract
PURPOSE OF REVIEW There is evidence from epidemiologic studies that variability in cardiovascular risk factors influences risk of cardiovascular disease. We review new studies and novel findings in the relationship between visit-to-visit glycemic variability and blood pressure variability and risk of adverse outcomes. RECENT FINDINGS Visit-to-visit glycemic variability is consistently linked to macrovascular disease. This relationship has been observed in both clinical trials and retrospective studies of electronic health records. Long-term blood pressure variability also predicts cardiovascular outcomes, and the association appears stronger in those with lower levels of systolic and diastolic function. As epidemiologic evidence increases in support of a role for metabolic risk factor variability in cardiovascular risk, there is a corresponding rise in interest in applying this information toward improving risk factor prediction and treatment. Future investigation of underlying mechanisms for these associations as well as implications for therapy is also warranted. The potential additive contribution of variability of multiple parameters also merits additional scrutiny. As our technology for capturing risk factor variability continues to improve, this will only enhance our understanding of its links with vascular disease and how to best utilize this information to reduce cardiovascular outcomes.
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Zhao MJY, Prentice JC, Mohr DC, Conlin PR. Association between hemoglobin A1c variability and hypoglycemia-related hospitalizations in veterans with diabetes mellitus. BMJ Open Diabetes Res Care 2021; 9:9/1/e001797. [PMID: 33431600 PMCID: PMC7802724 DOI: 10.1136/bmjdrc-2020-001797] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Revised: 11/10/2020] [Accepted: 12/14/2020] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION To study the impact of hemoglobin A1c (A1c) variability on the risk of hypoglycemia-related hospitalization (HRH) in veterans with diabetes mellitus. RESEARCH DESIGN AND METHODS 342 059 veterans with diabetes aged 65 years or older were identified for a retrospective cohort study. All participants had a 3-year baseline period from January 1, 2005 to December 31, 2016, during which they had at least four A1c tests. A1c variability measures included coefficient of variation (A1c CV), A1c SD, and adjusted A1c SD. HRH was identified during a 2-year follow-up period from Medicare and the Veterans Health Administration through validated algorithms of International Classification of Diseases (ICD)-9 and ICD-10 codes. Logistic regression modeling was used to evaluate the relationship between A1c variability and HRH risk while controlling for relevant clinical covariates. RESULTS 2871 patients had one or more HRH in the 2-year follow-up period. HRH risk increased with greater A1c variability, and this was consistent across A1c CV, A1c SD, and adjusted A1c SD. Average A1c levels were also independently associated with HRH, with levels <7.0% (53 mmol/mol) having lower risk and >9% (75 mmol/mol) with greater risk. The relationships between A1c variability remained significant after controlling for average A1c levels and prior HRH during the baseline period. CONCLUSION Increasing A1c variability and elevated A1c levels are associated with a greater risk of HRH in older adults with diabetes. Clinicians should consider A1c variability when assessing patients for risk of severe hypoglycemia.
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Affiliation(s)
- Molly J Y Zhao
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Health Care System, Boston, Massachusetts, USA
- Boston University School of Medicine, Boston, Massachusetts, USA
| | - Julia C Prentice
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Health Care System, Boston, Massachusetts, USA
- Psychiatry, Boston University School of Medicine, Boston, Massachusetts, USA
| | - David C Mohr
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Health Care System, Boston, Massachusetts, USA
- Health Law, Policy and Management, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Paul R Conlin
- Medical Service (111), VA Boston Healthcare System, West Roxbury, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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Kaze AD, Santhanam P, Erqou S, Ahima RS, Echouffo-Tcheugui JB. Long-term variability of glycemic markers and risk of all-cause mortality in type 2 diabetes: the Look AHEAD study. BMJ Open Diabetes Res Care 2020; 8:8/2/e001753. [PMID: 33257421 PMCID: PMC7705503 DOI: 10.1136/bmjdrc-2020-001753] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 10/08/2020] [Accepted: 11/03/2020] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION Glycemic variability may predict poor outcomes in type 2 diabetes. We evaluated the associations of long-term variability in glycosylated hemoglobin (HbA1C) and fasting plasma glucose (FPG) with cardiovascular disease (CVD) and death among individuals with type 2 diabetes. RESEARCH DESIGN AND METHODS We conducted a secondary, prospective cohort analysis of the Look AHEAD (Action for Health in Diabetes) data, including 3560 participants who attended four visits (baseline, 12 months, 24 months, and 36 months) at the outset. Variability of HbA1C and FPG was assessed using four indices across measurements from four study visits. Participants without CVD during the first 36 months were followed for incident outcomes including a CVD composite (myocardial infarction, stroke, hospitalization for angina, and CVD-related deaths), heart failure (HF), and deaths. RESULTS Over a median follow-up of 6.8 years, there were 164 deaths from any cause, 33 CVD-related deaths, 91 HF events, and 340 participants experienced the CVD composite. Adjusted HRs comparing the highest to lowest quartile of SD of HbA1C were 2.10 (95% CI 1.26 to 3.51), 3.43 (95% CI 0.95 to 12.38), 1.01 (95% CI 0.69 to 1.46), and 1.71 (95% CI 0.69 to 4.24) for all-cause mortality, CVD mortality, CVD composite and HF, respectively. The equivalent HRs for highest versus lowest quartile of SD of FPG were 1.66 (95% CI 0.96 to 2.85), 2.20 (95% CI 0.67 to 7.25), 0.94 (95% CI 0.65 to 1.35), and 2.05 (95% CI 0.80 to 5.31), respectively. CONCLUSIONS A greater variability in HbA1C was associated with elevated risk of mortality. Our findings underscore the need to achieve normal and consistent glycemic control to improve clinical outcomes among individuals with type 2 diabetes.
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Affiliation(s)
- Arnaud D Kaze
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Prasanna Santhanam
- Department of Medicine, Division of Endocrinology, Diabetes & Metabolism, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Sebhat Erqou
- Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Rexford S Ahima
- Department of Medicine, Division of Endocrinology, Diabetes & Metabolism, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Justin Basile Echouffo-Tcheugui
- Department of Medicine, Division of Endocrinology, Diabetes & Metabolism, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Yang CY, Su PF, Hung JY, Ou HT, Kuo S. Comparative predictive ability of visit-to-visit HbA1c variability measures for microvascular disease risk in type 2 diabetes. Cardiovasc Diabetol 2020; 19:105. [PMID: 32631323 PMCID: PMC7339461 DOI: 10.1186/s12933-020-01082-9] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 07/02/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND To assess the associations of various HbA1c measures, including a single baseline HbA1c value, overall mean, yearly updated means, standard deviation (HbA1c-SD), coefficient of variation (HbA1c-CV), and HbA1c variability score (HVS), with microvascular disease (MVD) risk in patients with type 2 diabetes. METHODS Linked data between National Cheng Kung University Hospital and Taiwan's National Health Insurance Research Database were utilized to identify the study cohort. The primary outcome was the composite MVD events (retinopathy, nephropathy, or neuropathy) occurring during the study follow-up. Cox model analyses were performed to assess the associations between HbA1c measures and MVD risk, with adjustment for patients' baseline HbA1c, demographics, comorbidities/complications, and treatments. RESULTS In the models without adjustment for baseline HbA1c, all HbA1c variability and mean measures were significantly associated with MVD risk, except HVS. With adjustment for baseline HbA1c, HbA1c-CV had the strongest association with MVD risk. For every unit of increase in HbA1c-CV, the MVD risk significantly increased by 3.42- and 2.81-fold based on the models without and with adjustment for baseline HbA1c, respectively. The associations of HbA1c variability and mean measures with MVD risk in patients with baseline HbA1c < 7.5% (58 mmol/mol) were stronger compared with those in patients with baseline HbA1c ≥ 7.5% (58 mmol/mol). CONCLUSIONS HbA1c variability, especially HbA1c-CV, can supplement conventional baseline HbA1c measure for explaining MVD risk. HbA1c variability may play a greater role in MVD outcomes among patients with relatively optimal baseline glycemic control compared to those with relatively poor baseline glycemic control.
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Affiliation(s)
- Chen-Yi Yang
- Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, 1 University Road, Tainan, 701, Taiwan
| | - Pei-Fang Su
- Department of Statistics, National Cheng Kung University, Tainan, Taiwan
| | - Jo-Ying Hung
- Department of Statistics, National Cheng Kung University, Tainan, Taiwan
| | - Huang-Tz Ou
- Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, 1 University Road, Tainan, 701, Taiwan. .,Department of Pharmacy, College of Medicine, National Cheng Kung University, Tainan, Taiwan. .,Department of Pharmacy, National Cheng Kung University Hospital, Tainan, Taiwan.
| | - Shihchen Kuo
- Division of Metabolism, Endocrinology & Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA.,Michigan Center for Diabetes Translational Research, University of Michigan, Ann Arbor, MI, USA
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