Association of Kidney Disease, Potassium, and Cardiovascular Risk Factor Prevalence with Coronary Arteriosclerotic Burden, by Sex

The present study aimed to determine the relationship between the prevalence of cardiovascular risk factors and the number and severity of coronary artery atherosclerotic lesions obtained by coronary angiography. We reviewed and analyzed 1642 records from consecutive patients at the Catheter Laboratory of Talca Regional Hospital in Chile between March 2018 and May 2019. Patients were stratified according to the presence and severity of atherosclerotic lesions: 632 (38.5%) had no lesions or <30% stenosis and 1010 (61.5%) had at least one coronary atherosclerotic lesion with ≥30% stenosis (CALS-30). CALS-30 was more frequent in males, smokers, and patients with diabetes and/or hypertension (all p-values < 0.02). Serum potassium, glycaemia, creatinine and glomerular filtration rates were also associated with CALS-30 (all p-values < 0.01) in males. The age and the proportion of males with CALS-30 increased with the number of risk factors (p-values for trends < 0.001). Our results showed a stronger association between the accumulation of risk factors and CALS-30 in women than in men. Serum potassium levels were inversely associated with CALS-30 in men but not in women.

Diabetes, Cardiovascular Disease, and Cardiovascular Risk in Patients with Chronic Kidney Disease

INTRODUCTION

It is unclear whether the increased risk associated with diabetes in patients on dialysis is due to diabetes or a consequence of associated cardiovascular disease (CVD).

AIM

The purpose of this work was to answer the question: do diabetes and CVD have a similar impact on the incidence of cardiovascular events in patients undergoing maintenance hemodialysis?

METHODS

A prespecified protocol was used to prospectively evaluate and follow up 310 diabetic patients on hemodialysis without clinical evidence of CVD and 395 nondiabetic patients with CVD. Endpoint was the incidence of composite CV events and coronary events.

RESULTS

The incidence of composite CV events (log-rank = 0.540) and coronary events (log-rank = 0.400) did not differ between groups. Because of the potential influence of occult CVD in patients with diabetes, we repeated the analysis excluding subjects with altered ejection fraction, a myocardial perfusion scan defect, and coronary artery disease in the group of patients with diabetes. Again we found no difference between groups (log-rank = 0.657).

CONCLUSION

In patients on hemodialysis, diabetes and CVD carry similar risks for CV events. These results are congruent with the diabetes mellitus-CVD equivalence risk concept reported in the general population.

Lack of effects of evidence-based, individualised counselling on medication use in insured patients with mild hypertension in China: a randomised controlled trial

OBJECTIVE

To evaluate whether evidence-based, individualised (EBI) counselling regarding hypertension and the treatment would affect medication use in insured patients with mild hypertension in China.

METHODS

We conducted a parallel-group, randomised controlled trial in two primary care centres in Shenzhen, a metropolitan city in China. Patients with mild primary hypertension, 10-year risk of cardiovascular diseases (CVDs) lower than 20% and no history of CVDs were recruited and randomly allocated to two groups. EBI plus general counselling was provided to the intervention group and general counselling alone to the control group. EBI counselling included information on the 10-year CVD risk and treatment benefit in terms of absolute risk reduction estimated for each individual and information on average side effects and costs of antihypertensive drugs. The outcomes included use of antihypertensive drugs and adherence to the treatment at 6-month follow-up, with the former being primary outcome.

RESULTS

Two hundred and ten patients were recruited, with 103 and 107 allocated to the intervention and control groups, respectively. At baseline, 62.4% of the patients were taking antihypertensive drugs that were all covered by health insurance. At the end of 6-month follow-up, there was no statistically significant difference in the rate of medication use between the intervention group and the control group (65.0% vs 57.9%; OR=1.35, 95% CI: 0.77 to 2.36). The difference in adherence rate between the two groups was not statistically significant either (43.7% vs 40.2%; OR=1.15, 95% CI 0.67 to 2.00]). The results were robust in sensitivity analyses that used different cutoffs to define the two outcomes.

CONCLUSIONS

The EBI counselling by health educators other than the caring physicians had little impact on treatment choices and drug-taking behaviours in insured patients with mild primary hypertension in this study. It remains unclear whether EBI counselling would make a difference in uninsured patients, especially when conducted by the caring physicians.

TRIAL REGISTRATION NUMBER

ChiCTR-TRC-14004169.

Comparative performance of diabetes-specific and general population-based cardiovascular risk assessment models in people with diabetes mellitus

AIM

Multivariable models for estimating cardiovascular disease (CVD) risk in people with diabetes comprise general population-based models and those from diabetic cohorts. Whether one set of models should receive preference is unclear. We evaluated the evidence on direct comparisons of the performance of general population vs diabetes-specific CVD risk models in people with diabetes.

METHODS

MEDLINE and EMBASE databases were searched up to March 2013. Two reviewers independently identified studies that compared the performance of general CVD models vs diabetes-specific ones in the same group of people with diabetes. Independent, dual data extraction on study design, risk models, outcomes; and measures of performance was conducted.

RESULTS

Eleven articles reporting on 22 pair wise comparisons of a diabetes-specific model (UKPDS, ADVANCE and DCS risk models) to a general population model (three variants of the Framingham model, Prospective Cardiovascular Münster [PROCAM] score, CardioRisk Manager [CRM], Joint British Societies Coronary Risk Chart [JBSRC], Progetto Cuore algorithm and the CHD-Riskard algorithm) were eligible. Absolute differences in C-statistic of diabetes-specific vs general population-based models varied from -0.13 to 0.09. Comparisons for other performance measures were unusual. Outcomes definitions were congruent with those applied during model development. In 14 comparisons, the UKPDS, ADVANCE or DCS diabetes-specific models were superior to the general population CVD risk models. Authors reported better C-statistic for models they developed.

CONCLUSION

The limited existing evidence suggests a possible discriminatory advantage of diabetes-specific over general population-based models for CVD risk stratification in diabetes. More robust head-to-head comparisons are needed to confirm this trend and strengthen recommendations.

On the importance of global cardiovascular risk assessment in people with type 2 diabetes

This narrative review examines the concept of diabetes as a cardiovascular disease (CVD) risk equivalent, the rationale and approaches to absolute CVD risk estimation in type 2 diabetes. In people with diabetes, CVD risk follows a gradient. Reliably capturing this gradient depends on the combination of several risk factors. Existing CVD risk tools applicable to people with diabetes have shown a modest-to-acceptable performance. Future improvements may include updating existing models or constructing new ones with improved predictive accuracy. Ultimately, developed models should be tested in independent populations, and the impact of their uptake on clinical decision making and the outcome of care assessed.

Update on type 2 diabetes as a cardiovascular disease risk equivalent

Type 2 diabetes increases the risk of cardiovascular disease (CVD) from two- to four-fold. In our large Finnish population-based study published in 1998 subjects with medication for type 2 diabetes had as high a risk of fatal and nonfatal myocardial infarction (MI) during the 7- year follow-up as non-diabetic subjects with a prior MI, suggesting that type 2 diabetes is a CVD equivalent. In another large study, including all 3.3 million residents of Denmark, subjects requiring glucose-lowering therapy exhibited a CVD risk similar to that of non-diabetic subjects with a prior MI. Subsequent studies have not systematically replicated aforementioned results. Some studies have supported the concept that type 2 diabetes is a CVD equivalent only in some subgroups, and many studies have reported negative findings. This is likely to be due to many differences across the studies published, for example ethnicity, gender, age and other demographic factors of the populations involved, study design, validation of diabetes status and CVD events, statistical analyses (adjustments for confounding factors), duration of diabetes, and treatment of hyperglycemia among diabetic participants. Varying results reflect the fact that not all diabetic patients are at a similar risk for CVD. Therefore, CVD risk assessment and the tailoring of preventive measures should be done individually, taking into consideration each patient's long-term risk of developing cardiovascular events.

Mortality associated with diabetes and cardiovascular disease in older women

Background

Current guidelines for the prevention of cardiovascular disease (CVD) recommend diabetes as a CVD risk equivalent. However, reports that have examined the risk of diabetes in comparison to pre-existing CVD are lacking among older women. We aimed to assess whether diabetes was associated with a similar risk of total and cause-specific mortality as a history of CVD in older women.

Methodology/Principal Findings

We studied 9218 women aged 68 years or older enrolled in a prospective cohort study (Study of Osteoporotic Fracture) during a mean follow-up period of 11.7 years and compared all-cause, cardiovascular and coronary heart disease mortality among 4 groups: non-diabetic women with and without existing CVD, diabetic women with and without existing CVD. Mean (SD) age of the participants was 75.2 (5.3) years, 3.5% reported diabetes and 6.8% reported existing CVD. During follow-up, 5117 women died with 36% from CVD. The multivariate adjusted risk of cardiovascular mortality was increased among both non-diabetic women with CVD (hazard ratio (HR) 2.32, 95% CI: 1.97–2.74, P<0.001) and diabetic women without CVD (HR 2.06, CI: 1.62–2.64, P<0.001) compared to non-diabetic women without existing CVD. All-cause, cardiovascular and coronary mortality of non-diabetic women with CVD were not significantly different from diabetic women without CVD.

Conclusions/Significance

Older diabetic women without CVD have a similar risk of cardiovascular mortality compared to non-diabetic women with pre-existing CVD. The equivalence of diabetes and CVD seems to extend to older women, supporting current guidelines for cardiovascular prevention.

Should diabetes still be considered a coronary artery disease equivalent?

Diabetes is well established as a cardiovascular risk factor and is currently regarded as a coronary artery disease equivalent. However, some recent data have contradicted the concept. We review the currently available data and usefulness or otherwise of this concept. While the concept of coronary artery disease equivalence has served to highlight the importance of diabetes as a risk factor, it has a number of problems. We propose that it would be more useful to consider diabetes as a myocardial infarction risk equivalent. This is not only more precise and in line with the literature but also conveys better the message that patients with diabetes and one or more previous myocardial infarction(s) are at even higher risk.

Mortality in diabetes compared with previous cardiovascular disease: a gender-specific meta-analysis

AIMS

Diabetes has been described as a cardiovascular disease (CVD) risk equivalent. There is evidence, however, that its impact may differ between women and men. For this reason, our study aimed to obtain gender-specific hazard ratios (HRs) comparing diabetes and CVD patients in terms of all-cause, CVD and coronary heart disease (CHD) mortality.

METHODS

Individuals with diabetes (without CVD) and those with CVD (without diabetes) were examined through a systematic review of articles that provided gender-specific HRs for mortality. Searches included Medline, Embase and the Cochrane Library database (from January 1998 to December 2009) and exploded MeSH headings [cardiovascular diseases, risk, epidemiologic studies, case-control studies, cohort studies, mortality, outcome assessment (health care), sex factors, survival analysis and diabetes mellitus, type 2]. Two observers selected and reviewed the studies and hierarchical Bayesian random-effects models were used to combine HRs, thereby accommodating any between-study differences through inclusion of a between-study variance in HRs.

RESULTS

Out of 5425 studies, nine were relevant (0.17%). CVD and CHD mortality in men was lower for diabetes alone (CVD mortality HR: 0.82, 95% CrI: 0.69-0.98; CHD mortality HR: 0.73, 95% CrI: 0.65-0.83). In contrast, rates appeared to be higher in women with diabetes alone (CVD mortality HR: 1.29, 95% CrI: 0.79-2.26; CHD mortality HR: 1.28, 95% CrI: 0.75-2.22), although wide credible intervals precluded any definitive conclusions. All-cause mortality in men was similar for diabetes and previous CVD (HR: 1.02, 95% CrI: 0.93-1.12) whereas, among women, it was at least as high and possibly higher for diabetes alone (HR: 1.25, 95% CrI: 0.89-1.76).

CONCLUSION

Compared with previous CVD, diabetes alone leads to lower CVD and CHD mortality risk in men, and similar all-cause mortality. In contrast, although further studies are needed, it is possible that diabetes leads to higher CVD, CHD and all-cause mortality in women.

Sex does not influence prognosis in diabetic patients. The Barbanza Diabetes study

INTRODUCTION AND OBJECTIVES

To determine the influence of sex on cardiovascular complications in diabetic patients.

METHODS

This multicenter prospective cohort study involved 1423 consecutive patients with diabetes mellitus who were recruited during consultations with 31 primary care physicians. The patients' characteristics were recorded and they were followed up for 45 + or - 10 months.

RESULTS

The mean age of the patients (50% female) was 66 years, 64% had hypertension, 70% had dyslipidemia, and 26% had had a previous cardiovascular event. Cardiovascular disease, predominantly ischemic heart disease, was observed more frequently in men and a higher percentage had end-organ damage (57.7% of males versus 45.4% of females; P< .0001). Women had poorer glycemic control, higher total cholesterol levels and lower high-density lipoprotein cholesterol levels. By the end of follow-up, 81 patients had died (5.7% of males versus 6.7% of females; P=.513). There were no sex differences in cardiovascular complications during follow up (15.8% in males versus 13.7% in females; P=.368). Multivariate analysis identified the following factors as independent predictors of morbidity or mortality: age (hazard ratio [HR]=1.04; 95% confidence interval [CI], 1.02-1.06), existing cardiovascular disease (HR=1.96; 95% CI, 1.38-2.79), diuretic treatment (HR=1.62; 95% CI, 1.10-2.38), and albuminuria (HR=1.86; 95% CI, 1.33-2.61).

CONCLUSIONS

No difference was observed in mediumterm prognosis, with regard to mortality and cardiovascular selecmorbidity, between male and female diabetics from the same geographical area, despite the presence of clinical differences between the sexes.

Preventing diabetic complications: a primary care perspective

While controlling cardiometabolic risk factors remains central to diabetes management, substantial disease burden persists despite intensive targeting of blood glucose, blood pressure and lipids. Data from the Fenofibrate Intervention and Event Lowering in Diabetes (FIELD) study provide some new insights. As well as significant reduction in total cardiovascular disease events, especially among patients with marked atherogenic dyslipidaemia (low high-density lipoprotein (HDL) cholesterol and hypertriglyceridaemia), fenofibrate had preventive effects on microvascular outcomes, reducing laser treatment for retinopathy, progression of albuminuria, and non-traumatic amputations. These findings suggest re-evaluation of fenofibrate as an option for reducing the risk of diabetic vascular complications.