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Abdel-Rahman N, Manor O, Cohen A, Elran E, Cohen AG, Krieger M, Paltiel O, Valinsky L, Ben-Yehuda A, Calderon-Margalit R. Adherence to diabetes quality indicators in primary care and all-cause mortality: A nationwide population-based historical cohort study. PLoS One 2024; 19:e0302422. [PMID: 38723050 PMCID: PMC11081362 DOI: 10.1371/journal.pone.0302422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 04/03/2024] [Indexed: 05/13/2024] Open
Abstract
BACKGROUND In the last three decades, much effort has been invested in measuring and improving the quality of diabetes care. We assessed the association between adherence to diabetes quality indicators and all-cause mortality in the primary care setting. METHODS A nationwide, population-based, historical cohort study of all people aged 45-80 with pharmacologically-treated diabetes in 2005 (n = 222,235). Data on annual performance of quality indicators (including indicators for metabolic risk factor management and glycemic control) and vital status were retrieved from electronic medical records of the four Israeli health maintenance organizations. Cox proportional hazards and time-dependent models were used to estimate hazard ratios (HRs) for mortality by degree of adherence to quality indicators. RESULTS During 2,000,052 person-years of follow-up, 35.8% of participants died. An inverse dose-response association between the degree of adherence and mortality was shown for most of the quality indicators. Participants who were not tested for proteinuria or did not visit an ophthalmologist during the first-5-years of follow-up had HRs of 2.60 (95%CI:2.49-2.69) and 2.09 (95%CI:2.01-2.16), respectively, compared with those who were fully adherent. In time-dependent analyses, not measuring LDL-cholesterol, blood pressure, HbA1c, or HbA1c>9% were similarly associated with mortality (HRs ≈1.5). The association of uncontrolled blood pressure with mortality was modified by age, with increased mortality shown for those with controlled blood pressure at older ages (≥65 years). CONCLUSIONS Longitudinal adherence to diabetes quality indicators is associated with reduced all-cause mortality. Primary care professionals need to be supported by health care systems to perform quality indicators.
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Affiliation(s)
- Nura Abdel-Rahman
- Braun School of Public Health, Hebrew University of Jerusalem Hadassah Medical School, Jerusalem, Israel
| | - Orly Manor
- Braun School of Public Health, Hebrew University of Jerusalem Hadassah Medical School, Jerusalem, Israel
| | | | - Einat Elran
- Maccabi Healthcare Services, Tel Aviv, Israel
| | | | - Michal Krieger
- Braun School of Public Health, Hebrew University of Jerusalem Hadassah Medical School, Jerusalem, Israel
| | - Ora Paltiel
- Braun School of Public Health, Hebrew University of Jerusalem Hadassah Medical School, Jerusalem, Israel
| | | | | | - Ronit Calderon-Margalit
- Braun School of Public Health, Hebrew University of Jerusalem Hadassah Medical School, Jerusalem, Israel
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Zhou C, Yi Q, Luo Y, Wei H, Ge H, Liu H, Li X, Zhang J, Pan P, Yi M, Cheng L, Liu L, Zhang J, Peng L, Aili A, Liu Y, Pu J, Zhou H. Low diastolic blood pressure and adverse outcomes in inpatients with acute exacerbation of chronic obstructive pulmonary disease: A multicenter cohort study. Chin Med J (Engl) 2023; 136:941-950. [PMID: 37192019 PMCID: PMC10278704 DOI: 10.1097/cm9.0000000000002666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Indexed: 05/18/2023] Open
Abstract
BACKGROUND Although intensively studied in patients with cardiovascular diseases (CVDs), the prognostic value of diastolic blood pressure (DBP) has little been elucidated in patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD). This study aimed to reveal the prognostic value of DBP in AECOPD patients. METHODS Inpatients with AECOPD were prospectively enrolled from 10 medical centers in China between September 2017 and July 2021. DBP was measured on admission. The primary outcome was all-cause in-hospital mortality; invasive mechanical ventilation and intensive care unit (ICU) admission were secondary outcomes. Least absolute shrinkage and selection operator (LASSO) and multivariable Cox regressions were used to identify independent prognostic factors and calculate the hazard ratio (HR) and 95% confidence interval (CI) for adverse outcomes. RESULTS Among 13,633 included patients with AECOPD, 197 (1.45%) died during their hospital stay. Multivariable Cox regression analysis showed that low DBP on admission (<70 mmHg) was associated with increased risk of in-hospital mortality (HR = 2.16, 95% CI: 1.53-3.05, Z = 4.37, P <0.01), invasive mechanical ventilation (HR = 1.65, 95% CI: 1.32-2.05, Z = 19.67, P <0.01), and ICU admission (HR = 1.45, 95% CI: 1.24-1.69, Z = 22.08, P <0.01) in the overall cohort. Similar findings were observed in subgroups with or without CVDs, except for invasive mechanical ventilation in the subgroup with CVDs. When DBP was further categorized in 5-mmHg increments from <50 mmHg to ≥100 mmHg, and 75 to <80 mmHg was taken as reference, HRs for in-hospital mortality increased almost linearly with decreased DBP in the overall cohort and subgroups of patients with CVDs; higher DBP was not associated with the risk of in-hospital mortality. CONCLUSION Low on-admission DBP, particularly <70 mmHg, was associated with an increased risk of adverse outcomes among inpatients with AECOPD, with or without CVDs, which may serve as a convenient predictor of poor prognosis in these patients. CLINICAL TRIAL REGISTRATION Chinese Clinical Trail Registry, No. ChiCTR2100044625.
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Affiliation(s)
- Chen Zhou
- West China School of Medicine, Sichuan University, Chengdu, Sichuan 610041, China
| | - Qun Yi
- Department of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
- Sichuan Cancer Hospital and Institution, Sichuan Cancer Center, Cancer Hospital Affiliated to School of Medicine, UESTC, Chengdu, Sichuan 610041, China
| | - Yuanming Luo
- State Key Laboratory of Respiratory Disease, Guangzhou Medical University, Guangzhou, Guangdong 510120, China
| | - Hailong Wei
- Department of Respiratory and Critical Care Medicine, People's Hospital of Leshan, Leshan, Sichuan 614000, China
| | - Huiqing Ge
- Department of Respiratory and Critical Care Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310016, China
| | - Huiguo Liu
- Department of Respiratory and Critical Care Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430030, China
| | - Xianhua Li
- Department of Respiratory and Critical Care Medicine, The First People's Hospital of Neijiang City, Neijiang, Sichuan 641000, China
| | - Jianchu Zhang
- Department of Respiratory and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430022, China
| | - Pinhua Pan
- Department of Respiratory and Critical Care Medicine, Xiangya Hospital, Central South University, Changsha, Hunan 410008, China
| | - Mengqiu Yi
- Department of Emergency, the First People's Hospital of Jiujiang, Jiujiang, Jiangxi 332000, China
| | - Lina Cheng
- Department of Emergency, the First People's Hospital of Jiujiang, Jiujiang, Jiangxi 332000, China
| | - Liang Liu
- Department of Respiratory and Critical Care Medicine, The Affiliated Hospital of Chengdu University, Chengdu, Sichuan 610041, China
| | - Jiarui Zhang
- Department of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Lige Peng
- Department of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Adila Aili
- Department of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Yu Liu
- Department of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Jiaqi Pu
- Department of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Haixia Zhou
- Department of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
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Savage K, Williams JS, Garacci E, Egede LE. Association Between Cardiovascular Disease Risk Factors and Mortality in Adults With Diabetes: A Stratified Analysis by Sex, Race, and Ethnicity. Int J Public Health 2022; 67:1604472. [PMID: 35465388 PMCID: PMC9020257 DOI: 10.3389/ijph.2022.1604472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 03/02/2022] [Indexed: 01/15/2023] Open
Abstract
Objectives: To assess sex and racial/ethnic differences in the relationship between multiple cardiovascular disease (CVD) risk factors and mortality among a nationally representative sample of adults with diabetes. Methods: Data were analyzed from 3,503 adults with diabetes from the National Health and Nutrition Examination Survey 2001–2010 and its linked mortality data through 31 December 2011. The outcome was mortality; the independent variables were sex and race/ethnicity. Covariates included demographics, comorbidity, and lifestyle variables. Cox proportional hazards regression was used to test associations between mortality and CVD risk factors. Results: In adjusted analyses, the association between diastolic blood pressure and mortality was significantly different by sex and race/ethnicity (unadjusted p = 0.009; adjusted p = 0.042). Kaplan-Meier survival curves showed Hispanic women had the highest survival compared to Hispanic men and Non-Hispanic Black (NHB) and Non-Hispanic White (NHW) men and women; NHW men had the lowest survival probability. Conclusion: In this nationally representative sample, stratified analyses showed women had higher survival rates compared to men within each race/ethnicity group, and Hispanic women had the highest survival compared to all other groups.
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Affiliation(s)
- Kristina Savage
- Center for Advancing Population Science (CAPS), Medical College of Wisconsin, Milwaukee, WI, United States
| | - Joni S. Williams
- Center for Advancing Population Science (CAPS), Medical College of Wisconsin, Milwaukee, WI, United States
- Division of General Internal Medicine, Department of Medicine, Froedtert & The Medical College of Wisconsin, Milwaukee, WI, United States
| | - Emma Garacci
- Center for Advancing Population Science (CAPS), Medical College of Wisconsin, Milwaukee, WI, United States
| | - Leonard E. Egede
- Center for Advancing Population Science (CAPS), Medical College of Wisconsin, Milwaukee, WI, United States
- Division of General Internal Medicine, Department of Medicine, Froedtert & The Medical College of Wisconsin, Milwaukee, WI, United States
- *Correspondence: Leonard E. Egede,
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Blood pressure, antihypertensive drugs, and incident frailty: The Multidomain Alzheimer Preventive Trial (MAPT). Maturitas 2022; 162:8-14. [DOI: 10.1016/j.maturitas.2022.03.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 02/15/2022] [Accepted: 03/05/2022] [Indexed: 12/21/2022]
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Niu XD, Chi JT, Guo JB, Ruan HH, Zhang J, Tao HX, Wang YH. Effects of nurse-led web-based interventions on people with type 2 diabetes mellitus: A systematic review and meta-analysis. J Telemed Telecare 2021; 27:269-279. [PMID: 33966522 DOI: 10.1177/1357633x211010019] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Diabetes mellitus is an expanding global health problem. Currently, the home management of diabetes is mainly led by a multidisciplinary team based on telemedicine. However, the role nurses play in it remains inconclusive. This study aimed to investigate the effectiveness of nurse-led web-based intervention on glycated haemoglobin, blood pressure and lipid profile in patients with type 2 diabetes. METHODS An exhaustive systematic literature search was undertaken using the following databases: PubMed, Web of Science, Embase, The Cochrane Central Register of Controlled Trials and CINAHL. Two investigators independently extracted data and assessed the quality of the studies by examining the risk of bias and using Modified Jadad Score system. We conducted a meta-analysis of randomized controlled trials that had been published from inception to July 2020, using Review Manager 5.3. RESULTS Eleven randomized controlled trials were selected that included 2063 participants. Meta-analyses results indicated significant effects on not only glycated haemoglobin (pooled mean difference (MD) = -0.40, 95% confidence interval (CI): -0.5 to -0.26, p < 0.00001), but also on systolic blood pressure (pooled MD = -1.91, 95% CI: -3.73 to -0.09, p = 0.04) and low density lipoprotein (pooled standardized MD = -0.29, 95% CI: -0.44 to -0.15, p < 0.0001). There were no effects of nurse-led web-based intervention on fasting blood glucose, diastolic blood pressure, high density lipoprotein, body mass index and triglycerides. DISCUSSION Nurse-led web-based intervention is a promising way to complement routine clinical care. However, the specific intervention content and intervention media still need to carry out large-scale well-designed randomized controlled trials. Systematic review registration: PROSPERO CRD 42020204565.
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Affiliation(s)
| | | | - Jing-Bo Guo
- School of Nursing, Lanzhou University, China
| | | | - Jing Zhang
- School of Nursing, Lanzhou University, China
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McKay AJ, Gunn LH, Vamos EP, Valabhji J, Molina G, Molokhia M, Majeed A. Associations between attainment of incentivised primary care diabetes indicators and mortality in an English cohort. Diabetes Res Clin Pract 2021; 174:108746. [PMID: 33713716 DOI: 10.1016/j.diabres.2021.108746] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 02/11/2021] [Accepted: 03/02/2021] [Indexed: 01/10/2023]
Abstract
AIMS To describe associations between incentivised primary care clinical and process indicators and mortality, among patients with type 2 diabetes in England. METHODS A historical 2010-2017 cohort (n = 84,441 adults) was derived from the UK CPRD. Exposures included English Quality and Outcomes Framework glycated haemoglobin (HbA1c; 7.5%, 59 mmol/mol), blood pressure (140/80 mmHg), and cholesterol (5 mmol/L) indicator attainment; and number of National Diabetes Audit care processes completed, in 2010-11. The primary outcome was all-cause mortality. RESULTS Over median 3.9 (SD 2.0) years follow-up, 10,711 deaths occurred. Adjusted hazard ratios (aHR) indicated 12% (95% CI 8-16%; p < 0.0001) and 16% (11-20%; p < 0.0001) lower mortality rates among those who attained the HbA1c and cholesterol indicators, respectively. Rates were also lower among those who completed 7-9 vs. 0-3 or 4-6 care processes (aHRs 0.76 (0.71-0.82), p < 0.0001 and 0.61 (0.53-0.71), p < 0.0001, respectively), but did not obviously vary by blood pressure indicator attainment (aHR 1.04, 1.00-1.08; p = 0.0811). CONCLUSIONS Cholesterol, HbA1c and comprehensive process indicator attainment, was associated with enhanced survival. Review of community-based care provision could help reduce the gap between indicator standards and current outcomes, and in turn enhance life expectancy.
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Affiliation(s)
- Ailsa J McKay
- Department of Primary Care and Public Health, Imperial College London, London, UK.
| | - Laura H Gunn
- Department of Public Health Sciences and School of Data Science, University of North Carolina (UNC) at Charlotte, Charlotte, NC, USA; Department of Primary Care and Public Health, Imperial College London, London, UK.
| | - Eszter P Vamos
- Department of Primary Care and Public Health, Imperial College London, London, UK.
| | - Jonathan Valabhji
- NHS England and NHS Improvement, London, UK; Department of Diabetes and Endocrinology, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK; Division of Metabolism, Digestion and Reproduction, Imperial College London, London, UK.
| | | | - Mariam Molokhia
- Department of Population Health Sciences, King's College London, London, UK.
| | - Azeem Majeed
- Department of Primary Care and Public Health, Imperial College London, London, UK.
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Palladino R, Marrie RA, Majeed A, Chataway J. Evaluating the Risk of Macrovascular Events and Mortality Among People With Multiple Sclerosis in England. JAMA Neurol 2021; 77:820-828. [PMID: 32364569 DOI: 10.1001/jamaneurol.2020.0664] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Importance People with multiple sclerosis (MS) are associated with an increased risk of cardiovascular disease and mortality; however, evidence from population-based studies is sparse. Objective To assess whether the risk of macrovascular events and mortality differs among people with MS compared with a matched population without MS in England. Design, Setting, and Participants A population-based retrospective matched cohort study was conducted in general practices registered with the Clinical Practice Research Datalink in England between January 1, 1987, and September 30, 2018, with a mean (SD) follow-up of 11.3 (6.5) years. A total of 12 251 patients with MS were matched with up to 6 people without MS (n = 72 572) by age, sex, and general practice. People with 3 or more diagnoses of MS recorded during the study period were included. The first MS diagnosis was considered as index date. Exposures Multiple sclerosis status. Analyses were also stratified by sex. Main Outcomes and Measures Main outcomes were acute coronary syndrome, cerebrovascular disease, any macrovascular disease (including peripheral arterial disease), and mortality (all-cause mortality and cardiovascular disease-specific mortality). Cox proportional hazards regression and Fine and Gray proportional subhazard regression models were used to assess differences in rates. Results A total of 12 251 people with MS (66.9% women; mean [SD] age, 44.9 [13.3] years) were matched with 72 572 people without MS (69.8% women; mean [SD] age, 44.9 [13.3] years). As compared with people without MS, people with MS were associated with a 28% increased hazard of acute coronary syndrome (hazard ratio [HR], 1.28; 95% CI, 1.09-1.51), 59% increased hazard of cerebrovascular disease (HR, 1.59; 95% CI, 1.32-1.92), 32% increased hazard of any macrovascular disease (HR, 1.32; 95% CI, 1.15-1.52), 3.5-fold increased hazard of all-cause mortality (HR, 3.46; 95% CI, 3.28-3.65), and 1.5-fold increased hazard in cardiovascular disease mortality (HR, 1.47; 95% CI, 1.27-1.71). Differences in macrovascular events were more pronounced among women than men. Mortality risk was also higher for women than men. Treatment with lipid-lowering medications (mainly statins) was associated with lower mortality rates among people with MS. Conclusions and Relevance This study suggests that MS is associated with an increased risk of cardiovascular and cerebrovascular disease that is not completely accounted for by traditional vascular risk factors. Given the adverse effects of these comorbidities on outcomes in patients with MS, further investigation is needed.
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Affiliation(s)
- Raffaele Palladino
- Department of Primary Care and Public Health, School of Public Health, Imperial College of London, London, United Kingdom.,Department of Public Health, Federico II University, Naples, Italy
| | - Ruth Ann Marrie
- Department of Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada.,Department of Community Health Sciences, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Azeem Majeed
- Department of Primary Care and Public Health, School of Public Health, Imperial College of London, London, United Kingdom
| | - Jeremy Chataway
- Queen Square Multiple Sclerosis Centre, Department of Neuroinflammation, University College London Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London, London, United Kingdom.,National Institute for Health Research, University College London Hospitals, Biomedical Research Centre, London, United Kingdom
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Bansal N, Glidden DV, Mehrotra R, Townsend RR, Cohen J, Linke L, Palad F, Larson H, Hsu CY. Treating Home Versus Predialysis Blood Pressure Among In-Center Hemodialysis Patients: A Pilot Randomized Trial. Am J Kidney Dis 2021; 77:12-22. [PMID: 32800842 PMCID: PMC7752836 DOI: 10.1053/j.ajkd.2020.06.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 06/11/2020] [Indexed: 01/13/2023]
Abstract
RATIONALE & OBJECTIVE Observational studies have reported a U-shaped association between blood pressure (BP) before a hemodialysis session and death. In contrast, because a linear association between out-of-dialysis-unit BP and death has been reported, home BP may be a better target for treatment. To test the feasibility of this approach, we conducted a pilot trial of treating home versus predialysis BP in hemodialysis patients. STUDY DESIGN A 4-month, parallel, randomized, controlled trial. SETTINGS & PARTICIPANTS 50 prevalent hemodialysis patients in San Francisco and Seattle. Participants were randomly assigned using 1:1 block randomization, stratified by site. INTERVENTIONS To target home systolic BP (SBP) of 100-<140 mm Hg versus predialysis SBP of 100-<140mm Hg. Home and predialysis SBPs were ascertained every 2 weeks. Dry weight and BP medications were adjusted to reach the target SBP. OUTCOMES Primary outcomes were feasibility, adherence, safety. and tolerability. RESULTS 50 of 70 (71%) patients who were approached agreed to participate. All enrollees completed the study except for 1 who received a kidney transplant. In the home BP treatment group, adherence to obtaining/reporting home BP was 97.4% (and consistent over the 4 months). There was no increased frequency of high (defined as SBP>200mm Hg; 0.2% vs 0%) or low (defined as<90mm Hg; 1.8% vs 1.2%) predialysis BP readings in the home versus predialysis treatment arms, respectively. However, participants in the home BP arm had higher frequency of fatigue (32% vs 16%). LIMITATIONS Small sample size. CONCLUSIONS This pilot trial demonstrates feasibility and high adherence to home BP measurement and treatment in hemodialysis patients. Larger trials to test the long-term feasibility, efficacy, and safety of home BP treatment in hemodialysis patients should be conducted. FUNDERS National Institutes of Health, Satellite Healthcare, and Northwest Kidney Centers. TRIAL REGISTRATION Registered at ClinicalTrials.gov with study number NCT03459807.
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Affiliation(s)
- Nisha Bansal
- Division of Nephrology, Kidney Research Institute, University of Washington, Seattle, WA.
| | - David V Glidden
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA
| | - Rajnish Mehrotra
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA
| | | | - Jordana Cohen
- Division of Nephrology, University of Pennsylvania, Philadelphia, PA
| | - Lori Linke
- Division of Nephrology, Kidney Research Institute, University of Washington, Seattle, WA
| | - Farshad Palad
- Division of Nephrology, University of California, San Francisco, San Francisco, CA
| | - Hannah Larson
- Division of Nephrology, Kidney Research Institute, University of Washington, Seattle, WA
| | - Chi-Yuan Hsu
- Division of Nephrology, University of California, San Francisco, San Francisco, CA
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Associations of blood pressure with risk of injurious falls in old age vary by functional status: A cohort study. Exp Gerontol 2020; 140:111038. [PMID: 32738383 DOI: 10.1016/j.exger.2020.111038] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 06/26/2020] [Accepted: 07/23/2020] [Indexed: 11/21/2022]
Abstract
OBJECTIVES We aimed to examine to what extent blood pressure (BP) components are associated with injurious falls in older adults, and whether the possible associations differ by functional status (indicated by physical and cognitive impairment at baseline). METHODS This prospective cohort study included 3055 community-living participants of the Swedish National study on Aging and Care in Kungsholmen (aged ≥60 years). At baseline (2001-2004), we measured systolic BP (SBP) and diastolic BP (DBP), mean arterial pressure, pulse pressure (PP), and orthostatic hypotension. Physical function was assessed using tests of balance, chair stands, and walking speed. Cognitive function was assessed with the Mini-Mental State Examination. Injurious falls leading to inpatient or outpatient care during 3 and 10 years of follow-up were identified via patient registers. Data were analyzed using flexible parametric survival models adjusted for potential confounders. RESULTS During the 10-year follow-up period in people without functional impairment, the multi-adjusted hazard ratios (HR) of injurious falls were 1.77 (95% CI 1.02-3.07) for having SBP <130 mmHg, 1.73 (95% CI 1.05-2.83) for having SBP ≥160 mmHg (vs. 130-139), and 1.46 (1.05-2.02) for having higher tertile of PP (vs. lower tertile). During the 3-year follow-up period in people with functional impairment, the multi-adjusted HR of injurious falls was 1.91 (95% CI 1.17-3.13) for having SBP <130 mmHg (vs. 130-139) and 0.74 (0.59-0.94) for having higher tertile of PP (vs. lower tertile). There was no significant association between BP components and injurious falls either in people without functional impairment during the 3-year follow-up period, or in people with functional impairment during the 10-year follow-up period. CONCLUSIONS This large-scale Swedish study provides evidence that the associations between some specific components of BP and risk of injurious falls in older adults vary by functional status. This supports the view that a personalized approach to blood pressure management depending on functional status among older adults might be warranted in clinical settings.
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Wan EYF, Yu EYT, Chin WY, Wong ICK, Chan EWY, Chen S, Lam CLK. Age-Specific Associations Between Systolic Blood Pressure and Cardiovascular Disease: A 10-Year Diabetes Mellitus Cohort Study. J Am Heart Assoc 2020; 9:e015771. [PMID: 32673523 PMCID: PMC7660701 DOI: 10.1161/jaha.119.015771] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Background The relationship between systolic blood pressure (SBP) and cardiovascular disease (CVD) among patients with diabetes mellitus remains unclear. The study aimed to explore age-specific associations between SBP and CVD. Methods and Results A population-based retrospective cohort study was conducted on 180 492 Chinese adults with type 2 diabetes mellitus in 2008-2010, with follow-up to 2017. Age-specific associations (<50, 50-59, 60-69, and 70-79 years) between the average SBP in the previous 2 years and CVD risk were assessed by adjusted Cox proportional hazards regression with age-specific regression dilution ratios and patient characteristics stratified by subgroups. During a median follow-up of 9.3 years (1.5 million person-years), 32 545 patients developed a CVD, with an incidence rate of 23.4 per 1000 person-years. A positive and log-linear association between SBP and CVD risk was observed among the 4 age groups without evidence of a threshold down to 120 mm Hg, but the magnitude of SBP effect on CVD attenuated with increased age. The CVD risk in the age group <50 years was ≈22% higher than the age group 70 to 79 years (hazard ratio [HR], 1.33 [95% CI, 1.26-1.41] versus HR, 1.09 [95% CI, 1.07-1.11]). Each 10-mm Hg higher SBP was associated with 12% (HR, 1.12 [95% CI, 1.10-1.13]), 11% (HR, 1.11 [95% CI, 1.10-1.13]), and 20% (HR, 1.20 [95% CI, 1.17-1.22]) higher risk of all composite CVD events, individual CVD, and CVD mortality, respectively. Conclusions There is a significant log-linear relationship between baseline SBP and the risk of CVD among patients with diabetes mellitus in China. The risk increases from an SBP of 120 mm Hg onward. Age influences this relationship significantly, with younger patients (<50 years) having a greater risk of CVD for a similar rise in SBP as compared with those who are older. These findings suggest that differential target blood pressures stratified by age maybe useful.
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Affiliation(s)
- Eric Yuk Fai Wan
- Department of Family Medicine and Primary Carethe University of Hong KongAp Lei ChauHong Kong
- Department of Pharmacology and Pharmacythe University of Hong KongHong Kong
| | - Esther Yee Tak Yu
- Department of Family Medicine and Primary Carethe University of Hong KongAp Lei ChauHong Kong
| | - Weng Yee Chin
- Department of Family Medicine and Primary Carethe University of Hong KongAp Lei ChauHong Kong
| | - Ian Chi Kei Wong
- Department of Pharmacology and Pharmacythe University of Hong KongHong Kong
- Research Department of Practice and PolicySchool of PharmacyUniversity College LondonLondonUnited Kingdom
| | - Esther Wai Yin Chan
- Department of Pharmacology and Pharmacythe University of Hong KongHong Kong
- Centre for Safe Medication Practice and ResearchDepartment of Pharmacology and Pharmacythe University of Hong Kong????Hong Kong
| | - Shiqi Chen
- Department of Family Medicine and Primary Carethe University of Hong KongAp Lei ChauHong Kong
| | - Cindy Lo Kuen Lam
- Department of Family Medicine and Primary Carethe University of Hong KongAp Lei ChauHong Kong
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Berra C, Manfrini R, Regazzoli D, Radaelli MG, Disoteo O, Sommese C, Fiorina P, Ambrosio G, Folli F. Blood pressure control in type 2 diabetes mellitus with arterial hypertension. The important ancillary role of SGLT2-inhibitors and GLP1-receptor agonists. Pharmacol Res 2020; 160:105052. [PMID: 32650058 DOI: 10.1016/j.phrs.2020.105052] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 06/09/2020] [Accepted: 06/25/2020] [Indexed: 02/06/2023]
Abstract
Type 2 diabetes mellitus and arterial hypertension are major cardiovascular risks factors which shares metabolic and haemodynamic abnormalities as well as pathophysiological mechanisms. The simultaneous presence of diabetes and arterial hypertension increases the risk of left ventricular hypertrophy, congestive heart failure, and stroke, as compared to either condition alone. A number of guidelines recommend lifestyle measures such as salt restriction, weight reduction and ideal body weight mainteinance, regular physical activity and smoking cessation, together with moderation of alcohol consumption and high intake of vegetables and fruits, as the basis for reduction of blood pressure and prevention of CV diseases. Despite the availability of multiple drugs effective for hypertension, BP targets are reached in only 50 % of patients, with even fewer individuals with T2DM-achieving goals. It is established that new emerging classes of type 2 diabetes mellitus treatment, SGLT2 inhibitors and GLP1-receptor agonists, are efficacious on glucose control, and safe in reducing HbA1c significantly, without increasing hypoglycemic episodes. Furthermore, in recent years, many CVOT trials have demonstrated, using GLP1-RA or SGLT2-inihibitors compared to placebo (in combination with the usual diabetes medications) important benefits on reducing MACE (cardio-cerebral vascular events) in the diabetic population. In this hypothesis-driven review, we have examined the anti-hypertensive effects of these novel molecules of the two different classes, in the diabetic population, and suggest that they could have an interesting ancillary role in controlling blood pressure in type 2 diabetic patients.
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Affiliation(s)
- C Berra
- Department of Endocrine and Metabolic Diseases, IRCCS MultiMedica, Sesto San Giovanni, Milan, Italy.
| | - R Manfrini
- Departmental Unit of Diabetes and Metabolic Disease, ASST Santi Paolo e Carlo, Milan, Italy
| | - D Regazzoli
- Department of Cardiovascular Disease, Humanitas Research Hospital, Rozzano, Milan, Italy
| | - M G Radaelli
- Department of Endocrine and Metabolic Diseases, IRCCS MultiMedica, Sesto San Giovanni, Milan, Italy
| | - O Disoteo
- Endocrinology and Diabetology Service, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - C Sommese
- IRCCS MultiMedica, Sesto San Giovanni, Milan, Italy
| | - P Fiorina
- University of Milano, Milan, Italy; TID International Center, Invernizzi Research Center, Milan, Italy; Endocrinology and Diabetology Unit, ASST Fatebenefratelli-Sacco, Luigi Sacco Hospital, Milan, Italy
| | - G Ambrosio
- University of Perugia School of Medicine, Perugia, Italy
| | - F Folli
- Departmental Unit of Diabetes and Metabolic Disease, ASST Santi Paolo e Carlo, Milan, Italy; University of Milano, Milan, Italy; Endocrinology and Metabolism, Department of Health Science University of Milano, Italy
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12
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Palladino R, Tabak AG, Khunti K, Valabhji J, Majeed A, Millett C, Vamos EP. Association between pre-diabetes and microvascular and macrovascular disease in newly diagnosed type 2 diabetes. BMJ Open Diabetes Res Care 2020; 8:8/1/e001061. [PMID: 32332069 PMCID: PMC7202749 DOI: 10.1136/bmjdrc-2019-001061] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 03/22/2020] [Accepted: 03/28/2020] [Indexed: 01/06/2023] Open
Abstract
OBJECTIVE The associated risk of vascular disease following diagnosis of type 2 diabetes in people previously identified as having pre-diabetes in real-world settings is unknown. We examined the presence of microvascular and macrovascular disease in individuals with newly diagnosed type 2 diabetes by glycemic status within 3 years before diagnosis. RESEARCH DESIGN AND METHODS We identified 159 736 individuals with newly diagnosed type 2 diabetes from the UK Clinical Practice Research Datalink database in England between 2004 and 2017. We used logistic regression models to compare presence of microvascular (retinopathy and nephropathy) and macrovascular (acute coronary syndrome, cerebrovascular and peripheral arterial disease) disease at the time of type 2 diabetes diagnosis by prior glycemic status. RESULTS Half of the study population (49.9%) had at least one vascular disease, over one-third (37.4%) had microvascular disease, and almost a quarter (23.5%) had a diagnosed macrovascular disease at the time of type 2 diabetes diagnosis.Compared with individuals with glycemic values within the normal range, those detected with pre-diabetes before the diagnosis had 76% and 14% increased odds of retinopathy and nephropathy (retinopathy: adjusted OR (AOR) 1.76, 95% CI 1.69 to 1.85; nephropathy: AOR 1.14, 95% CI 1.10 to 1.19), and 7% higher odds of the diagnosis of acute coronary syndrome (OR 1.07, 95% CI 1.03 to 1.12) in fully adjusted models at time of diabetes diagnosis. CONCLUSIONS Microvascular and macrovascular diseases are detected in 37%-24% of people with newly diagnosed type 2 diabetes. Pre-diabetes before diagnosis of type 2 diabetes is associated with increased odds of microvascular disease and acute coronary syndrome. Detection of pre-diabetes might represent an opportunity for reducing the burden of microvascular and macrovascular disease through heightened attention to screening for vascular complications.
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Affiliation(s)
- Raffaele Palladino
- Public Health Policy Evaluation Unit, School of Public Health, Imperial College London, London, UK
- Department of Public Health, University "Federico II" of Naples, Naples, Italy
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Adam G Tabak
- Department of Epidemiology and Public Health, University College London, London, UK
- 1st Department of Medicine, Semmelweis University Faculty of Medicine, Budapest, Hungary
| | - Kamlesh Khunti
- Diabetes Research Centre, Leicester Diabetes Centre, University of Leicester, Leicester, UK
| | - Jonathan Valabhji
- Imperial College Healthcare NHS Trust, London, UK
- NHS England, Skipton House, London, UK
| | - Azeem Majeed
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Christopher Millett
- Public Health Policy Evaluation Unit, School of Public Health, Imperial College London, London, UK
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Eszter P Vamos
- Public Health Policy Evaluation Unit, School of Public Health, Imperial College London, London, UK
- Department of Primary Care and Public Health, Imperial College London, London, UK
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13
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Anioke IC, Ezedigboh AN, Dozie-Nwakile OC, Chukwu IJ, Kalu PN. Predictors of poor glycemic control in adult with type 2 diabetes in South-Eastern Nigeria. Afr Health Sci 2019; 19:2819-2828. [PMID: 32127857 PMCID: PMC7040317 DOI: 10.4314/ahs.v19i4.3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The study investigated predictors of poor glycemic control in type 2 diabetes (T2DM). METHODS Data on demographics, anthropometric and clinical parameters were collected in a cross-section survey from 140 adults with T2DM, using standard tools/instruments. Glycated hemoglobin (A1C) was assessed as a measure of glycemic control. RESULTS Majority (83.3%) had poor glycemic control status of which about 95% constitute the elderly. The elderly (OR= 5.90, 95% Cl: 1.66-20.96) were more likely associated with poor glycemic control than the non-elderly (p = 0.006). Adjustment for significant predictor variables: Age, waist-hip ratio (WHR), Fasting plasma glucose (FPG) and Systolic blood pressure (SBP), although attenuated the odds (OR= 5.00, 95% CI: 1.19-20.96) of poor glycemic control, it still remained significantly (p = 0.028) higher in the elderly. Patients outside tight FPG control significantly (p = 0.001) showed poor glycemic cotrol than those within tight FPG (OR= 17.39, 95%Cl: 5.83-51.90), even with attenuated OR (OR= 10.85, 95%Cl: 3.10-37.96) and (OR=12.08, 95%Cl: 3.64-40.09) when non-significant and significant predictor variables were accounted for, respectively. CONCLUSION Age, WHR, FPG, and SBP were significantly associated with differences in glycemic control. The elderly and FPG outside tight control showed significantly increased odds of poor glycemic control status.
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Affiliation(s)
- Innocent Chidi Anioke
- Clinical Chemistry Unit; Department of Medical Laboratory Sciences, Faculty of Health Sciences and Technology, College of Medicine, University of Nigeria Enugu Campus, Nigeria
- Public Health- Health Promotion, School of Health and Wellbeing, Faculty of Health and Social Science, Leeds Beckett University, Leeds, United Kingdom
| | - Azubike Nnamdi Ezedigboh
- Chemical pathology Unit; Department of Medical Laboratory Services, University of Nigeria Teaching Hospital Ituku/Ozolla Enugu, Nigeria
| | - Ogechukwu Calista Dozie-Nwakile
- Medical Laboratory Microbiology Unit; Department of Medical Laboratory Sciences, Faculty of Health Sciences and Technology, College of Medicine, University of Nigeria Enugu Campus, Nigeria
| | - Ikechukwu Johnpaul Chukwu
- Clinical Chemistry Unit; Department of Medical Laboratory Sciences, Faculty of Health Sciences and Technology, College of Medicine, University of Nigeria Enugu Campus, Nigeria
- Biomolecular and Biomedical Sciences, Glasgow Caledonian University, United Kingdom
| | - Peculiar Ngozi Kalu
- Department of Chemical Pathology, College of Medicine, Nnamdi Azikiwe University, Nnewi, Nigeria
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14
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Shen Y, Dai Y, Wang XQ, Zhang RY, Lu L, Ding FH, Shen WF. Searching for optimal blood pressure targets in type 2 diabetic patients with coronary artery disease. Cardiovasc Diabetol 2019; 18:160. [PMID: 31733658 PMCID: PMC6858977 DOI: 10.1186/s12933-019-0959-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Accepted: 10/31/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Controversies exist regarding the optimal blood pressure (BP) level that is safe and provides cardiovascular protection in patients with type 2 diabetes mellitus (T2DM) and coexistent coronary artery disease. Several new glucose-lowering agents have been found to lower BP as well, making the interaction between BP and T2DM even more complex. METHODS With the reference to recent literature, this review article describes the potential mechanisms of increased risk of hypertension in T2DM and outlines the possible optimal BP levels based upon recommendations on the management of hypertension by the current guidelines, in combination with our research findings, for type 2 diabetic patients with coronary artery disease. RESULTS The development of hypertension in T2DM involves multiple processes, including enhanced sympathetic output, inappropriate activation of renin-angiotensin- aldosterone system, endothelial dysfunction induced through insulin resistance, and abnormal sodium handling by the kidney. Both AGE-RAGE axis and adipokine dysregulation activate intracellular signaling pathways, increase oxidative stress, and aggravate vascular inflammation. Pancreatic β-cell specific microRNAs are implicated in gene expression and diabetic complications. Non-pharmacological intervention with lifestyle changes improves BP control, and anti-hypertensive medications with ACEI/ARB, calcium antagonists, β-blockers, diuretics and new hypoglycemic agent SGLT2 inhibitors are effective to decrease mortality and prevent major adverse cardiovascular events. For hypertensive patients with T2DM and stable coronary artery disease, control of BP < 130/80 mmHg but not < 120/70 mmHg is reasonable, whereas for those with chronic total occlusion or acute coronary syndromes, an ideal BP target may be somewhat higher (< 140/90 mmHg). Caution is advised with aggressive lowering of diastolic BP to a critical threshold (< 60 mmHg). CONCLUSIONS Hypertension and T2DM share certain similar aspects of pathophysiology, and BP control should be individualized to minimize adverse events and maximize benefits especially for patients with T2DM and coronary artery disease.
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Affiliation(s)
- Ying Shen
- Department of Cardiology, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, People's Republic of China
| | - Yang Dai
- Institute of Cardiovascular Disease, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, People's Republic of China
| | - Xiao Qun Wang
- Department of Cardiology, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, People's Republic of China
| | - Rui Yan Zhang
- Department of Cardiology, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, People's Republic of China
| | - Lin Lu
- Department of Cardiology, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, People's Republic of China.,Institute of Cardiovascular Disease, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, People's Republic of China
| | - Feng Hua Ding
- Department of Cardiology, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, People's Republic of China.
| | - Wei Feng Shen
- Department of Cardiology, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, People's Republic of China. .,Institute of Cardiovascular Disease, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, People's Republic of China.
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15
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Zhang YQ, Li Y, Dong YG, Wu YH, Bian R, Li JH, Ji LN. A nationwide assessment of blood pressure control and the associated factors in Chinese type 2 diabetes mellitus patients. J Clin Hypertens (Greenwich) 2019; 21:1654-1663. [PMID: 31603618 DOI: 10.1111/jch.13675] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2019] [Revised: 06/10/2019] [Accepted: 06/28/2019] [Indexed: 11/28/2022]
Abstract
A subgroup analysis of the nationwide, cross-sectional 3B STUDY was performed to understand the current blood pressure (BP) control status and treatment patterns in Chinese diabetes patients as well as to identify factors associated with BP control. The demographic data, anthropometric parameters, and laboratory results were collected from 24 512 type 2 diabetes patients. The BP goal was a systolic BP <130 mm Hg and a diastolic BP <80 mm Hg regardless of a history of hypertension or current antihypertensive treatment. The overall prevalence of hypertension was 59.9% with geographical differences. Among the diabetes patients with hypertension, 76.9% received antihypertensive medicines. Calcium channel blockers (39.3%), angiotensin II receptor antagonists (26.6%), and then β-blockers (14.0%) or angiotensin-converting enzyme inhibitors (13.6%) were frequently used for BP control. Only 17.5% (n = 2658) of diabetes patients with hypertension reached the recommended target BP. Body mass index <24 kg/m2 , urban resident, frequent physical activity, good adherence to medication, comorbidity with cardiovascular disease, achieving glycemic goal (HbA1c <7.0%), achieving lipid goal (low-density lipoprotein cholesterol <2.59 mmol/L) were independent factors that predicted achievement of target BP goal. On the contrary, comorbidity with chronic kidney disease predicted failure to achieve target BP goal. Patients who were treated in a cardiology department or lived in the North were more likely to achieve BP goals. A considerable proportion of diabetic patients failed to achieve guideline-recommended BP targets. More aggressive efforts should be made to overcome the diverse barriers and facilitate the optimization of diabetes management.
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Affiliation(s)
- Yu-Qing Zhang
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Yong Li
- Division of Cardiology, Department of Medicine, HuaShan Hospital, Shanghai, China
| | - Yu-Gang Dong
- The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Yan-Hua Wu
- MSD China Holding Company, Shanghai, China
| | - Rui Bian
- MSD China Holding Company, Shanghai, China
| | - Ji-Hu Li
- MSD China Holding Company, Shanghai, China
| | - Li-Nong Ji
- Department of Endocrinology and Metabolism, Peking University People's Hospital, Beijing, China
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16
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Raghavan S, Ho YL, Kini V, Rhee MK, Vassy JL, Gagnon DR, Cho K, Wilson PWF, Phillips LS. Association Between Early Hypertension Control and Cardiovascular Disease Incidence in Veterans With Diabetes. Diabetes Care 2019; 42:1995-2003. [PMID: 31515207 PMCID: PMC6754236 DOI: 10.2337/dc19-0686] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Accepted: 07/26/2019] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Guidelines for hypertension treatment in patients with diabetes diverge regarding the systolic blood pressure (SBP) threshold at which treatment should be initiated and treatment goal. We examined associations of early SBP treatment with atherosclerotic cardiovascular disease (ASCVD) events in U.S. adults with diabetes. RESEARCH DESIGN AND METHODS We studied 43,986 patients with diabetes who newly initiated antihypertensive therapy between 2002 and 2007. Patients were classified into categories based on SBP at treatment initiation (130-139 or ≥140 mmHg) and after 2 years of treatment (100-119, 120-129, 130-139, 140-159, and ≥160 mmHg). The primary outcome was composite ASCVD events (fatal and nonfatal myocardial infarction and stroke), estimated using inverse probability of treatment-weighted Poisson regression and multivariable Cox proportional hazards regression. RESULTS Relative to individuals who initiated treatment when SBP was 130-139 mmHg, those with pretreatment SBP ≥140 mmHg had higher ASCVD risk (hazard ratio 1.10 [95% CI 1.02, 1.19]). Relative to those with pretreatment SBP of 130-139 mmHg and on-treatment SBP of 120-129 mmHg (reference group), ASCVD incidence was higher in those with pretreatment SBP ≥140 mmHg and on-treatment SBP 120-129 mmHg (adjusted incidence rate difference [IRD] 1.0 [-0.2 to 2.1] events/1,000 person-years) and in those who achieved on-treatment SBP 130-139 mmHg (IRD 1.9 [0.6, 3.2] and 1.1 [0.04, 2.2] events/1,000 person-years for those with pretreatment SBP 130-139 mmHg and ≥140 mmHg, respectively). CONCLUSIONS In this observational study, patients with diabetes initiating antihypertensive therapy when SBP was 130-139 mmHg and those achieving on-treatment SBP <130 mmHg had better outcomes than those with higher SBP levels when initiating or after 2 years on treatment.
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Affiliation(s)
- Sridharan Raghavan
- Veterans Affairs Eastern Colorado Healthcare System, Aurora, CO
- Division of Hospital Medicine, University of Colorado School of Medicine, Aurora, CO
- Colorado Cardiovascular Outcomes Research Consortium, Aurora, CO
| | - Yuk-Lam Ho
- Veterans Affairs Boston Healthcare System, Boston, MA
| | - Vinay Kini
- Colorado Cardiovascular Outcomes Research Consortium, Aurora, CO
- Division of Cardiology, University of Colorado School of Medicine, Aurora, CO
| | - Mary K Rhee
- Atlanta Veterans Affairs Medical Center, Decatur, GA
- Division of Endocrinology, Metabolism, and Lipids, Emory University School of Medicine, Atlanta, GA
| | - Jason L Vassy
- Veterans Affairs Boston Healthcare System, Boston, MA
- Department of Medicine, Harvard Medical School, Boston, MA
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA
| | - David R Gagnon
- Veterans Affairs Boston Healthcare System, Boston, MA
- Department of Biostatistics, Boston University School of Public Health, Boston, MA
| | - Kelly Cho
- Veterans Affairs Boston Healthcare System, Boston, MA
- Department of Medicine, Harvard Medical School, Boston, MA
| | - Peter W F Wilson
- Atlanta Veterans Affairs Medical Center, Decatur, GA
- Division of Cardiology, Emory University School of Medicine, Atlanta, GA
| | - Lawrence S Phillips
- Atlanta Veterans Affairs Medical Center, Decatur, GA
- Division of Endocrinology, Metabolism, and Lipids, Emory University School of Medicine, Atlanta, GA
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17
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Divisón-Garrote JA, Prieto-Díaz MÁ, Alonso-Moreno FJ, Velilla-Zancada SM, Escobar-Cervantes C, Llisterri-Caro JL, Cinza-Sanjurjo S, Rodríguez-Roca GC, Polo-García J, Pallarés-Carratalá V. Prevalence of hypotension in hypertensive treated patients within the Primary Care setting. The PRESCAP 2010 study. Semergen 2019; 46:107-114. [PMID: 31395479 DOI: 10.1016/j.semerg.2019.07.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2019] [Revised: 06/23/2019] [Accepted: 07/05/2019] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To determine the prevalence of hypotension and associated factors in hypertensive patients treated in the Primary Care setting. MATERIALS AND METHODS A cross-sectional, descriptive, and multicentre study was conducted with a total of 2635 general practitioners consecutively including 12,961 hypertensive patients treated in a Primary Care setting in Spain. An analysis was performed on the variables of age, gender, weight, height, body mass index, waist circumference, cardiovascular risk factors (diabetes, dyslipidaemia, smoking, obesity, sedentary lifestyle), fasting plasma glucose, complete lipid profile, as well as the presence of target organ damage (left ventricular hypertrophy, microalbuminuria, carotid atherosclerosis) and associated clinical conditions. Hypotension was defined as a systolic blood pressure less than 110mmHg or a diastolic blood pressure less than 70mmHg. A multivariate analysis was performed to determine the variables associated with the presence of hypotension. RESULTS The mean age was 66.2 years, and 51.7% of patients were women. The mean time of onset of hypertension was 9.1 years. A total of 13.1% of patients (95% confidence interval 12.4-13.6%) had hypotension, 95% of whom had low diastolic blood pressure. The prevalence of hypotension was higher in elderly patients (25.7%) and in those individuals with coronary heart disease (22.6%). The variables associated with the presence of hypotension included a history of cardiovascular disease, being treated with at least 3 antihypertensive drugs, diabetes, and age. CONCLUSIONS One out of 4-5 elderly patients, or those with cardiovascular disease, had hypotension. General practitioners should identify these patients in order to determine the causes and adjust treatment to avoid complications.
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Affiliation(s)
- J A Divisón-Garrote
- Centro de Salud Casas Ibañez, Albacete, Spain; Director Cátedra de Medicina de Familia SEMERGEN, Universidad Católica San Antonio de Murcia, Spain
| | - M Á Prieto-Díaz
- Centro de Salud Vallobín-La Florida, Oviedo, Spain; Doctorando en Facultad de Medicina, Cátedra Universidad Santiago de Compostela - SEMERGEN, Spain.
| | | | | | | | | | - S Cinza-Sanjurjo
- Centro de Salud Porto do Son, A Coruña, Spain; Cátedra SEMERGEN Universidad de Santiago de Compostela, Spain
| | | | - J Polo-García
- Centro de Salud Centro de Salud Casar de Cáceres, Cáceres, Spain
| | - V Pallarés-Carratalá
- Unidad de Vigilancia de la Salud, Unión de Mutuas, Castellón, Spain; Departamento de Medicina, Universitat Jaume I, Castellón, Spain
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18
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Wan EYF, Yu EYT, Chin WY, Fong DYT, Choi EPH, Lam CLK. Association of Blood Pressure and Risk of Cardiovascular and Chronic Kidney Disease in Hong Kong Hypertensive Patients. Hypertension 2019; 74:331-340. [PMID: 31230539 PMCID: PMC6635057 DOI: 10.1161/hypertensionaha.119.13123] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 04/04/2019] [Accepted: 05/28/2019] [Indexed: 01/13/2023]
Abstract
The association between systolic blood pressure, cardiovascular disease, and chronic kidney disease remains unclear. This study aimed to evaluate these relationships. A population-based cohort of 267 469 adult patients with hypertension but without diabetes mellitus, cardiovascular disease, or chronic kidney disease were identified. Using baseline and repeated systolic blood pressure (average of all systolic blood pressure measurements in the past 5 years), the risks of cardiovascular disease and chronic kidney disease associated with systolic blood pressure were evaluated by Cox regression. Subgroup analyses were conducted by baseline characteristics. Over 1.4 million person-years follow-up (median 6 years), 29 500 cardiovascular disease and 30 993 chronic kidney disease events diagnosed. A J-shape association between baseline systolic blood pressure and risks of cardiovascular disease and chronic kidney disease was observed. Using repeated systolic blood pressure, a positive and log-linear association was identified. There was no evidence of a threshold down to the repeated systolic blood pressure of 120 mm Hg. Increases of 10 mm Hg of repeated systolic blood pressure was associated with a 16% (hazard ratio, 1.15; [95% CI, 1.13-1.16]), 11% (1.11; [1.08-1.13]), and 22% (1.22; [1.20-1.24]) higher risk of composite of cardiovascular disease and chronic kidney disease, individual cardiovascular disease and chronic kidney disease, respectively. Strength of the associations was similar across different subpopulations. This study showed that hypertensive patients with elevated repeated systolic blood pressure are at increased risk of cardiovascular disease or chronic kidney disease, irrespective of different characteristics. Very low single measurement of systolic blood pressure may be a potential indicator for poor health, but there seems to be no threshold for usual systolic blood pressure.
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Affiliation(s)
- Eric Yuk Fai Wan
- From the Department of Family Medicine and Primary Care (E.Y.F.W., E.Y.T.Y., W.Y.C., C.L.K.L.), the University of Hong Kong
| | - Esther Yee Tak Yu
- From the Department of Family Medicine and Primary Care (E.Y.F.W., E.Y.T.Y., W.Y.C., C.L.K.L.), the University of Hong Kong
- Department of Pharmacology and Pharmacy (E.Y.F.W.), the University of Hong Kong
| | - Weng Yee Chin
- From the Department of Family Medicine and Primary Care (E.Y.F.W., E.Y.T.Y., W.Y.C., C.L.K.L.), the University of Hong Kong
| | | | | | - Cindy Lo Kuen Lam
- From the Department of Family Medicine and Primary Care (E.Y.F.W., E.Y.T.Y., W.Y.C., C.L.K.L.), the University of Hong Kong
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19
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Jhee JH, Park J, Kim H, Kee YK, Park JT, Han SH, Yang CW, Kim NH, Kim YS, Kang SW, Kim YL, Yoo TH. The Optimal Blood Pressure Target in Different Dialysis Populations. Sci Rep 2018; 8:14123. [PMID: 30237432 PMCID: PMC6148061 DOI: 10.1038/s41598-018-32281-w] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Accepted: 09/03/2018] [Indexed: 12/16/2022] Open
Abstract
Hypertension is common and contributes to adverse outcomes in patients undergoing dialysis. However, the proper blood pressure (BP) target remains controversial and several factors make this difficult. This study aimed to investigate the adequate BP target in patients undergoing prevalent dialysis. Data were retrieved from the Clinical Research Center for End-Stage Renal Disease (2009–2014). 2,299 patients undergoing dialysis were evaluated. Patients were assigned into eight groups according to predialysis systolic blood pressure (SBP). The primary outcome was all-cause mortality. During the median follow-up of 4.5 years, a U-shape relation between SBP and mortality was found. The risk of mortality was increased in the SBP <110 and ≥170 mmHg groups. In subgroup analysis, the risk of mortality was similarly shown U-shape with SBP in subjects with no comorbidities, and no use of antihypertensive agents. However, only lowest SBP was a risk factor for mortality in patients with older, having diabetes or coronary artery disease, whereas highest SBP was an only risk factor in younger patients. In respect of dialysis characteristics, patients undergoing hemodialysis showed U-shape between SBP and mortality, while patients undergoing peritoneal dialysis did not. Among hemodialysis patients, patients with shorter dialysis vintage and less interdialytic weight gain showed U-shape association between SBP and mortality. This study showed that the lowest or highest SBP group had higher risk of mortality. Nevertheless, the optimal target BP should be applied according to individual condition of each patient.
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Affiliation(s)
- Jong Hyun Jhee
- Division of Nephrology and Hypertension, Department of Internal Medicine, Inha University College of Medicine, Incheon, Korea
| | - Jimin Park
- Department of Internal Medicine, College of Medicine, Severance Biomedical Science Institute, Brain Korea 21 PLUS, Institute of Kidney Disease Research, Yonsei University, Seoul, Korea
| | - Hyoungnae Kim
- Department of Internal Medicine, College of Medicine, Institute of Kidney Disease Research, Yonsei University, Seoul, Korea
| | - Youn Kyung Kee
- Department of Internal Medicine, College of Medicine, Institute of Kidney Disease Research, Yonsei University, Seoul, Korea
| | - Jung Tak Park
- Department of Internal Medicine, College of Medicine, Institute of Kidney Disease Research, Yonsei University, Seoul, Korea
| | - Seung Hyeok Han
- Department of Internal Medicine, College of Medicine, Institute of Kidney Disease Research, Yonsei University, Seoul, Korea
| | - Chul Woo Yang
- Department of Internal Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Nam-Ho Kim
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Yon Su Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Shin-Wook Kang
- Department of Internal Medicine, College of Medicine, Institute of Kidney Disease Research, Yonsei University, Seoul, Korea.,Department of Internal Medicine, College of Medicine, Severance Biomedical Science Institute, Brain Korea 21 PLUS, Institute of Kidney Disease Research, Yonsei University, Seoul, Korea
| | - Yong-Lim Kim
- Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea
| | - Tae-Hyun Yoo
- Department of Internal Medicine, College of Medicine, Institute of Kidney Disease Research, Yonsei University, Seoul, Korea.
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20
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Wan EYF, Yu EYT, Chin WY, Fung CSC, Fong DYT, Choi EPH, Chan AKC, Lam CLK. Effect of Achieved Systolic Blood Pressure on Cardiovascular Outcomes in Patients With Type 2 Diabetes: A Population-Based Retrospective Cohort Study. Diabetes Care 2018; 41:1134-1141. [PMID: 29592967 DOI: 10.2337/dc17-2443] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Accepted: 03/04/2018] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The objective of this study was to compare the incidence of cardiovascular disease (CVD) among patients with type 2 diabetes mellitus (T2DM) with treated hypertension who achieved systolic blood pressures (SBPs) of <120, <130, and <140 mmHg after an increase in their antihypertensive regimen. RESEARCH DESIGN AND METHODS A retrospective cohort study was conducted on 28,014 primary care adult patients with T2DM with no prior diagnosis of CVD and who achieved SBP readings <140 mmHg after an increase in the number of antihypertensive medications prescribed. Using an extension of propensity score matching, a total of 2,079, 10,851, and 15,084 matched patients with achieved SBP measurements of <120, <130, and <140 mmHg were identified. The association between achieved SBP and incident CVD were evaluated using Cox regressions. Subgroup analyses were conducted by stratifying patients' baseline characteristics. RESULTS Over a median follow-up period of 4.8 years, the incidence of CVD in patients with achieved SBP measures of <120, <130, and <140 mmHg were 318 (15.3%; incidence rate [IR] 34.3/1,000 person-years [PY]), 992 (9.1%; IR 20.4/1,000 PY), and 1,635 (10.8%; IR 21.4/1,000 PY). Achieved SBP <120 mmHg was associated with a higher risk of CVD compared with achieved SBP <130 mmHg (hazard ratio [HR] 1.75 [95% CI 1.53, 2.00]) and achieved SBP <140 mmHg (HR 1.67 [95% CI 1.46, 1.90]). There was a significant reduction in CVD risk in patients <65 years (HR 0.81 [95% CI 0.69, 0.96]) but no difference for other patients, including patients ≥65 years, who achieved SBP <130 mmHg when compared with the group that achieved SBP <140 mmHg. CONCLUSIONS Our findings support a SBP treatment target of 140 mmHg and suspect no risk reduction attenuation on CVD for lower SBP targets (<120 or <130 mmHg) for most patients with uncomplicated T2DM. A randomized control trial is still needed to confirm these findings.
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Affiliation(s)
- Eric Yuk Fai Wan
- Department of Family Medicine and Primary Care, The University of Hong Kong, Hong Kong, China
| | - Esther Yee Tak Yu
- Department of Family Medicine and Primary Care, The University of Hong Kong, Hong Kong, China
| | - Weng Yee Chin
- Department of Family Medicine and Primary Care, The University of Hong Kong, Hong Kong, China
| | - Colman Siu Cheung Fung
- Department of Family Medicine and Primary Care, The University of Hong Kong, Hong Kong, China
| | | | | | - Anca Ka Chun Chan
- Department of Family Medicine and Primary Care, The University of Hong Kong, Hong Kong, China
| | - Cindy Lo Kuen Lam
- Department of Family Medicine and Primary Care, The University of Hong Kong, Hong Kong, China
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21
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Shen Y, Ding FH, Dai Y, Wang XQ, Zhang RY, Lu L, Shen WF. Reduced coronary collateralization in type 2 diabetic patients with chronic total occlusion. Cardiovasc Diabetol 2018; 17:26. [PMID: 29422093 PMCID: PMC5804044 DOI: 10.1186/s12933-018-0671-6] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2017] [Accepted: 02/01/2018] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND The extent of coronary collateral formation is a primary determinant of the severity of myocardial damage and mortality after coronary artery occlusion. Type 2 diabetes mellitus (T2DM) represents an important risk factor for impaired collateral vessel growth. However, the mechanism of reduced coronary collateralization in type 2 diabetic patients remains unclear. METHODS With the reference to the recent researches, this review article describes the pathogenic effects of T2DM on collateral development and outlines possible clinical and biochemical markers associated with reduced coronary collateralization in type 2 diabetic patients with chronic total occlusion (CTO). RESULTS Diffuse coronary atherosclerosis in T2DM reduces pressure gradient between collateral donor artery and collateral recipient one, limiting collateral vessel growth and function. An interaction between advanced glycation end-products and their receptor activates several intracellular signaling pathways, enhances oxidative stress and aggravates inflammatory process. Diabetic condition decreases pro-angiogenic factors especially vascular endothelial growth factor and other collateral vessel growth related parameters. Numerous clinical and biochemical factors that could possibly attenuate the development of coronary collaterals have been reported. Increased serum levels of glycated albumin, cystatin C, and adipokine C1q tumor necrosis factor related protein 1 were associated with poor coronary collateralization in type 2 diabetic patients with stable coronary artery disease and CTO. Diastolic blood pressure and stenosis severity of the predominant collateral donor artery also play a role in coronary collateral formation. CONCLUSIONS T2DM impairs collateral vessel growth through multiple mechanisms involving arteriogenesis and angiogenesis, and coronary collateral formation in patients with T2DM and CTO is influenced by various clinical, biochemical and angiographic factors. This information provides insights into the understanding of coronary pathophysiology and searching for potential new therapeutic targets in T2DM.
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Affiliation(s)
- Ying Shen
- Department of Cardiology, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025 People’s Republic of China
| | - Feng Hua Ding
- Department of Cardiology, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025 People’s Republic of China
| | - Yang Dai
- Institute of Cardiovascular Disease, Shanghai Jiao Tong University School of Medicine, 197 Rui Jin Road II, Shanghai, 200025 People’s Republic of China
| | - Xiao Qun Wang
- Department of Cardiology, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025 People’s Republic of China
| | - Rui Yan Zhang
- Department of Cardiology, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025 People’s Republic of China
| | - Lin Lu
- Department of Cardiology, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025 People’s Republic of China
- Institute of Cardiovascular Disease, Shanghai Jiao Tong University School of Medicine, 197 Rui Jin Road II, Shanghai, 200025 People’s Republic of China
| | - Wei Feng Shen
- Department of Cardiology, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025 People’s Republic of China
- Institute of Cardiovascular Disease, Shanghai Jiao Tong University School of Medicine, 197 Rui Jin Road II, Shanghai, 200025 People’s Republic of China
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22
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Lee CJ, Hwang J, Oh J, Lee SH, Kang SM, Kim HC, Park S. Relation Between Blood Pressure and Clinical Outcome in Hypertensive Subjects With Previous Stroke. J Am Heart Assoc 2017; 6:JAHA.117.007102. [PMID: 29212651 PMCID: PMC5779023 DOI: 10.1161/jaha.117.007102] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Background This study investigated whether a mean blood pressure (BP) of <130/80 mm Hg is associated with further reduction in cardiovascular outcomes in treated hypertensive subjects with previous stroke. Methods and Results Subjects from the Korea National Health Insurance Service health examinee cohort diagnosed as having stroke and hypertension from January 1st, 2003 and December 31st, 2006 (N=2320) were grouped according to mean systolic (<130, 130–<140, and ≥140 mm Hg) and diastolic (<80, 80–<90, and ≥90 mm Hg) BP recorded during follow‐up health examinations. All‐cause and cardiovascular mortality over 11 years were compared. Compared with subjects with a systolic BP of ≥140 mm Hg (N=736), subjects with a systolic BP of 130 to <140 mm Hg (N=793) had a significantly lower risk of all‐cause death (hazard ratio [HR], 0.61; 95% confidence interval [CI], 0.47–0.79; P<0.001), cardiovascular mortality (HR, 0.39; 95% CI, 0.25–0.61; P<0.001), and fatal ischemic stroke (HR, 0.25; 95% CI, 0.10–0.63; P=0.003). Systolic BP of <130 mm Hg (N=791) was associated with lower risk of nonfatal hemorrhagic stroke. Subjects with a diastolic BP of 80 to <90 mm Hg (N=1100) had significantly lower risk of all‐cause death (HR, 0.60, 95% CI, 0.45–0.80; P<0.001) and cardiovascular mortality (HR, 0.45; 95% CI, 0.30–0.70; P<0.001) than those with a diastolic BP of ≥90 mm Hg (N=342). Diastolic BP of <80 mm Hg (N=878) was associated with reduced risk of nonfatal hemorrhagic stroke and further lowering of all‐cause mortality and cardiovascular mortality. Conclusions BP of <130/80 mm Hg was associated with improved outcomes in hypertensive subjects with previous stroke.
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Affiliation(s)
- Chan Joo Lee
- Department of Health Promotion, Severance Hospital, Seoul, Korea
| | - Jinseub Hwang
- Department of Computer Science and Statistics, Daegu University, Gyeongbuk, Korea
| | - Jaewon Oh
- Cardiology Division, Severance Cardiovascular Hospital and Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Sang-Hak Lee
- Cardiology Division, Severance Cardiovascular Hospital and Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Seok-Min Kang
- Cardiology Division, Severance Cardiovascular Hospital and Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Hyeon Chang Kim
- Department of Preventive Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Sungha Park
- Department of Computer Science and Statistics, Daegu University, Gyeongbuk, Korea
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23
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Wan EYF, Yu EYT, Fung CSC, Chin WY, Fong DYT, Chan AKC, Lam CLK. Do We Need a Patient-Centered Target for Systolic Blood Pressure in Hypertensive Patients With Type 2 Diabetes Mellitus? Hypertension 2017; 70:1273-1282. [PMID: 29038204 DOI: 10.1161/hypertensionaha.117.10034] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Revised: 07/31/2017] [Accepted: 09/18/2017] [Indexed: 01/09/2023]
Abstract
The current trend on diabetes mellitus management advocates replacing the paradigm from a uniform to an individualized patient-centered systolic blood pressure (SBP), but there is no consensus on the achieved treatment goals of SBP level. The study aimed at evaluating the association between SBP and the risk of cardiovascular diseases (CVD) and all-cause mortality for diabetic patients to identify patient-centered treatment targets. A retrospective study was conducted on 95 086 Chinese adult primary care patients with type 2 diabetes mellitus and hypertension. Using the average of the annual SBP records (updated SBP) over a median follow-up of 5.9 years, the risks of overall CVD, all-cause mortality, and their composite associated with SBP were evaluated using Cox proportional hazards regression. Subgroup analysis was performed on the incidence of CVD by stratifying patient's baseline characteristics. The SBP range for the lowest risk of CVD and all-cause mortality was 130 to 134 mm Hg among type 2 diabetes mellitus population. A J-shaped curvilinear relationship was identified between SBP and risk of CVD and all-cause mortality, irrespective of patients' characteristics. The findings showed that all patients with SBP <125 mm Hg or ≥140 mm Hg had an increased risk of CVD and mortality. This large territory-wide study showed the level of achieved SBP of 125 to 139 mm Hg in pharmacological therapy, irrespective of patients' characteristics, suggested that the SBP treatment goal of <140 mm Hg and individualized SBP target may not be necessary in diabetic management.
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Affiliation(s)
- Eric Yuk Fai Wan
- From the Department of Family Medicine and Primary Care (E.Y.F.W., E.Y.T.Y., C.S.C.F., W.Y.C., A.K.C.C., C.L.K.L.) and School of Nursing (D.Y.T.F.), The University of Hong Kong
| | - Esther Yee Tak Yu
- From the Department of Family Medicine and Primary Care (E.Y.F.W., E.Y.T.Y., C.S.C.F., W.Y.C., A.K.C.C., C.L.K.L.) and School of Nursing (D.Y.T.F.), The University of Hong Kong.
| | - Colman Siu Cheung Fung
- From the Department of Family Medicine and Primary Care (E.Y.F.W., E.Y.T.Y., C.S.C.F., W.Y.C., A.K.C.C., C.L.K.L.) and School of Nursing (D.Y.T.F.), The University of Hong Kong
| | - Weng Yee Chin
- From the Department of Family Medicine and Primary Care (E.Y.F.W., E.Y.T.Y., C.S.C.F., W.Y.C., A.K.C.C., C.L.K.L.) and School of Nursing (D.Y.T.F.), The University of Hong Kong
| | - Daniel Yee Tak Fong
- From the Department of Family Medicine and Primary Care (E.Y.F.W., E.Y.T.Y., C.S.C.F., W.Y.C., A.K.C.C., C.L.K.L.) and School of Nursing (D.Y.T.F.), The University of Hong Kong
| | - Anca Ka Chun Chan
- From the Department of Family Medicine and Primary Care (E.Y.F.W., E.Y.T.Y., C.S.C.F., W.Y.C., A.K.C.C., C.L.K.L.) and School of Nursing (D.Y.T.F.), The University of Hong Kong
| | - Cindy Lo Kuen Lam
- From the Department of Family Medicine and Primary Care (E.Y.F.W., E.Y.T.Y., C.S.C.F., W.Y.C., A.K.C.C., C.L.K.L.) and School of Nursing (D.Y.T.F.), The University of Hong Kong
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24
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Chang YK, Huang LF, Shin SJ, Lin KD, Chong K, Yen FS, Chang HY, Chuang SY, Hsieh TJ, Hsiung CA, Hsu CC. A Point-based Mortality Prediction System for Older Adults with Diabetes. Sci Rep 2017; 7:12652. [PMID: 28978911 PMCID: PMC5627261 DOI: 10.1038/s41598-017-12751-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Accepted: 09/15/2017] [Indexed: 02/07/2023] Open
Abstract
The mortality prediction models for the general diabetic population have been well established, but the corresponding elderly-specific model is still lacking. This study aims to develop a mortality prediction model for the elderly with diabetes. The data used for model establishment were derived from the nationwide adult health screening program in Taiwan in 2007-2010, from which we applied a 10-fold cross-validation method for model construction and internal validation. The external validation was tested on the MJ health screening database collected in 2004-2007. Multivariable Cox proportional hazards models were used to predict five-year mortality for diabetic patients ≥65 years. A total of 220,832 older subjects with diabetes were selected for model construction, of whom 23,241 (10.5%) died by the end of follow-up (December 31, 2011). The significant predictors retained in the final model included age, gender, smoking status, body mass index (BMI), fasting glucose, systolic and diastolic blood pressure, leukocyte count, liver and renal function, total cholesterol, hemoglobin, albumin, and uric acid. The Harrell's C in the development, internal-, and external-validation datasets were 0.737, 0.746, and 0.685, respectively. We established an easy-to-use point-based model that could accurately predict five-year mortality risk in older adults with diabetes.
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Affiliation(s)
- Y K Chang
- Department of Medical Research, Tung's Taichung MetroHarbor Hospital, Taichung, Taiwan
| | - L F Huang
- Institute of Population Health Sciences, National Health Research Institutes, Zhunan, Taiwan
| | - S J Shin
- College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Ditvision of Endocrinology and Metabolism, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
- Department of Internal Medicine, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung, Taiwan
| | - K D Lin
- College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Ditvision of Endocrinology and Metabolism, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
- Department of Internal Medicine, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung, Taiwan
| | - K Chong
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Min-Sheng General Hospital, Taoyuan, Taiwan
| | - F S Yen
- Dr. Yen's Clinic, Taoyuan, Taiwan
| | - H Y Chang
- Institute of Population Health Sciences, National Health Research Institutes, Zhunan, Taiwan
| | - S Y Chuang
- Institute of Population Health Sciences, National Health Research Institutes, Zhunan, Taiwan
| | - T J Hsieh
- Institute of Population Health Sciences, National Health Research Institutes, Zhunan, Taiwan
| | - C A Hsiung
- Institute of Population Health Sciences, National Health Research Institutes, Zhunan, Taiwan
| | - C C Hsu
- Institute of Population Health Sciences, National Health Research Institutes, Zhunan, Taiwan.
- Department of Health Services Administration, China Medical University, Taichung, Taiwan.
- Department of Family Medicine, Min-Sheng General Hospital, Taoyuan, Taiwan.
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25
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Seong SC, Kim YY, Park SK, Khang YH, Kim HC, Park JH, Kang HJ, Do CH, Song JS, Lee EJ, Ha S, Shin SA, Jeong SL. Cohort profile: the National Health Insurance Service-National Health Screening Cohort (NHIS-HEALS) in Korea. BMJ Open 2017; 7:e016640. [PMID: 28947447 PMCID: PMC5623538 DOI: 10.1136/bmjopen-2017-016640] [Citation(s) in RCA: 536] [Impact Index Per Article: 76.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
PURPOSE The National Health Insurance Service-Health Screening Cohort (NHIS-HEALS) is a cohort of participants who participated in health screening programmes provided by the NHIS in the Republic of Korea. The NHIS constructed the NHIS-HEALS cohort database in 2015. The purpose of this cohort is to offer relevant and useful data for health researchers, especially in the field of non-communicable diseases and health risk factors, and policy-maker. PARTICIPANTS To construct the NHIS-HEALS database, a sample cohort was first selected from the 2002 and 2003 health screening participants, who were aged between 40 and 79 in 2002 and followed up through 2013. This cohort included 514 866 health screening participants who comprised a random selection of 10% of all health screening participants in 2002 and 2003. FINDINGS TO DATE The age-standardised prevalence of anaemia, diabetes mellitus, hypertension, obesity, hypercholesterolaemia and abnormal urine protein were 9.8%, 8.2%, 35.6%, 2.7%, 14.2% and 2.0%, respectively. The age-standardised mortality rate for the first 2 years (through 2004) was 442.0 per 100 000 person-years, while the rate for 10 years (through 2012) was 865.9 per 100 000 person-years. The most common cause of death was malignant neoplasm in both sexes (364.1 per 100 000 person-years for men, 128.3 per 100 000 person-years for women). FUTURE PLANS This database can be used to study the risk factors of non-communicable diseases and dental health problems, which are important health issues that have not yet been fully investigated. The cohort will be maintained and continuously updated by the NHIS.
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Affiliation(s)
| | - Yeon-Yong Kim
- Big Data Steering Department, National Health Insurance Service, Wonju, Korea
| | - Sue K Park
- Department of Preventive Medicine, Seoul National University College of Medicine, Seoul, Korea
- Department of Biomedical Science, Seoul National University College of Medicine, Seoul, Korea
- Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Young Ho Khang
- Department of Health Policy and Management, Seoul National University College of Medicine, Seoul, Korea
- Institute of Health Policy and Management, Seoul National University Medical Research Center, Seoul, Korea
| | - Hyeon Chang Kim
- Department of Preventive Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Jong Heon Park
- Big Data Steering Department, National Health Insurance Service, Wonju, Korea
| | - Hee-Jin Kang
- Big Data Steering Department, National Health Insurance Service, Wonju, Korea
| | - Cheol-Ho Do
- Big Data Steering Department, National Health Insurance Service, Wonju, Korea
| | - Jong-Sun Song
- Big Data Steering Department, National Health Insurance Service, Wonju, Korea
| | - Eun-Joo Lee
- Big Data Steering Department, National Health Insurance Service, Wonju, Korea
| | - Seongjun Ha
- Big Data Steering Department, National Health Insurance Service, Wonju, Korea
| | - Soon Ae Shin
- Gwanak Branch, National Health Insurance Service, Seoul, Korea
| | - Seung-Lyeal Jeong
- Big Data Steering Department, National Health Insurance Service, Wonju, Korea
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26
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de Boer IH, Bangalore S, Benetos A, Davis AM, Michos ED, Muntner P, Rossing P, Zoungas S, Bakris G. Diabetes and Hypertension: A Position Statement by the American Diabetes Association. Diabetes Care 2017; 40:1273-1284. [PMID: 28830958 DOI: 10.2337/dci17-0026] [Citation(s) in RCA: 370] [Impact Index Per Article: 52.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
| | | | | | | | - Erin D Michos
- The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Paul Muntner
- School of Public Health, University of Alabama at Birmingham, Birmingham, AL
| | - Peter Rossing
- Steno Diabetes Center Copenhagen, University of Copenhagen, Copenhagen, Denmark
| | - Sophia Zoungas
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
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27
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Muntner P, Whelton PK. Using Predicted Cardiovascular Disease Risk in Conjunction With Blood Pressure to Guide Antihypertensive Medication Treatment. J Am Coll Cardiol 2017; 69:2446-2456. [PMID: 28494981 DOI: 10.1016/j.jacc.2017.02.066] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Revised: 02/16/2017] [Accepted: 02/20/2017] [Indexed: 12/21/2022]
Abstract
Using cardiovascular disease (CVD) risk instead of or in addition to blood pressure (BP) to guide antihypertensive treatment is an active area of research. The purpose of this review is to provide an overview of studies that could inform this treatment paradigm. We review data from randomized trials on relative and absolute CVD risk reduction that can occur when antihypertensive treatment is guided by CVD risk. We also review population-level data on using CVD risk in conjunction with BP to guide antihypertensive treatment, the broad distribution in CVD risk for people with similar BP levels, and the use of CVD risk for guiding antihypertensive treatment among subgroups including older adults, young adults, and those with diabetes mellitus or chronic kidney disease. In addition, we review potential challenges in implementing antihypertensive treatment recommendations that incorporate CVD risk. In closing, we provide recommendations for using CVD risk in combination with BP to guide antihypertensive treatment.
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Affiliation(s)
- Paul Muntner
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama.
| | - Paul K Whelton
- Department of Epidemiology, School of Public Health and Tropical Medicine, Tulane University, New Orleans, Louisiana
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28
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Ogurtsova K, da Rocha Fernandes JD, Huang Y, Linnenkamp U, Guariguata L, Cho NH, Cavan D, Shaw JE, Makaroff LE. IDF Diabetes Atlas: Global estimates for the prevalence of diabetes for 2015 and 2040. Diabetes Res Clin Pract 2017; 128:40-50. [PMID: 28437734 DOI: 10.1016/j.diabres.2017.03.024] [Citation(s) in RCA: 2294] [Impact Index Per Article: 327.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2017] [Accepted: 03/26/2017] [Indexed: 02/06/2023]
Abstract
AIM To produce current estimates of the national, regional and global impact of diabetes for 2015 and 2040. METHODS A systematic literature review was conducted to identify data sources on the prevalence of diabetes from studies conducted in the period from 1990 to 2015. An analytic hierarchy process was used to select the most appropriate studies for each country, and estimates for countries without data were modelled using extrapolation from similar countries that had available data. A logistic regression model was used to generate smoothed age-specific estimates, which were applied to UN population estimates. RESULTS 540 data sources were reviewed, of which 196 sources from 111 countries were selected. In 2015 it was estimated that there were 415 million (uncertainty interval: 340-536 million) people with diabetes aged 20-79years, 5.0 million deaths attributable to diabetes, and the total global health expenditure due to diabetes was estimated at 673 billion US dollars. Three quarters (75%) of those with diabetes were living in low- and middle-income countries. The number of people with diabetes aged 20-79years was predicted to rise to 642 million (uncertainty interval: 521-829 million) by 2040. CONCLUSION Diabetes prevalence, deaths attributable to diabetes, and health expenditure due to diabetes continue to rise across the globe with important social, financial and health system implications.
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Affiliation(s)
- K Ogurtsova
- International Diabetes Federation, Chaussee de la Hulpe 166, Brussels, Belgium
| | | | - Y Huang
- International Diabetes Federation, Chaussee de la Hulpe 166, Brussels, Belgium.
| | - U Linnenkamp
- International Diabetes Federation, Chaussee de la Hulpe 166, Brussels, Belgium
| | - L Guariguata
- International Diabetes Federation, Chaussee de la Hulpe 166, Brussels, Belgium.
| | - N H Cho
- International Diabetes Federation, Chaussee de la Hulpe 166, Brussels, Belgium; Department of Preventive Medicine, Ajou University School of Medicine, 164 World Cup-ro, Suwon, South Korea.
| | - D Cavan
- International Diabetes Federation, Chaussee de la Hulpe 166, Brussels, Belgium.
| | - J E Shaw
- Baker Heart and Diabetes Institute, 75 Commercial Rd, Melbourne, Australia.
| | - L E Makaroff
- International Diabetes Federation, Chaussee de la Hulpe 166, Brussels, Belgium; Department of Microbiology and Immunology, University of Leuven, Herestraat 49, Leuven, Belgium.
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29
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Grenier J, Goodman SG, Leiter LA, Langer A, Teoh H, Bhatt DL, Cheng AYY, Tan MK, Ransom T, Connelly KA, Yan AT. Blood Pressure Management in Adults With Type 2 Diabetes: Insights From the Diabetes Mellitus Status in Canada (DM-SCAN) Survey. Can J Diabetes 2017; 42:130-137. [PMID: 28552652 DOI: 10.1016/j.jcjd.2017.01.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Revised: 01/02/2017] [Accepted: 01/11/2017] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Optimal treatment of blood pressure (BP) and other cardiovascular risk factors, including hyperglycemia, is integral to diabetes management. There are limited data from the primary care setting concerning the contemporary and comprehensive management of type 2 diabetes and other cardiovascular risk factors in relation to guideline-recommended BP target achievement. METHODS The Diabetes Mellitus Status in Canada (DM-SCAN) survey included 5172 ambulatory patients with type 2 diabetes. Data were collected on patient demographics, medical histories, medication usage, BP levels and laboratory investigations. We stratified the study population based on their attainment of the BP target recommended by the Canadian Diabetes Association 2013 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada and the Canadian Hypertension Education Program (<130/80 mmHg) and compared patient clinical characteristics and treatments. RESULTS Of the 5145 patients with available BP data, 36% achieved the BP target. Prevalence of smoking, known coronary artery disease, retinopathy, neuropathy and nephropathy were similar in the groups with BP 130/80 mmHg or higher and BP 130/80 mmHg or lower. Patients with BP 130/80 mmHg or higher were taking more antihypertensive agents and were more likely to be taking angiotensin-converting enzyme inhibitors and/or angiotensin receptor blockers, diuretics and calcium channel blockers. They also had significantly higher glycated hemoglobin and low-density lipoprotein-cholesterol levels. Overall, these patients were also less likely to achieve guideline-recommended glycemic and lipid targets. CONCLUSIONS Only about one-third of patients with diabetes achieved the target BP of below 130/80 mmHg. Patients with BP 130/80 mmHg or higher were also less likely to achieve optimal guideline-recommended glycated hemoglobin and low-density lipoprotein-cholesterol targets. Improved comprehensive management of all risk factors in patients with diabetes is warranted.
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Affiliation(s)
- Jasmine Grenier
- Division of Cardiology, St Michael's Hospital, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada
| | - Shaun G Goodman
- Division of Cardiology, St Michael's Hospital, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada; Canadian Heart Research Centre, Toronto, Ontario, Canada
| | - Lawrence A Leiter
- University of Toronto, Toronto, Ontario, Canada; Division of Endocrinology and Metabolism, St Michael's Hospital, Toronto, Ontario, Canada
| | - Anatoly Langer
- University of Toronto, Toronto, Ontario, Canada; Canadian Heart Research Centre, Toronto, Ontario, Canada
| | - Hwee Teoh
- Division of Endocrinology and Metabolism, St Michael's Hospital, Toronto, Ontario, Canada
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, Massachusetts, United States
| | - Alice Y Y Cheng
- University of Toronto, Toronto, Ontario, Canada; The Credit Valley Hospital and St Michael's Hospital, Toronto, Ontario, Canada
| | - Mary K Tan
- Canadian Heart Research Centre, Toronto, Ontario, Canada
| | - Thomas Ransom
- Queen Elizabeth II Health Sciences Centre, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Kim A Connelly
- Division of Cardiology, St Michael's Hospital, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada
| | - Andrew T Yan
- Division of Cardiology, St Michael's Hospital, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada.
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Yannoutsos A, Kheder-Elfekih R, Halimi JM, Safar ME, Blacher J. Should blood pressure goal be individualized in hypertensive patients? Pharmacol Res 2017; 118:53-63. [DOI: 10.1016/j.phrs.2016.11.037] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2016] [Revised: 10/15/2016] [Accepted: 11/30/2016] [Indexed: 12/27/2022]
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Tringali S, Huang J. Reduction of diastolic blood pressure: Should hypertension guidelines include a lower threshold target? World J Hypertens 2017; 7:1-9. [DOI: 10.5494/wjh.v7.i1.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Revised: 11/10/2016] [Accepted: 12/19/2016] [Indexed: 02/06/2023] Open
Abstract
Reduction of diastolic blood pressure to less than 60-80 mmHg does not improve mortality and may lead to adverse cardiovascular events in high risk patient populations. Despite a growing body of evidence supporting the J-curve phenomenon, no major society guidelines on hypertension include a lower threshold target for diastolic blood pressure. Many major society guidelines for hypertension have been updated in the last 5 years. Some guidelines include goals specific to age and co-morbid conditions. The Sixth Joint Task Force of the European Society of Cardiology and the Canadian Hypertension Education Program are the only guidelines to date that have recommended a lower threshold target, with the Canadian guidelines recommending a caution against diastolic blood pressure less than or equal to 60 mmHg in patients with coronary artery disease. While systolic blood pressure has been proven to be the overriding risk factor in hypertensive patients over the age of 50 years, diastolic blood pressure is an important predictor of mortality in younger adults. Post hoc data analysis of previous clinical trials regarding safe lower diastolic blood pressure threshold remains inconsistent. Randomized clinical trials designed to determine the appropriate diastolic blood pressure targets among different age groups and populations with different comorbidities are warranted. Hypertension guideline goals should be based on an individual’s age, level of risk, and certain co-morbid conditions, especially coronary artery disease, stroke, chronic kidney disease, and diabetes.
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Towfighi A, Cheng EM, Ayala-Rivera M, McCreath H, Sanossian N, Dutta T, Mehta B, Bryg R, Rao N, Song S, Razmara A, Ramirez M, Sivers-Teixeira T, Tran J, Mojarro-Huang E, Montoya A, Corrales M, Martinez B, Willis P, Macias M, Ibrahim N, Wu S, Wacksman J, Haber H, Richards A, Barry F, Hill V, Mittman B, Cunningham W, Liu H, Ganz DA, Factor D, Vickrey BG. Randomized controlled trial of a coordinated care intervention to improve risk factor control after stroke or transient ischemic attack in the safety net: Secondary stroke prevention by Uniting Community and Chronic care model teams Early to End Disparities (SUCCEED). BMC Neurol 2017; 17:24. [PMID: 28166784 PMCID: PMC5294765 DOI: 10.1186/s12883-017-0792-7] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Accepted: 01/09/2017] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Recurrent strokes are preventable through awareness and control of risk factors such as hypertension, and through lifestyle changes such as healthier diets, greater physical activity, and smoking cessation. However, vascular risk factor control is frequently poor among stroke survivors, particularly among socio-economically disadvantaged blacks, Latinos and other people of color. The Chronic Care Model (CCM) is an effective framework for multi-component interventions aimed at improving care processes and outcomes for individuals with chronic disease. In addition, community health workers (CHWs) have played an integral role in reducing health disparities; however, their effectiveness in reducing vascular risk among stroke survivors remains unknown. Our objectives are to develop, test, and assess the economic value of a CCM-based intervention using an Advanced Practice Clinician (APC)-CHW team to improve risk factor control after stroke in an under-resourced, racially/ethnically diverse population. METHODS/DESIGN In this single-blind randomized controlled trial, 516 adults (≥40 years) with an ischemic stroke, transient ischemic attack or intracerebral hemorrhage within the prior 90 days are being enrolled at five sites within the Los Angeles County safety-net setting and randomized 1:1 to intervention vs usual care. Participants are excluded if they do not speak English, Spanish, Cantonese, Mandarin, or Korean or if they are unable to consent. The intervention includes a minimum of three clinic visits in the healthcare setting, three home visits, and Chronic Disease Self-Management Program group workshops in community venues. The primary outcome is blood pressure (BP) control (systolic BP <130 mmHg) at 1 year. Secondary outcomes include: (1) mean change in systolic BP; (2) control of other vascular risk factors including lipids and hemoglobin A1c, (3) inflammation (C reactive protein [CRP]), (4) medication adherence, (5) lifestyle factors (smoking, diet, and physical activity), (6) estimated relative reduction in risk for recurrent stroke or myocardial infarction (MI), and (7) cost-effectiveness of the intervention versus usual care. DISCUSSION If this multi-component interdisciplinary intervention is shown to be effective in improving risk factor control after stroke, it may serve as a model that can be used internationally to reduce race/ethnic and socioeconomic disparities in stroke in resource-constrained settings. TRIAL REGISTRATION ClinicalTrials.gov Identifier NCT01763203 .
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Affiliation(s)
- Amytis Towfighi
- Los Angeles County Department of Health Services, Los Angeles, California USA
- University of Southern California, Los Angeles, California USA
- Rancho Los Amigos National Rehabilitation Center, Downey, California USA
| | - Eric M. Cheng
- University of California, Los Angeles (UCLA), Los Angeles, California USA
| | - Monica Ayala-Rivera
- Rancho Los Amigos National Rehabilitation Center, Downey, California USA
- University of California, Los Angeles (UCLA), Los Angeles, California USA
| | - Heather McCreath
- University of California, Los Angeles (UCLA), Los Angeles, California USA
| | - Nerses Sanossian
- University of Southern California, Los Angeles, California USA
- Los Angeles County-University of Southern California (USC) Medical Center, Los Angeles, California USA
| | - Tara Dutta
- Rancho Los Amigos National Rehabilitation Center, Downey, California USA
- Kaiser Permanente, Sacramento, California USA
| | - Bijal Mehta
- University of California, Los Angeles (UCLA), Los Angeles, California USA
- Harbor-UCLA Medical Center, Torrance, California USA
| | - Robert Bryg
- University of California, Los Angeles (UCLA), Los Angeles, California USA
- Olive View-UCLA Medical Center, Sylmar, California USA
| | - Neal Rao
- University of California, Los Angeles (UCLA), Los Angeles, California USA
- Olive View-UCLA Medical Center, Sylmar, California USA
| | - Shlee Song
- Cedars Sinai Medical Center, Los Angeles, California USA
| | - Ali Razmara
- Rancho Los Amigos National Rehabilitation Center, Downey, California USA
- Kaiser Permanente, Irvine, California USA
| | - Magaly Ramirez
- Fielding School of Public Health, Department of Health Policy and Management, University of California, Los Angeles, Los Angeles, California USA
| | - Theresa Sivers-Teixeira
- University of Southern California, Los Angeles, California USA
- Rancho Los Amigos National Rehabilitation Center, Downey, California USA
| | - Jamie Tran
- Harbor-UCLA Medical Center, Torrance, California USA
| | - Elizabeth Mojarro-Huang
- Rancho Los Amigos National Rehabilitation Center, Downey, California USA
- Los Angeles County-University of Southern California (USC) Medical Center, Los Angeles, California USA
| | - Ana Montoya
- Rancho Los Amigos National Rehabilitation Center, Downey, California USA
- Harbor-UCLA Medical Center, Torrance, California USA
- Olive View-UCLA Medical Center, Sylmar, California USA
| | - Marilyn Corrales
- Los Angeles County Department of Health Services, Los Angeles, California USA
- Rancho Los Amigos National Rehabilitation Center, Downey, California USA
| | - Beatrice Martinez
- Rancho Los Amigos National Rehabilitation Center, Downey, California USA
- Harbor-UCLA Medical Center, Torrance, California USA
| | - Phyllis Willis
- Watts Labor Community Action Committee, Watts, California USA
| | - Mireya Macias
- Worker Education and Resource Center, Los Angeles, California USA
| | - Nancy Ibrahim
- Esperanza Community Housing, Los Angeles, California USA
| | - Shinyi Wu
- School of Social Work, Edward R. Roybal Institute on Aging, and Daniel J. Epstein Department of Industrial and Systems Engineering, University of Southern California, Los Angeles, California USA
- RAND Corporation, Santa Monica, California USA
| | | | | | - Adam Richards
- University of California, Los Angeles (UCLA), Los Angeles, California USA
| | - Frances Barry
- University of California, Los Angeles (UCLA), Los Angeles, California USA
| | - Valerie Hill
- Rancho Los Amigos National Rehabilitation Center, Downey, California USA
| | - Brian Mittman
- Department of Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California USA
| | - William Cunningham
- University of California, Los Angeles (UCLA), Los Angeles, California USA
| | - Honghu Liu
- University of California, Los Angeles (UCLA), Los Angeles, California USA
| | - David A. Ganz
- University of California, Los Angeles (UCLA), Los Angeles, California USA
- RAND Corporation, Santa Monica, California USA
- Department of Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California USA
| | - Diane Factor
- Worker Education and Resource Center, Los Angeles, California USA
| | - Barbara G. Vickrey
- University of California, Los Angeles (UCLA), Los Angeles, California USA
- Icahn School of Medicine at Mount Sinai, New York, New York USA
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Datta-Nemdharry P, Thomson A, Beynon J. Opportunities and Challenges in Developing a Cohort of Patients with Type 2 Diabetes Mellitus Using Electronic Primary Care Data. PLoS One 2016; 11:e0162236. [PMID: 27861488 PMCID: PMC5115653 DOI: 10.1371/journal.pone.0162236] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Accepted: 08/20/2016] [Indexed: 11/24/2022] Open
Abstract
Purpose To develop a cohort of patients with T2DM treated with insulin using CPRD to obtain an accurate diagnosis date. This was used to analyse time from T2DM diagnosis to first ever insulin prescription between 01/01/2000 and 30/06/2012, for patients in England and Wales. Methods Patients aged 18 years and over at diagnosis, were included if prescribed an anti-diabetic drug and were excluded if first diagnosis-specific code was inconsistent with a T2DM diagnosis. Diagnosis codes were split into 8 categories based on whether they related to specific T2DM or non-specific diabetes codes. Patients were excluded if they had non-specific diagnosis codes and were prescribed insulin as their first-ever treatment for diabetes. Descriptive statistics for time from T2DM diagnosis to insulin initiation were calculated. Results Two hundred and fifty-six codes were identified which were consistent with a first-ever diagnosis of T2DM. 7 codes were considered to clearly define a diagnosis of T2DM, which were reported for 64% of patients. The final cohort comprised 11,917 patients and the median time to first insulin prescription from the date of diagnosis was 4.4 years. Conclusions A clear definition of cohort development is required to compare and interpret results from studies. Use of diagnosis and product codes is essential when examining use of drugs such as insulin, where competing diagnoses need to be considered separately.
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Affiliation(s)
- Preeti Datta-Nemdharry
- Vigilance and Risk Management of Medicines (VRMM), MHRA, Victoria, London SW1W 9SZ, United Kingdom
| | - Andrew Thomson
- Vigilance and Risk Management of Medicines (VRMM), MHRA, Victoria, London SW1W 9SZ, United Kingdom
| | - Julie Beynon
- Vigilance and Risk Management of Medicines (VRMM), MHRA, Victoria, London SW1W 9SZ, United Kingdom
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The CPRD and the RCGP: building on research success by enhancing benefits for patients and practices. Br J Gen Pract 2016; 65:54-5. [PMID: 25624277 DOI: 10.3399/bjgp15x683353] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
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Affiliation(s)
- Raymond R. Townsend
- From the Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Division of Nephrology and Hypertension, University of Miami Miller School of Medicine, FL
| | - Murray Epstein
- From the Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Division of Nephrology and Hypertension, University of Miami Miller School of Medicine, FL
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Liang Y, Fratiglioni L, Wang R, Santoni G, Welmer AK, Qiu C. Effects of biological age on the associations of blood pressure with cardiovascular and non-cardiovascular mortality in old age: A population-based study. Int J Cardiol 2016; 220:508-13. [DOI: 10.1016/j.ijcard.2016.06.118] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Revised: 05/18/2016] [Accepted: 06/21/2016] [Indexed: 10/21/2022]
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Datta-Nemdharry P, Thomson A, Beynon J, Donegan K. Patterns of anti-diabetic medication use in patients with type 2 diabetes mellitus in England and Wales. Pharmacoepidemiol Drug Saf 2016; 26:127-135. [DOI: 10.1002/pds.4092] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Revised: 05/13/2016] [Accepted: 08/10/2016] [Indexed: 12/19/2022]
Affiliation(s)
| | - Andrew Thomson
- Vigilance and Risk Management of Medicines (VRMM); MHRA; London UK
| | - Julie Beynon
- Vigilance and Risk Management of Medicines (VRMM); MHRA; London UK
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Divisón-Garrote JA, Banegas JR, De la Cruz JJ, Escobar-Cervantes C, De la Sierra A, Gorostidi M, Vinyoles E, Abellán-Aleman J, Segura J, Ruilope LM. Hypotension based on office and ambulatory monitoring blood pressure. Prevalence and clinical profile among a cohort of 70,997 treated hypertensives. ACTA ACUST UNITED AC 2016; 10:714-23. [DOI: 10.1016/j.jash.2016.06.035] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2016] [Revised: 06/11/2016] [Accepted: 06/18/2016] [Indexed: 10/21/2022]
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Krakoff LR. A Tale of 3 Trials: ACCORD, SPRINT, and SPS3. What Happened? Am J Hypertens 2016; 29:1020-3. [PMID: 27357398 DOI: 10.1093/ajh/hpw065] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Accepted: 06/03/2016] [Indexed: 11/13/2022] Open
Abstract
Within the last several years, the National Institutes of Health has supported three randomized clinical trials to determine whether lower than usually recommended goals for treatment of hypertension would have greater benefit for prevention of cardiovascular disease and stroke. These were the ACCCORD, SPRINT, and Secondary Prevention of Small Subcortical Strokes (SPS3) Trials. Together they enrolled 17,114 participants. Results for all three have been reported. The trials differ from each other in their inclusion criteria, target blood pressures for the lower goal (intensive treatment), but are similar in many respects. The results with regard to their primary outcome were different: not significant for ACCORD and SPS3, but definitely significant for SPRINT. Subgroup analysis revealed differences and similarities. When viewed together and with recent large observational studies, they support a conclusion that a systolic pressure in the range of 125-135 mm Hg range is likely to be optimal on treatment for most hypertensive patients.
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Affiliation(s)
- Lawrence R Krakoff
- Department of Medicine/Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
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Abstract
AIMS In order to eventually improve blood pressure (BP) management, the aim of this study was to identify subgroups of type 2 diabetes mellitus (T2DM) patients with distinct trajectories of SBP levels. Identifying subgroups with distinct SBP trajectories helps to better understand the course of SBP levels in T2DM patients and its associated consequences. Subgroup characteristics were determined and the prevalence of complications and mortality rates over time in the different subgroups was investigated. METHODS Five thousand, seven hundred and eleven T2DM patients with at least two SBP follow-up measurements were selected from a prospective T2DM cohort of 9849 T2DM patients. The mean follow-up period was 5.7 years (range 2-9 years). Latent Class Growth Modeling, as currently the most flexible cluster analysis available, was performed to identify subgroups of patients with distinct SBP trajectories. Subgroup characteristics were determined by multinomial logistic regression analyses. RESULTS Four subgroups with distinct SBP trajectories were identified. The largest subgroup (85.6%) showed adequate SBP control (at or around 140 mmHg) over time. The second subgroup (5.6%) were hypertensive in the first years, responded slowly to BP management and eventually reached SBP control. The third subgroup (3.4%) showed deteriorating hypertension during the first 4 years, then showed insufficient response to BP management. The fourth subgroup (5.4%) showed deteriorating hypertension over time. Patients within subgroups 2-4 were significantly older, comprised more women, used more antihypertensive medication and had a higher prevalence of retinopathy, microalbuminuria and cardiovascular disease (CVD) mortality. CONCLUSION More than 85% reached and maintained adequate SBP control. Subgroups with a more unfavourable course of SBP control also showed higher rates of microvascular complications and CVD mortality over time. This study identified important subgroups to target in order to improve BP management in T2DM patients.
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Shih CJ, Chen YT, Ou SM, Lin CH, Tarng DC. Observed Blood Pressure and Mortality Among People Aged 65 Years and Older: A Community-Based Cohort Study. J Am Med Dir Assoc 2016; 17:654-62. [PMID: 27209272 DOI: 10.1016/j.jamda.2016.04.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Accepted: 04/06/2016] [Indexed: 11/17/2022]
Abstract
OBJECTIVES The 2014 Eighth Joint National Committee guidelines for hypertension management emphasize the upper limit of blood pressure (BP) as the target for treatment in the elderly population. Given the uncertainty regarding optimal BP range, we aimed to investigate the association between observed BP and subsequent mortality in older people. DESIGN, SETTING, AND PARTICIPANTS We extracted data from 128,765 participants ≥65 years of age who underwent annual health examinations in a retrospective, observational community-based study from 2001 to 2010. Seated BP was measured using an oscillometric device. The outcomes were all-cause and cardiovascular mortality. RESULTS As compared to participants with systolic BP at 130 to 139 mm Hg, the risk of all-cause mortality was significantly higher among those with <110 (adjusted hazard ratios [aHRs], 1.12; 95% confidence interval [CI], 1.05-1.20), 140 to 149 (aHR, 1.08; 95% CI, 1.03-1.14), 150 to 159 (aHR, 1.07; 95% CI, 1.01-1.17), 160 to 169 (aHR, 1.11; 95% CI, 1.04-1.19), and ≥170 mm Hg (aHR, 1.25; 95% CI, 1.17-1.33), whereas the differences were not significant for those with 110 to119 (aHR, 1.06; 95% CI, 1.00-1.12) and 120 to 129 mm Hg (aHR, 1.03; 95% CI, 0.97-1.08). Similarly, diastolic BP at 40 to 79 mm Hg was associated with the lowest risk of all-cause mortality. The J-shaped curve relationship between BP and cardiovascular mortality was also observed. CONCLUSIONS Observed systolic and diastolic BP other than 110 to 139 and 40 to 79 mm Hg, respectively, were associated with a worse outcome. Our large cohort study supports the J-shaped mortality with observed BP in older people.
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Affiliation(s)
- Chia-Jen Shih
- School of Medicine, National Yang-Ming University, Taipei, Taiwan; Deran Clinic, Yilan, Taiwan; Department of Medicine, Taipei Veterans General Hospital, Yuanshan Branch, Yilan, Taiwan
| | - Yung-Tai Chen
- School of Medicine, National Yang-Ming University, Taipei, Taiwan; Department of Medicine, Taipei City Hospital Heping Fuyou Branch, Taipei, Taiwan
| | - Shuo-Ming Ou
- School of Medicine, National Yang-Ming University, Taipei, Taiwan; Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Chi-Hung Lin
- Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan; Institute of Microbiology and Immunology, National Yang-Ming University, Taipei, Taiwan
| | - Der-Cherng Tarng
- School of Medicine, National Yang-Ming University, Taipei, Taiwan; Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan; Department and Institute of Physiology, National Yang-Ming University, Taipei, Taiwan.
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Kabir MSH, Uddin MMN, Hosen SMZ. Investigation on hypoglycemic effects of ethanol extract of Alpinia nigra (Gaertn.) in animal model. JOURNAL OF COMPLEMENTARY MEDICINE RESEARCH 2016; 5:131-6. [PMID: 27104033 PMCID: PMC4835987 DOI: 10.5455/jice.20160307112256] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Accepted: 02/24/2016] [Indexed: 11/22/2022]
Abstract
Background: Our study aims at exploring the hypoglycemic effect, efficacy, and possible mode of action of ethanol extract of Alpinia nigra (EEAN) as an antidiabetic agent in an animal model. Methods: Oral glucose tolerance test (OGTT) was used to identify primary hypoglycemic effect in mice. Three tests (glucose absorption, sucrose absorption, and disaccharidase activity) were carried out by gut perfusion and six segments studies to assess carbohydrate absorption and glucose utilization. Results: In OGTT, at 400 mg/kg and 800 mg/kg dose of EEAN extract significantly improved oral glucose tolerance among normal mice at 60 min and 90 min with compared to control. Both doses of extract significantly (P < 0.01) reduced blood glucose level and showed the hypoglycemic effect by retarding 11.43% and 20.82% of blood glucose level after 2 h of administration in glucose-induced mice, respectively. In situ perfused rat intestinal model demonstrated reduced glucose absorption at a 500 mg/kg dose. Inhibition of intestinal disaccharidase was also found by the extract. This was confirmed, yet again, via the six segment study. Throughout the length of the gastrointestinal tract, sucrose digestion was found to be inhibited which is also evident in the six segment study. Conclusions: This study suggests that the EEAN has hypoglycemic effects in a dose-dependent manner by inhibiting intestinal glucose absorption, and these may be effective in the treatment of diabetes. Further study is required to explicate the effect this extract or the active compounds have on the individual glucose transporters and the precise mechanism.
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Affiliation(s)
| | | | - S M Zahid Hosen
- Department of Pharmacology, Division of Pharmacology Research, Bangladesh Council of Scientific and Industrial Research, Chittagong - 4220, Bangladesh
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Optimal home SBP targets for preventing the progression of diabetic nephropathy in patients with type 2 diabetes mellitus. J Hypertens 2016; 33:1853-9; discussion 1859. [PMID: 26136206 DOI: 10.1097/hjh.0000000000000636] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Home blood pressure control can reduce the risk of increased urinary albumin excretion in patients with diabetes mellitus. However, the optimal home blood pressure targets to prevent the onset or progression of diabetic nephropathy are not well defined. METHODS We performed a retrospective cohort study of 851 patients with type 2 diabetes mellitus. Logistic regression models were used to evaluate the correlations of home SBP levels with progression of diabetic nephropathy. RESULTS During the follow-up of 2 years, 86 patients had progression of diabetic nephropathy. Adjusted odds ratios (95% confidence interval) for progression of diabetic nephropathy in patients with morning SBP of 120-129 mmHg [2.725 (1.074-6.917), P = 0.035], 130-139 mmHg [3.703 (1.519-9.031), P = 0.004] and in those with morning SBP equal or more than 140 mmHg [2.994 (1.182-7.581), P = 0.021] were significantly higher than that in those with morning SBP less than 120 mmHg in multiple logistic analyses. CONCLUSION The preferable morning SBP targets might be less than 120 mmHg for preventing the onset or progression of diabetic nephropathy in patients with type 2 diabetes mellitus.
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Association of blood pressure and coronary collateralization in type 2 diabetic and nondiabetic patients with stable angina and chronic total occlusion. J Hypertens 2016; 33:621-6; discussion 626. [PMID: 25490709 DOI: 10.1097/hjh.0000000000000455] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE We investigated whether and to what extent blood pressure (BP) affects coronary collateralization in type 2 diabetic and nondiabetic patients with stable angina and chronic total occlusion. METHODS Brachial BP was measured using an inflatable cuff manometer in 431 diabetic and 287 nondiabetic patients with stable angina and angiographic total occlusion of at least one major coronary artery. They were classified according to the SBP (<100, 100-119, 120-139, 140-159, 160-179, and ≥180 mmHg), DBP (<60, 60-69, 70-79, 80-89, 90-99, and ≥100 mmHg), and pulse (<40, 40-49, 50-59, 60-69, 70-79, and ≥80 mmHg) BP ranges. The degree of coronary collaterals supplying the distal aspect of a total occlusion from the contralateral vessel was graded as poor (Rentrop score of 0 or 1) or good collateralization (Rentrop score of 2 or 3). RESULTS In diabetic patients, the incidence of poor collateralization was related to the DBP in a U-shaped pattern, with the lowest risk at 80-89 mmHg. In nondiabetic patients, an optimal DBP range was 90-99 mmHg for good collaterals, but no U-shaped relation between DBP and coronary collateralization was observed. After adjusting for the baseline characteristics in the logistic regression models, the increased risk of poor collateralization persisted for low or high DBP ranges in diabetic [odds ratio (OR) 2.02-7.29, P ≤ 0.04] and nondiabetic patients (OR 3.62-5.98, P ≤ 0.02). No such relations were observed between collateral grades and SBP and pulse BP. CONCLUSION This study demonstrates that 80-89 and 90-99 mmHg are the optimal ranges for DBP in diabetic and nondiabetic patients with stable angina and chronic total occlusion, within which the risk of poor collateralization is low.
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Engelmann J, Manuwald U, Rubach C, Kugler J, Birkenfeld AL, Hanefeld M, Rothe U. Determinants of mortality in patients with type 2 diabetes: a review. Rev Endocr Metab Disord 2016; 17:129-37. [PMID: 27068710 DOI: 10.1007/s11154-016-9349-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
UNLABELLED We aimed to review and summarize the evidence from accomplished trials analyzing factors influencing mortality in patients with T2DM and to provide some recommendations for targets and treatment in the European region. The following databases were searched for relevant trials: PubMed and the Cochrane Library. Of 3.806 citations, 134 trials met our inclusion criteria. RESULTS The reduction in lifetime for 65 + -years-old patients having less than 10 years T2DM amounts to 1.8 years. Having T2DM for more than 10 years lifetime will be reduced by 2.7 years. However, the lifetime shortening factor of T2DM will even be stronger for 40 + -years-old patients at onset. Males will lose 11.6 years of life and 18.6 QUALYs. T2DM among females will reduce life by 14 QUALYs by 22 years. From a statistical point of view, the highest mortality rate will occur in an over 55-years-old European smoking and non-compliant diabetic woman with alcohol abuse living in a rural area with a low level of education and a low socio-economic status. Furthermore, other co-morbidities such as cardiovascular diseases, gout, and depression affect mortality. Additionally, mortality will increase with a BMI over 35 and also with a BMI under 20-25. This refers to the obesity paradox indicating a higher mortality rate among normal weight patients with T2DM compared to overweight patients with T2DM. HbA1c-levels between 6.5 % and 7 % are associated with the lowest impact on mortality.
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Affiliation(s)
- Jana Engelmann
- Health Sciences/Public Health, Faculty of Medicine, TUD, Fetscherstraße 74, D-01307, Dresden, Germany
| | - Ulf Manuwald
- Health Sciences/Public Health, Faculty of Medicine, TUD, Fetscherstraße 74, D-01307, Dresden, Germany
| | - Constanze Rubach
- Health Sciences/Public Health, Faculty of Medicine, TUD, Fetscherstraße 74, D-01307, Dresden, Germany
| | - Joachim Kugler
- Health Sciences/Public Health, Faculty of Medicine, TUD, Fetscherstraße 74, D-01307, Dresden, Germany
| | - Andreas L Birkenfeld
- Medical Clinic III, University Clinic, Faculty of Medicine, TUD, Fetscherstraße 74, D-01307, Dresden, Germany
- Study Center Prof. Hanefeld, Research for Metabolic Vascular Syndrome, GWT-TUD GmbH, Fiedlerstraße 34, D-01307, Dresden, Germany
| | - Markolf Hanefeld
- Study Center Prof. Hanefeld, Research for Metabolic Vascular Syndrome, GWT-TUD GmbH, Fiedlerstraße 34, D-01307, Dresden, Germany
| | - Ulrike Rothe
- Health Sciences/Public Health, Faculty of Medicine, TUD, Fetscherstraße 74, D-01307, Dresden, Germany.
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Li W, Katzmarzyk PT, Horswell R, Wang Y, Johnson J, Hu G. Blood pressure and all-cause mortality among patients with type 2 diabetes. Int J Cardiol 2016; 206:116-21. [PMID: 26788685 DOI: 10.1016/j.ijcard.2016.01.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Revised: 12/14/2015] [Accepted: 01/01/2016] [Indexed: 01/13/2023]
Abstract
BACKGROUND The recommended goal for blood pressure (BP) control has recently been adjusted for people with diabetes, but the optimal BP control range for the diabetic population is still uncertain. METHODS We performed a prospective cohort study of 35,261 patients with type 2 diabetes. Cox proportional hazard regression models were used to estimate the association of BP with all-cause mortality. RESULTS During a mean follow-up period of 8.7 years, 4199 deaths were identified. The multivariable-adjusted hazard ratios of all-cause mortality associated with different levels of systolic/diastolic BP (<110/65, 110-119/65-69, 120-129/70-80, 130-139/80-90 [reference group], 140-159/90-100, and ≥160/100 mmHg) were 1.70 (95% confidence interval [CI] 1.42-2.04), 1.26 (95% CI 1.07-1.50), 0.99 (95% CI 0.86-1.12), 1.00, 0.92 (95% CI 0.82-1.03), and 1.10 (95% CI 0.98-1.23) using baseline BP measurements, and 2.62 (95% CI 2.00-3.44), 1.77 (95% CI 1.51-2.09), 1.22 (95% CI 1.09-1.36), 1.00, 0.90 (95% CI 0.82-1.00), and 0.98 (95% CI 0.86-1.12) using an updated mean value of BP during follow-up, respectively. The U-shaped associations were confirmed in both African American and white patients, in both men and women, in those who were or were not taking antihypertensive drugs, and in patients aged 30-49 years and 50-59 years. CONCLUSIONS The current study found a U-shaped association between BP at baseline and during follow-up and the risk of all-cause mortality among patients with type 2 diabetes.
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Affiliation(s)
- Weiqin Li
- Pennington Biomedical Research Center, Baton Rouge, LA, USA; Tianjin Women's and Children's Health Center, Tianjin, China
| | | | | | - Yujie Wang
- Pennington Biomedical Research Center, Baton Rouge, LA, USA
| | - Jolene Johnson
- Louisiana State University Health Center, Baton Rouge, LA, USA
| | - Gang Hu
- Pennington Biomedical Research Center, Baton Rouge, LA, USA.
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Yu D, Simmons D. Association between pulse pressure and risk of hospital admissions for cardiovascular events among people with Type 2 diabetes: a population-based case-control study. Diabet Med 2015; 32:1201-6. [PMID: 25594137 DOI: 10.1111/dme.12693] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/12/2015] [Indexed: 01/03/2023]
Abstract
AIM To investigate the association between pulse pressure and risk of hospitalization for cardiovascular events among people with Type 2 diabetes. METHODS A population-based case-control study was carried out using data from medical databases. A total of 588 people with Type 2 diabetes from 18 general practices in Cambridgeshire recorded a first hospitalization for a cardiovascular event between 2009 and 2011, and a total of 2920 age-matched, gender-matched and practice-matched control subjects with Type 2 diabetes were selected based on risk-set sampling. Pulse pressure was assessed before admission in 2008-2009. Further dose-response relationships between pulse pressure and risks were explored using spline models. RESULTS There was a non-linear relationship between pulse pressure and the risk of hospitalization for a cardiovascular event (P < 0.001 for linearity test). The pulse pressure associated with the lowest risk of hospitalization for a cardiovascular event was 61 (95% CI 57-63) mmHg. CONCLUSION In people with Type 2 diabetes, pulse pressure is a good predictor of risk of hospitalization for cardiovascular events. The risk is lowest with a pulse pressure of 57-63 mmHg.
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Affiliation(s)
- D Yu
- Institute of Metabolic Science, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - D Simmons
- Institute of Metabolic Science, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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Pacilli A, Lamacchia O, Fontana A, Copetti M, Cignarelli M, Trischitta V, De Cosmo S. Target values of cardiovascular risk factors are not associated with all-cause mortality in patients with type 2 diabetes mellitus. PLoS One 2015; 10:e0124536. [PMID: 25928715 PMCID: PMC4415933 DOI: 10.1371/journal.pone.0124536] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2014] [Accepted: 03/15/2015] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND To investigate prospectively the relationship between target values of glycated hemoglobin, blood pressure and LDL-cholesterol, as considered in a combined fashion, and all-cause mortality in patients with type 2 diabetes mellitus. METHODS Two cohorts of patients with type 2 diabetes mellitus, the Gargano Mortality Study (n=810) and the Foggia Mortality Study (n=929), were investigated. A weighted target risk score was built as a weight linear combination of the recommended targets reached by each patient. RESULTS In the Gargano Mortality Study and in the Foggia Mortality Study (mean follow up=7.4 and 5.5 years, respectively), 161 (19.9%) and 220 (23.7%) patients died, with an age and sex adjusted annual incidence rate of 2.1 and 2.8 per 100 person-years, respectively. In both study samples the weighted target risk score tended to be linearly associated with all-cause mortality (HR for one point increment=1.30, 95% CI: 1.11-1.53, p=0.001, and HR=1.08, 95% CI: 0.95-1.24, p=0.243, respectively). When the two cohorts were pooled and analyzed together, a clear association between weighted target risk score and all-cause mortality was observed (HR for one point increment=1.17, 95% CI:1.05-1.30, p=0.004). This counterintuitive association was no longer observable in a model including age, sex, body mass index, smoking habit, estimated glomerular filtration rate, albuminuria and anti-diabetic, anti-hypertensive and anti-dyslipidemic treatment as covariates (HR for one point increment=0.99, 95% CI: 0.87-1.12, p=0.852). CONCLUSIONS In a real life clinical set of patients with type 2 diabetes mellitus, the combination of recommended target values of established cardiovascular risk factors is not associated with all-cause mortality.
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Affiliation(s)
- Antonio Pacilli
- Unit of Internal Medicine, Department of Medical Sciences, IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | - Olga Lamacchia
- Unit of Endocrinology and Metabolic Diseases, Department of Surgical and Medical Sciences, University of Foggia, Italy
| | - Andrea Fontana
- Unit of Biostatistics, IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | - Massimiliano Copetti
- Unit of Biostatistics, IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | - Mauro Cignarelli
- Unit of Endocrinology and Metabolic Diseases, Department of Surgical and Medical Sciences, University of Foggia, Italy
| | - Vincenzo Trischitta
- Research Unit of Diabetes and Endocrine Diseases, IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
- Department of Experimental Medicine, “Sapienza” University, Rome, Italy
| | - Salvatore De Cosmo
- Unit of Internal Medicine, Department of Medical Sciences, IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
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Kontopantelis E, Springate DA, Ashworth M, Webb RT, Buchan IE, Doran T. Investigating the relationship between quality of primary care and premature mortality in England: a spatial whole-population study. BMJ 2015; 350:h904. [PMID: 25733592 PMCID: PMC4353289 DOI: 10.1136/bmj.h904] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To quantify the relationship between a national primary care pay-for-performance programme, the UK's Quality and Outcomes Framework (QOF), and all-cause and cause-specific premature mortality linked closely with conditions included in the framework. DESIGN Longitudinal spatial study, at the level of the "lower layer super output area" (LSOA). SETTING 32482 LSOAs (neighbourhoods of 1500 people on average), covering the whole population of England (approximately 53.5 million), from 2007 to 2012. PARTICIPANTS 8647 English general practices participating in the QOF for at least one year of the study period, including over 99% of patients registered with primary care. INTERVENTION National pay-for-performance programme incentivising performance on over 100 quality-of-care indicators. MAIN OUTCOME MEASURES All-cause and cause-specific mortality rates for six chronic conditions: diabetes, heart failure, hypertension, ischaemic heart disease, stroke, and chronic kidney disease. We used multiple linear regressions to investigate the relationship between spatially estimated recorded quality of care and mortality. RESULTS All-cause and cause-specific mortality rates declined over the study period. Higher mortality was associated with greater area deprivation, urban location, and higher proportion of a non-white population. In general, there was no significant relationship between practice performance on quality indicators included in the QOF and all-cause or cause-specific mortality rates in the practice locality. CONCLUSIONS Higher reported achievement of activities incentivised under a major, nationwide pay-for-performance programme did not seem to result in reduced incidence of premature death in the population.
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Affiliation(s)
- Evangelos Kontopantelis
- Centre for Health Informatics, Institute of Population Health, University of Manchester, Manchester, UK NIHR School for Primary Care Research, Centre for Primary Care, Institute of Population Health, University of Manchester
| | - David A Springate
- NIHR School for Primary Care Research, Centre for Primary Care, Institute of Population Health, University of Manchester Centre for Biostatistics, Institute of Population Health, University of Manchester
| | - Mark Ashworth
- Primary Care and Public Health Sciences, King's College London, London, UK
| | - Roger T Webb
- Centre for Mental Health and Risk, University of Manchester
| | - Iain E Buchan
- Centre for Health Informatics, Institute of Population Health, University of Manchester, Manchester, UK
| | - Tim Doran
- Department of Health Sciences, University of York, York, UK
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Kontopantelis E, Springate DA, Reeves D, Ashcroft DM, Rutter MK, Buchan I, Doran T. Glucose, blood pressure and cholesterol levels and their relationships to clinical outcomes in type 2 diabetes: a retrospective cohort study. Diabetologia 2015; 58:505-18. [PMID: 25512005 DOI: 10.1007/s00125-014-3473-8] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Accepted: 11/25/2014] [Indexed: 01/08/2023]
Abstract
AIMS/HYPOTHESIS We aimed to describe the shape of observed relationships between risk factor levels and clinically important outcomes in type 2 diabetes after adjusting for multiple confounders. METHODS We used retrospective longitudinal data on 246,544 adults with type 2 diabetes from 600 practices in the Clinical Practice Research Datalink, 2006-2012. Proportional hazards regression models quantified the risks of mortality and microvascular or macrovascular events associated with four modifiable biological variables (HbA1c, systolic BP, diastolic BP and total cholesterol), while controlling for important patient and practice covariates. RESULTS U-shaped relationships were observed between all-cause mortality and levels of the four biometric risk factors. Lowest risks were associated with HbA1c 7.25-7.75% (56-61 mmol/mol), total cholesterol 3.5-4.5 mmol/l, systolic BP 135-145 mmHg and diastolic BP 82.5-87.5 mmHg. Coronary and stroke mortality related to the four risk factors in a positive, curvilinear way, with the exception of systolic BP, which related to deaths in a U-shape. Macrovascular events showed a positive and curvilinear relationship with HbA1c but a U-shaped relationship with total cholesterol and systolic BP. Microvascular events related to the four risk factors in a curvilinear way: positive for HbA1c and systolic BP but negative for cholesterol and diastolic BP. CONCLUSIONS/INTERPRETATION We identified several relationships that support a call for major changes to clinical practice. Most importantly, our results support trial data indicating that normalisation of glucose and BP can lead to poorer outcomes. This makes a strong case for target ranges for these risk factors rather than target levels.
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Affiliation(s)
- Evangelos Kontopantelis
- NIHR School for Primary Care Research, Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, UK,
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