Nationwide study on trends in hospital admissions for major cardiovascular events and procedures among people with and without diabetes in England, 2004-2009

Rosiglitazone improves insulin resistance but does not improve exercise capacity in individuals with impaired glucose tolerance: A randomized clinical study

Dysmetabolic states, such as type 2 diabetes (T2D), characterized by insulin resistance (IR), are associated with fatty liver, increased cardiovascular disease (CVD) risk, and decreased functional exercise capacity (FEC). Rosiglitazone (RO) improves exercise capacity and IR in T2D. However, the effects of RO on FEC and other markers of CVD risk in prediabetes are unknown. We hypothesized that insulin sensitization with RO would improve exercise capacity and markers of CVD risk in participants with impaired glucose tolerance (IGT). Exercise performance (peak oxygen consumption and oxygen uptake kinetics), IR (homeostasis model assessment of IR and quantitative insulin sensitivity check index), and surrogate cardiovascular endpoints (coronary artery calcium (CAC) volume and density and C-reactive protein (CRP)) were measured in participants with IGT after 12 and 18 months of RO or placebo (PL). RO did not significantly improve exercise capacity. Glycemic measures and IR were significantly lower in people on RO compared to PL at 18 months. CAC volume progression was not different between PL and RO groups. RO did not improve exercise capacity during an 18-month intervention despite improved IR and glycemia in people with IGT. Future studies should explore why effects on FEC with RO occur in T2D but not IGT. Understanding these questions may help in targeting therapeutic approaches in T2D and IGT.

Trends in incidence of ischaemic stroke in people with and without diabetes in Ireland 2005-2015

AIMS

We aim to describe the epidemiology of ischaemic stroke and in-hospital mortality associated with stroke among men and women with and without diabetes from 2005 to 2015.

METHODS

Secondary data analysis of national hospital discharge data from the Hospital Inpatient Enquiry database. Stroke incidence and in-hospital mortality rates in people with and without diabetes were calculated. Poisson regression models were used to estimate the incidence rate ratio (IRR) and assess trends over time.

RESULTS

The age-adjusted incidence of stroke was twice as high in people with diabetes compared to those without diabetes (men IRR 2.0 [95% CI 1.95-2.06] and women IRR 2.2 [95% CI 2.12-2.27]). The incidence of ischaemic stroke decreased by an average 1.7% per year in men with diabetes and 3.3% per year in women with diabetes. In people without diabetes, the average annual reduction was smaller (0.2% per year in men and 1% per year in women). In-hospital mortality associated with admission with ischaemic stroke was approximately twice as high in those with diabetes compared to those without diabetes among men [IRR 1.81 (1.67-1.97)] and women [IRR 2 (95% CI 1.84-2.18)].

CONCLUSION

Despite decreases in incidence of ischaemic stroke and associated in-hospital mortality, there remains a twofold increased risk of ischaemic stroke and mortality in people with diabetes. Therefore, priority must be given to management of risk factors for ischaemic stroke in people with diabetes as well as continued development of targeted stroke prevention strategies.

Association between circulating asprosin levels and carotid atherosclerotic plaque in patients with type 2 diabetes

BACKGROUND

Carotid plaque is one of the typical manifestations and precursors of diabetic cardiovascular complications. As a new adipokine, asprosin participates in the development of diabetes and cardiovascular diseases, and is considered to be closely related to insulin resistance and glucolipid metabolism. This study aimed to analyze the relationship between serum asprosin level and carotid plaque in patients with type 2 diabetes mellitus (T2DM).

METHODS

A total of 180 patients with T2DM were selected. The basic parameters and biochemical indexes of the subjects were measured, and the serum asprosin concentration of the subjects was detected by ELISA. The carotid plaque was evaluated by color Doppler ultrasound.

RESULTS

The level of serum asprosin in the T2DM with carotid plaque group was significantly higher than that in T2DM without carotid plaque group [2.53(1.73-3.21) vs 1.72(1.23-2.34) ng/mL, P < 0.05]. The incidence of carotid plaque in the low, middle and high quartiles was 31.7 %, 48.3 % and 70 % respectively. Correlation analysis showed that serum asprosin was positively correlated with BMI, WHR, SBP, DBP, FIns, LDL-C, HOMA-IR, and HOMA-β (P < 0.05). Linear regression analysis showed that WHR, DBP, FIns, and LDL-C were independent influencing factors of asprosin. Logistic regression analysis showed that serum asprosin was still significantly correlated with carotid plaque in T2DM patients after adjusting for multiple confounding factors. The area under receiver-operating curve (ROC) of asprosin predicting carotid plaque was 0.701 (0.625-0.777) in T2DM.

CONCLUSION

The level of serum asprosin in T2DM patients with carotid plaques is significantly higher, suggesting that asprosin may play a role in the occurrence and development of carotid plaques in T2DM. Detection of this index can provide new clinical evidence for the prevention and treatment of diabetic cardiovascular disease.

Temporal changes in risk of cardiovascular events in people with newly diagnosed type 2 diabetes with and without cardiovascular disease

AIMS

Examine temporal changes in the risk of cardiovascular events in people with newly diagnosed type 2 diabetes with and without cardiovascular disease (CVD).

METHODS

283,600 individuals with newly diagnosed type 2 diabetes and age-, sex-, and CVD-matched controls without diabetes were identified through Danish nationwide registries between 1997 and 2014. Using Cox regression models, we report the standardized absolute 5-year risk of cardiovascular death, myocardial infarction, stroke, and heart failure for people with diabetes and controls.

RESULTS

Individuals with newly diagnosed diabetes were at increased risk of cardiovascular events compared to controls. From 1997-2002 to 2009-2014 reductions in cardiovascular events for people with diabetes were: cardiovascular death; 26.5% to 13.8% in people with CVD and from 7.3% to 3.2% in people without CVD, myocardial infarction; 13.1% to 6.5% in people with CVD and from 4.1% to 1.9% in people without CVD, stroke; 14.2% to 8.8% in people with CVD and from 4.9% to 2.2% in people without CVD, and heart failure; 21.0% to 13.8% in people with CVD and from 5.0% to 2.6% in people without CVD. The risk of cardiovascular events declined more among people with diabetes than controls.

CONCLUSIONS

Newly diagnosed type 2 diabetes was associated with an increased risk of cardiovascular events, and the risk decreased significantly 1997-2014 in both people with and without CVD. Furthermore, the excess risk associated with type 2 diabetes decreased significantly during the study period.

Trends in leading causes of hospitalisation of adults with diabetes in England from 2003 to 2018: an epidemiological analysis of linked primary care records

BACKGROUND

Diabetes leads to a wide range of established vascular and metabolic complications that has resulted in the implementation of diverse prevention programmes across high-income countries. Diabetes has also been associated with an increased risk of a broader set of conditions including cancers, liver disease, and common infections. We aimed to examine the trends in a broad set of cause-specific hospitalisations in individuals with diabetes in England from 2003 to 2018.

METHODS

In this epidemiological analysis, we identified 309 874 individuals 18 years or older with diabetes (type 1 or 2) in England from the Clinical Practice Research Datalink linked to Hospital Episode Statistics inpatient data from 2003 to 2018. We generated a mixed prevalent and incident diabetes study population through serial cross sections and follow-up over time. We used a discretised Poisson regression model to estimate annual cause-specific hospitalisation rates in men and women with diabetes across 17 cause groupings. We generated a 1:1 age-matched and sex-matched population of individuals without diabetes to compare cause-specific hospitalisation rates in those with and without diabetes.

FINDINGS

Hospitalisation rates were higher for all causes in persons with diabetes than in those without diabetes throughout the study period. Diabetes itself and ischaemic heart disease were the leading causes of excess (defined as absolute difference in the rate in the populations with and without diabetes) hospitalisation in 2003. By 2018, non-infectious and non-cancerous respiratory conditions, non-diabetes-related cancers, and ischaemic heart disease were the most common causes of excess hospitalisation across men and women. Hospitalisation rates of people with diabetes declined and causes of hospitalisation changed. Almost all traditional diabetes complication groups (vascular diseases, amputations, and diabetes) decreased, while conditions non-specific to diabetes (cancers, infections, non-infectious and non-cancerous respiratory conditions) increased. These differing trends represented a change in the cause of hospitalisation, such that the traditional diabetes complications accounted for more than 50% of hospitalisation in 2003, but only approximately 30% in 2018. In contrast, the proportion of hospitalisations due to respiratory infections between the same time period increased from 3% to 10% in men and from 4% to 12% in women.

INTERPRETATIONS

Changes in the composition of excess risk and hospitalisation burden in those with diabetes means that preventative and clinical measures should evolve to reflect the diverse set of causes that are driving persistent excess hospitalisation in those with diabetes.

FUNDING

Wellcome Trust.

Trends in inpatient admissions and emergency department visits for heart failure in adults with versus without diabetes in the USA, 2006-2017

INTRODUCTION

Heart failure (HF) is a major contributor to cardiovascular morbidity and mortality in people with diabetes. In this study, we estimated trends in the incidence of HF inpatient admissions and emergency department (ED) visits by diabetes status.

RESEARCH DESIGN AND METHODS

Population-based age-standardized HF rates in adults with and without diabetes were estimated from the 2006-2017 National Inpatient Sample, Nationwide ED Sample and year-matched National Health Interview Survey, and stratified by age and sex. Trends were assessed using Joinpoint.

RESULTS

HF inpatient admissions did not change in adults with diabetes between 2006 and 2013 (from 53.9 to 50.4 per 1000 persons; annual percent change (APC): -0.3 (95% CI -2.5 to 1.9) but increased from 50.4 to 62.3 between 2013 and 2017 (APC: 4.8 (95% CI 0.3 to 9.6)). In adults without diabetes, inpatient admissions initially declined (from 14.8 in 2006 to 12.9 in 2014; APC -2.3 (95% CI -3.2 to -1.2)) and then plateaued. Patterns were similar in men and women, but relative increases were greatest in young adults with diabetes. HF-related ED visits increased overall, in men and women, and in all age groups, but increases were greater in adults with (vs without) diabetes.

CONCLUSIONS

Causes of increased HF rates in hospital settings are unknown, and more detailed data are needed to investigate the aetiology and determine prevention strategies, particularly among adults with diabetes and especially young adults with diabetes.

Temporal trends in rates of infection-related hospitalisations in Hong Kong people with and without diabetes, 2001-2016: a retrospective study

AIMS/HYPOTHESIS

Infection is an under-recognised but important complication in people with diabetes. Studies on temporal trends in incidence of infection in this population are limited. We report the trends in infection-related hospitalisation in people with diabetes and compared hospitalisation rates between people with and without diabetes in Hong Kong.

METHODS

Hospital admissions with infection, including pneumonia, influenza, tuberculosis, kidney infection, urinary tract infection, cellulitis, osteomyelitis, foot infection and sepsis, listed as principal diagnosis occurring between 2001 and 2016 were identified from people with diabetes in the electronic medical record system of the Hong Kong Hospital Authority. Data on hospitalisation for a subset of these infections in the general population between 2007 and 2016 were obtained from the Department of Health. The number of people with diabetes ranged between 117,322 in 2001 and 570,929 in 2016, and the number without diabetes ranged between 5,242,614 in 2007 and 5,593,153 in 2016. Joinpoint regression was used to describe the trends.

RESULTS

In people with diabetes, over a period of 16 years, the age-standardised annual rates of hospitalisation decreased for tuberculosis but increased for influenza; rates of hospitalisation for pneumonia increased up until 2004/2005 and declined in men and stabilised in women. The rates of hospitalisation for most infection types were unchanged or increased in the 20-44 year and 45-64 year age groups and decreased in those aged 65 years or above. Trends for most of the infections were similar when comparing sexes. Between 2007 and 2016, the rate ratios of hospitalisation for most infection types between people with and without diabetes were stable, and the rate ratios remained higher in people with diabetes, ranging from 1.3-1.4 for pneumonia to 3.2-4.9 for kidney infections in 2016 compared with non-diabetic individuals.

CONCLUSIONS/INTERPRETATION

Despite advances in medical care, hospitalisation due to infections remains a major healthcare burden in people with diabetes. Graphical abstract.

Association Between Systolic Blood Pressure and Cardiovascular Inpatient Cost Moderated by Peer-Support Intervention Among Adult Patients With Type 2 Diabetes: A 2-Cohort Study

OBJECTIVES

People with type 2 diabetes and increased systolic blood pressure (SBP) are at high risk of cardiovascular disease (CVD). In this study, we aimed to investigate the association between CVD-related hospital payments and SBP and tested whether this association is influenced by diabetes peer support.

METHODS

Two cohorts comprising people with type 2 diabetes were included in the study. The first cohort comprised 4,704 patients with type 2 diabetes assessed between 2008 and 2009 from 18 general practices in Cambridgeshire and followed up to 2009-2011. The second cohort comprised 1,121 patients with type 2 diabetes from post-trial follow-up data, recruited between 2011 and 2012 and followed up to 2015. SBP was measured at baseline. Inpatient payments for CVD hospitalization within 2 years since baseline was the main outcome. The impact of 1:1, group or combined diabetes peer support and usual care were investigated in the second cohort. Adjusted mean CVD inpatient payments per person were estimated using a 2-part model after adjusting for baseline characteristics.

RESULTS

A "hockey-stick" relationship between baseline SBP and estimated CVD inpatient payment was identified in both cohorts, with a threshold at 133 to 141 mmHg, suggesting increased payments for patients with SBP below and above the threshold. The combined peer-support intervention altered the aforementioned association, with no increased payment with SBP above the threshold, and payment slightly decreased with SBP beyond the threshold.

CONCLUSIONS

SBP maintained between 133 and 141 mmHg is associated with the lowest CVD disease management costs for patients with type 2 diabetes. Combined peer-support intervention could significantly decrease CVD-related hospital payments.

ANGPTL8 Gene Polymorphism rs2278426 Is Related to Carotid Intima-Media Thickness in T2DM

AIM

ANGPTL8 is a cytokine expressed and secreted by liver and adipose tissue, and is involved in glucose, lipid, and energy metabolism. Although studies have shown that ANGPTL8 is elevated in type 2 diabetes mellitus (T2DM) and cardiovascular disease, few have examined the association between ANGPTL8 single-nucleotide polymorphisms and the risk of macrovascular complications in T2DM patients. This study aimed to explore the relationship between rs2278426 and carotid intima-media thickening (cIMT) in T2DM.

METHODS

A total of 217 T2DM patients and 201 healthy control subjects with normal glucose tolerance were recruited in the study. T2DM patients were divided into two groups: T2DM patients without cIM thickening (cIMT <1 mm, 109 cases) and T2DM patients with cIM thickening (cIMT ≥1 mm, 108 cases). rs2278426 genotypes in all 418 subjects were determined and the risk of T2DM and T2DM with cIM thickening analyzed.

RESULTS

CT+TT-genotype frequency in T2DM was higher than in controls with normal glucose tolerance, and the proportion of the CT+TT genotype in the group with cIMT was higher than in the group (P<0.05). In addition, T alleles were associated with waist:hip ratio, triglycerides, high density-lipoprotein cholesterol, plasma glucose at 2 hours' oral glucose tolerance, and homeostatic model assessment of insulin resistance (P<0.05).

CONCLUSION

Generally, carriers of the T allele at rs2278426 are more likely to develop T2DM, and the risk of cIM thickening is significantly increased for T-allele carriers with T2DM, which indicates an increased risk of macroangiopathy.

Lipidomics Profile Changes of Type 2 Diabetes Mellitus with Acute Myocardial Infarction

The morbidity and mortality of cardiovascular disease (CVD)/acute myocardial infarction (AMI) of type 2 diabetes mellitus (T2DM) patients are extremely higher than those without T2DM. Biomarkers can be used to predict the occurrence of acute myocardial infarction, thus effectively reducing the incidence of CVD events, particularly in T2DM patients. Lipids have been shown to be biomarkers and potential therapeutic targets for human diseases. The aim of our study was to investigate the prognostic value of lipid biomarkers for predicting AMI in T2DM patients. A total of 420 subjects were recruited in this research. Liquid Chromatography-Electrospray Ionization-Quadrupole Time of Flight-Mass Spectrometer- (LC-ESI-QTOF-MS-) and Liquid Chromatography/Mass Spectrometer- (LC/MS-) based metabolomic methods were applied to characterize metabolic profiles in each plasma sample. In the first untargeted set, 40 T2DM patients with AMI, 40 T2DM patients without AMI, and 40 control subjects were gender- and age-matched. Eight lipid metabolites showed a significant difference among three groups. Then, in the second set, targeted metabolic profiling assays for these 8 lipid biomarker concentrations in plasma were performed; another 100 T2DM patients with AMI, 100 T2DM patients without AMI, and 100 control subjects were selected independently. Receiver operating characteristic (ROC) curves were constructed, and the area under the ROC curves (AUC) was calculated to determine the potential biomarkers. ROC curve analysis showed that the AUC value of lysophosphatidylcholine (LysoPC) 18:0 is more than 0.7, indicating that LysoPC 18:0 may be a potential sensitive and specific biomarker for T2DM with AMI. The changed plasma concentrations of lipids were significantly associated with T2DM with AMI, which showed great value to be biomarkers, though it requires a prospective cohort study for further validation.

miR‑132 inhibits high glucose‑induced vascular smooth muscle cell proliferation and migration by targeting E2F5

The dysregulated behavior of vascular smooth muscle cells (VSMCs) serves an important role in the pathogenesis of cardiovascular diseases in diabetes. The present study aimed to investigate the effects of microRNA (miR)‑132 on the proliferation and migration of VSMCs under high glucose conditions to mimic diabetes. We observed that the expression of miR‑132 was significantly decreased and that of E2F transcription factor 5 (E2F5) was upregulated in high glucose (HG)‑treated VSMCs or those obtained from diabetic rats. A dual luciferase reporter gene assay revealed that miR‑132 could specifically bind to the 3'‑untranslated region of E2F5 and significantly suppress the luciferase activity. The proliferation and migration of diabetic rat or HG‑treated VSMCs were increased compared with non‑diabetic rat VSMCs and those under normal glucose conditions. Upregulation of miR‑132 significantly inhibited the proliferation and migration of diabetic rat VSMCs; similar effects were observed following E2F5 downregulation. The inhibitory effects of miR‑132 on the proliferation and migration of HG‑treated VSMCs could be reversed by E2F5 overexpression. In conclusion, miR‑132 was proposed to inhibit the proliferation and migration of diabetic rat or high‑glucose‑treated VSMCs by targeting E2F5. The findings of the present study suggested that increasing the expression of miR‑132 may serve as a novel therapeutic approach to inhibit the progression of cardiovascular disease in diabetes.

Are We Optimizing the Use of Dual Antiplatelet Therapy in Patients Hospitalized with Acute Myocardial Infarction?

BACKGROUND

Dual antiplatelet therapy (DAPT) is a mainstay treatment for hospital survivors of an acute myocardial infarction (AMI). However, there are limited data on the prescribing patterns of DAPT among patients hospitalized with AMI during recent years.

OBJECTIVE

To examine decade-long trends (2001-2011) in the use of DAPT versus antiplatelet monotherapy and patient characteristics associated with DAPT use.

METHODS

The study population consisted of 2389 adults hospitalized with an initial AMI at all 11 central Massachusetts medical centers on a biennial basis between 2001 and 2011. DAPT was defined as the discharge use of aspirin plus either clopidogrel or prasugrel. Logistic regression analysis was used to identify patient characteristics associated with DAPT use.

RESULTS

The average age of the study population was 65 years, and 69% of patients were discharged on DAPT. The use of DAPT at the time of hospital discharge increased from 49% in 2001 to 74% in 2011; this increasing trend was seen across all age groups, both sexes, types of AMI, and in those who underwent a PCI. After multivariable adjustment, patients 65-74 years old (adjusted odds ratio (aOR) = 0.53, 95% CI: 0.36-0.80) and those who underwent coronary artery bypass surgery (aOR = 0.11, 95% CI: 0.07-0.18) were less likely to have received DAPT, while men (aOR = 14.60, 95% CI: 10.66-19.98) and those who underwent cardiac catheterization and stenting (aOR = 14.60, 95% CI: 10.66-19.98) were significantly more likely to have received DAPT at discharge than respective comparison groups.

CONCLUSIONS

Between 2001 and 2011, the use of DAPT increased markedly among patients hospitalized with AMI. However, a significant proportion of patients were not discharged on this therapy. Greater awareness is needed to incorporate DAPT into the management of patients hospitalized with AMI.

Trends in incidence and case fatality of acute myocardial infarction, angina and coronary revascularisation in people with and without type 2 diabetes in Scotland between 2006 and 2015

AIMS/HYPOTHESIS

The aim of the study was to examine trends in the incidence and case fatality of acute myocardial infarction (AMI) and in hospital admissions for angina and coronary revascularisation procedures in people with type 2 diabetes and in people without diabetes in Scotland between 2006 and 2015.

METHODS

In this retrospective cohort study, AMI, angina and revascularisation event data were obtained for adults from hospital admissions and death records linked to a population-based diabetes register. Incidence by diabetes status was estimated using negative binomial models with adjustment or stratification by age, sex, deprivation and calendar year. Logistic regression was used to estimate AMI case fatality by diabetes status.

RESULTS

There were 129,926 incident AMI events, 41,263 angina admissions and 69,875 coronary revascularisation procedures carried out during 34.9 million person-years of follow-up. The adjusted incidence of AMI, angina and revascularisation procedures declined by 2.0% (95% CI 1.73%, 2.26%), 9.62% (95% CI 9.22%, 10.01%) and 0.35% (95% CI -0.09%, 0.79%) per year, respectively. The rate of decline did not differ materially by diabetes status. RRs of AMI for type 2 diabetes were 1.86 (95% CI 1.74, 1.98) for men and 2.32 (95% CI 2.15, 2.51) for women. Of the 77,211 people admitted to hospital with a first AMI, 7842 (10.2%) died within 30 days of admission. Case fatality was higher in people with type 2 diabetes than in people without diabetes and declined in both groups by 7.93% (95% CI 7.03%, 8.82%) per year.

CONCLUSIONS/INTERPRETATION

The incidence of AMI, angina, revascularisation and AMI case fatality has declined over time, but the increased risk associated with type 2 diabetes has remained approximately constant.

Global trends in diabetes complications: a review of current evidence

In recent decades, large increases in diabetes prevalence have been demonstrated in virtually all regions of the world. The increase in the number of people with diabetes or with a longer duration of diabetes is likely to alter the disease profile in many populations around the globe, particularly due to a higher incidence of diabetes-specific complications, such as kidney failure and peripheral arterial disease. The epidemiology of other conditions frequently associated with diabetes, including infections and cardiovascular disease, may also change, with direct effects on quality of life, demands on health services and economic costs. The current understanding of the international burden of and variation in diabetes-related complications is poor. The available data suggest that rates of myocardial infarction, stroke and amputation are decreasing among people with diabetes, in parallel with declining mortality. However, these data predominantly come from studies in only a few high-income countries. Trends in other complications of diabetes, such as end-stage renal disease, retinopathy and cancer, are less well explored. In this review, we synthesise data from population-based studies on trends in diabetes complications, with the objectives of: (1) characterising recent and long-term trends in diabetes-related complications; (2) describing regional variation in the excess risk of complications, where possible; and (3) identifying and prioritising gaps for future surveillance and study.

Sustained Socioeconomic Inequalities in Hospital Admissions for Cardiovascular Events Among People with Diabetes in England

PURPOSE

This study aimed to determine changes in absolute and relative socioeconomic inequalities in hospital admissions for major cardiovascular causes among patients with diabetes in England.

METHODS

We identified all patients with diabetes aged ≥45 years admitted to the hospital in England between 2004-2005 and 2014-2015 for acute myocardial infarction, stroke, percutaneous coronary intervention, or coronary artery bypass graft. We measured socioeconomic status using the Index of Multiple Deprivation. Diabetes-specific admission rates were calculated for each year by deprivation quintile. We assessed temporal changes using negative binomial regression models.

RESULTS

Most admissions occurred among patients aged ≥65 years (71%) and men (63.3%). The number of admissions increased steadily from the least quintile to the most deprived quintile. Patients in the most deprived quintile had a 1.94-fold increased risk of acute myocardial infarction (95% confidence interval [CI], 1.79-2.10), 1.92-fold increased risk of stroke (95% CI, 1.78-2.07), 1.66-fold increased risk of coronary artery bypass graft (95% CI, 1.50-1.74), and 1.76-fold increased risk of percutaneous coronary intervention (95% CI, 1.64-1.89) compared with the least deprived group. Absolute differences in rates between the least and most deprived quintiles did not change significantly for acute myocardial infarction (P = .29) and were reduced for stroke, coronary artery bypass graft, and percutaneous coronary intervention (by 17.5, 15, and 11.8 per 100,000 patients with diabetes, respectively, P ≤ .01 for all).

CONCLUSIONS

Socioeconomic inequalities persist in diabetes-related hospital admissions for major cardiovascular events in England. Besides improved risk stratification strategies that consider socioeconomically defined needs, wide-reaching population-based policy interventions are required to reduce inequalities in diabetes outcomes.

Total/high density lipoprotein cholesterol and cardiovascular disease (re)hospitalization nadir in type 2 diabetes

Total cholesterol to HDL cholesterol ratio (TC/HDL) is an important prognostic factor for CVD. This study used restricted cubic spline modeling to investigate the dose-response associations between TC/HDL and both CVD hospitalization and CVD rehospitalization in two independent prospective cohorts. The East Cambridgeshire and Fenland cohort includes 4,704 patients with T2D from 18 general practices in Cambridgeshire. The Randomized controlled trial of Peer Support In type 2 Diabetes cohort comprises 1,121 patients with T2D with posttrial follow-up data. TC/HDL and other demographic and clinical measurements were measured at baseline. Outcomes were CVD hospitalization over 2 years and CVD rehospitalization after 90 days of the prior CVD hospitalization. Modeling showed nonlinear relationships between TC/HDL and risks of CVD hospitalization and rehospitalization consistently in both cohorts (all P < 0.001 for linear tests). The lowest risks of CVD hospitalization and rehospitalization were consistently found for TC/HDL at 2.8 (95% CI: 2.6-3.0) in both cohorts and both overall and by gender. This is lower than the current lipid control target, 4.0 of TC/HDL. Reducing the TC/HDL target to 2.8 would include a further 33-44% patients with TC/HDL in the 2.8-4.0 range. Studies are required to assess the effectiveness and cost-effectiveness of the earlier introduction of, and more intensive, lipid-lowering treatment needed to achieve this new lower TC/HDL target.

A long-term quality-of-care score for predicting the occurrence of macrovascular diseases in patients with type 2 diabetes mellitus

AIMS

The aim of this study was to develop a long-term quality-of-care score to predict the occurrence of macrovascular diseases in patients with type 2 diabetes mellitus, on the basis of the hypothesis that good quality of care can reduce the risk of macrovascular complications.

METHODS

Using Taiwan's Longitudinal Cohort of Diabetes Patients Database and the medical records in a medical center, we identified the incident patients diagnosed with type 2 diabetes during 1999-2003 and followed them until 2011. A summary score (from 0 to 8) was calculated according to process indicators (frequencies of HbA1_c and lipid profile testing and urine, foot and retinal examinations), intermediate outcome indicators (low-density lipoprotein, blood pressure and HbA1_c), and the co-morbidity of hypertension. We used Cox regression models to evaluate the association between the score and the incidence of macrovascular complications.

RESULTS

Of the 4275 patients enrolled, 1928 developed macrovascular complication events after a mean follow-up period of 8.2 years. Compared to the risk of developing a macrovascular disease event in patients with scores ≤1, the risk was 64% lower in those with quality-of-care scores ≥5 (adjusted hazard ratio = 0.36; 95% confidence interval: 0.28-0.45).

CONCLUSIONS

Good quality of care can reduce the risk of macrovascular diseases in patients with type 2 diabetes. The score developed in this study had a significant association with the risk of macrovascular complications and thus can be applied to guiding the care for these patients.

Development and External Validation of Risk Scores for Cardiovascular Hospitalization and Rehospitalization in Patients With Diabetes

CONTEXT

Cardiovascular disease (CVD) is a common and costly reason for hospitalization and rehospitalization among patients with type 2 diabetes.

OBJECTIVE

This study aimed to develop and externally validate two risk-prediction models for cardiovascular hospitalization and cardiovascular rehospitalization.

DESIGN

Two independent prospective cohorts.

SETTING

The derivation cohort includes 4704 patients with type 2 diabetes from 18 general practices in Cambridgeshire. The validation cohort comprises 1121 patients with type 2 diabetes from post-trial follow-up data.

MAIN OUTCOME MEASURE

Cardiovascular hospitalization over 2 years and cardiovascular rehospitalization after 90 days of the prior CVD hospitalization.

RESULTS

The absolute rate of cardiovascular hospitalization and rehospitalization was 12.5% and 6.7% in the derivation cohort and 16.3% and 7.0% in the validation cohort. Discrimination of the models was similar in both cohorts, with C statistics above 0.70 and excellent calibration of observed and predicted risks.

CONCLUSION

Two prediction models that quantify risks of cardiovascular hospitalization and rehospitalization have been developed and externally validated. They are based on a small number of clinical measurements that are available for patients with type 2 diabetes in many developed countries in primary care settings and could serve as the tools to screen the population at high risk of cardiovascular hospitalization and rehospitalization.

Declining Rates of Hospitalization for Selected Cardiovascular Disease Conditions Among Adults Aged ≥35 Years With Diagnosed Diabetes, U.S., 1998-2014

OBJECTIVE

Reductions in heart attack and stroke hospitalizations are well documented in the U.S. population with diabetes. We extended trend analyses to other cardiovascular disease (CVD) conditions, including stroke by type, and used four additional years of data.

RESEARCH DESIGN AND METHODS

Using 1998-2014 National (Nationwide) Inpatient Sample (NIS) data, we estimated the number of discharges having acute coronary syndrome (ACS) (ICD-9 codes 410-411), cardiac dysrhythmia (427), heart failure (428), hemorrhagic stroke (430-432), or ischemic stroke (433.x1, 434, and 436) as first-listed diagnosis and diabetes (250) as secondary diagnosis. Hospitalization rates for adults aged ≥35 years were calculated using estimates from the population with and the population without diabetes from the National Health Interview Survey (NHIS) and age-adjusted to the 2000 U.S. standard population. Joinpoint regression was used to analyze trends and calculate an average annual percentage change (AAPC) with 95% confidence limits (CLs).

RESULTS

From 1998 to 2014, in the population with diabetes, age-adjusted hospitalization rates declined significantly for ACS (AAPC -4.6% per year [95% CL -5.3, -3.8]), cardiac dysrhythmia (-0.7% [-1.1, -0.2]), heart failure (-3.6% [-4.6, -2.7]), hemorrhagic stroke (-1.1% [-1.4, -0.7]), and ischemic stroke (-2.9% [-3.9, -1.8]). In the population without diabetes, rates also declined significantly for these conditions, with the exception of dysrhythmia. By 2014, rates in the population with diabetes population remained two to four times as high as those for the population without diabetes, with the largest difference in heart failure rates.

CONCLUSIONS

CVD hospitalization rates declined significantly in both the population with diabetes and the population without diabetes. This may be due to several factors, including new or more aggressive treatments and reductions in CVD risk factors and CVD incidence.

Incident ischaemic stroke and Type 2 diabetes: trends in incidence and case fatality in Scotland 2004-2013

AIM

To describe trends in first ischaemic stroke incidence and case fatality in adults with and without a diagnosis of Type 2 diabetes prior to their ischaemic stroke event in Scotland between 2004 and 2013.

METHODS

Using population-wide hospital admission, death and diabetes datasets, we conducted a retrospective cohort study. Negative binomial and logistic regression models were used to calculate year-specific incidence and case-fatality rates for people with Type 2 diabetes and for people without diabetes.

RESULTS

During 41.0 million person-years of follow-up there were 69 757 ischaemic stroke events. Type 2 diabetes prevalence among patients who experienced ischaemic stroke increased from 13.5% to 20.3% between 2004 and 2013. Stroke incidence rates declined by 2.7% (95% CI 2.4, 3.0) annually for people with and without diabetes [diabetes/year interaction: rate ratio 0.99 (95% CI 0.98, 1.01)]. Type 2 diabetes was associated with an increased risk of ischaemic stroke in men [rate ratio 1.23 (95% CI 1.17, 1.30)] and women [rate ratio 1.41 (95% CI 1.35, 1.48)]. Case-fatality rates were 14.2% and 12.7% in people with Type 2 diabetes and without diabetes, respectively. Case fatality declined by 3.5% (95% CI 2.7, 4.5) annually [diabetes/year interaction: odds ratio 1.01 (95% CI 0.98, 1.02)].

CONCLUSIONS

Ischaemic stroke incidence declined no faster in people with a diagnosis of Type 2 diabetes than in people without diabetes. Increasing prevalence of Type 2 diabetes among stroke patients may mean that declines in case fatality over time will be less marked in the future.

Nation-wide trends in non-alcoholic steatohepatitis (NASH) in patients with and without diabetes between 2004-05 and 2014-15 in England

AIMS

There are no national studies evaluating the epidemiology of non-alcoholic steatohepatitis (NASH) in England. NASH is becoming an increasingly important health issue given the inexorable rise in obesity and diabetes. We evaluated the rates of NASH in people with and without diabetes from 2004-2005 to 2014-2015.

METHODS

We identified cases of biopsy-proven NASH in people with and without diabetes in England over an eleven-year period using Hospital Episode Statistics. We estimated incidence rates for each year. Negative binomial regression models were fitted to test trends.

RESULTS

Over the study period, people without diabetes recorded a 3% reduction in admission rates per year (incidence rate ratio (IRR) (95% CI) 0.97 (0.96-0.98), p<0.001), whilst there was an increase in admission rates in people with diabetes (IRR (95% CI) 1.01 (1.00-1.02), p=0.04). In people with diabetes, this upward trend was driven by people over 65years (IRR (95% CI) 1.03 (1.02-1.04), p<0.001) and men (IRR (95% CI) 1.01 (1.0-1.02), p=0.03). Inpatient mortality declined for people with diabetes by 2% per year after adjusting for age, sex and year (IRR (95% CI) 0.98 (0.95-0.99), p=0.03). The 2% decline per year in inpatient mortality for people without diabetes did not achieve statistical significance after adjustment (IRR (95% CI) 0.98 (0.95-1.01), p=0.175).

CONCLUSIONS

There was a decline in NASH-related hospital admissions amongst people without diabetes over eleven years, whilst rates increased in people with diabetes. These observations highlight the increasing burden of NASH.

Gender differences in hospital admissions for major cardiovascular events and procedures in people with and without diabetes in England: a nationwide study 2004-2014

Background

Secondary prevention of cardiovascular disease (CVD) has improved immensely during the past decade but controversies persist on cardiovascular benefits among women with diabetes. We investigated 11-year trends in hospital admission rates for acute myocardial infarction (AMI), stroke, percutaneous coronary intervention (PCI), and coronary artery bypass graft (CABG) in people with and without diabetes by gender in England.

Methods

We identified all hospital admissions for cardiovascular disease causes among people aged 17 years and above between 2004 and 2014 in England. We calculated diabetes-specific and non-diabetes-specific rates for study outcomes by gender. To assess temporal changes, we fitted negative binomial regression models.

Results

Diabetes-related admission rates remained unchanged for AMI (incidence rate ratio (IRR) 0.99 [95% CI 0.98–1.01]), increased for stroke by 2% (1.02 [1.01–1.03]) and PCI by 3% (1.03 [1.01–1.04]) and declined for CABG by 3% (0.97 [0.96–0.98]) annually. Trends did not differ significantly by diabetes status. Women with diabetes had significantly lower rates of AMI (IRR 0.46 [95% CI 0.40–0.53]) and stroke (0.73 [0.63–0.84]) compared with men with diabetes. However, gender differences in admission rates for AMI attenuated in diabetes compared with the non-diabetic group. While diabetes tripled admission rates for AMI in men (IRR 3.15 [95% CI 2.72–3.64]), it increased it by over fourfold among women (4.27 [3.78–4.93]). Furthermore, while the presence of diabetes was associated with a threefold increased rates for PCI and fivefold increased rates for CABG (IRR 3.14 [2.83–3.48] and 5.01 [4.59–5.05], respectively) in men, among women diabetes was associated with a 4.4-fold increased admission rates for PCI and 6.2-fold increased rates for CABG (4.37 [3.93–4.85] and 6.24 [5.66–6.88], respectively). Proportional changes in rates were similar in men and women for all study outcomes, leaving the relative risk of admissions unchanged.

Conclusions

Diabetes still confers a greater increase in risk of hospital admission for AMI in women relative to men. However, the absolute risk remains higher in men. These results call for intensified CVD risk factor management among people with diabetes, consideration of gender-specific treatment targets and treatment intensity to be aligned with levels of CVD risk.

Hospitalization costs and clinical outcomes in CABG patients treated with intensive insulin therapy

BACKGROUND

The financial impact of intensive (blood glucose [BG] 100-140mg/dl [5.5-7.8mM] vs. conservative (141-180mg/dl (7.9-10.0mM) glucose control in the ICU in patients, with and without diabetes, undergoing coronary artery bypass graft (CABG) surgery is not known.

METHODS

This post-hoc cost analysis determined differences in hospitalization costs, resource utilization and perioperative complications in 288 CABG patients with diabetes (n=143) and without diabetes (n=145), randomized to intensive (n=143) and conservative (n=145) glucose control.

RESULTS

Intensive glucose control resulted in lower BG (131.4±14mg/dl-(7.2±0.8mM) vs. 151.6±17mg/dl (8.4±0.8mM, p<0.001), a nonsignificant reduction in the median length of stay (LOS, 7.9 vs. 8.5days, p=0.17) and in a composite of perioperative complications including wound infection, bacteremia, acute renal and respiratory failure, major cardiovascular events (42% vs 52%, p=0.10) compared to conservative control. Median hospitalization costs were lower in the intensive group ($39,366 vs. $42,141, p=0.040), with a total cost savings of $3654 (95% CI: $1780-$3723), than conservative control. Resource utilization for radiology (p=0.008), laboratory (p=0.014), consultation service (p=0.013), and ICU utilization (p=0.007) were also lower in the intensive group. Compared to patients without perioperative complications, those with complications had longer hospital length of stay (10.7days vs. 6.7days, p<0.001), higher total hospitalization cost ($48,299 vs. $32,675, p<0.001), and higher resource utilization units (2745 vs. 1710, p<0.001).

CONCLUSION

Intensive glycemic control [BG 100-140mg/dl (5.5-7.8mM)] in patients undergoing CABG resulted in significant reductions in hospitalization costs and resource utilization compared to patients treated with conservative [BG 141-180mg/dl (7.9-10.0mM)] glucose control.

PCSK9 inhibition: the dawn of a new age in cholesterol lowering?

Proprotein convertase subtilisin/kexin type 9 (PCSK9) is a circulating enzyme of hepatic origin that plays a key role in LDL receptor turnover. Genetic studies have confirmed that individuals with gain-of-function PCSK9 mutations have increased PCSK9 activity, elevated LDL-cholesterol levels and a severe form of familial hypercholesterolaemia. Those with variants leading to reduced PCSK9 have lower LDL-cholesterol levels and a reduced risk of coronary heart disease, and this has led to the development of various strategies aimed at reducing circulating PCSK9. Monoclonal antibodies to PCSK9, given every 2-4 weeks by subcutaneous injection, have been shown to reduce LDL-cholesterol by 50-60% compared with placebo in individuals with and without diabetes. PCSK9 inhibition also reduces lipoprotein(a), an atherogenic lipid particle, by around 20-30%. Major cardiovascular outcome trials for two agents, evolocumab and alirocumab, are expected to report from 2017. These trials involve over 45,000 participants and are likely to include about 15,000 individuals with diabetes. PCSK9-binding adnectins have been employed as an alternative method of removing circulating PCSK9. Small interfering RNA targeting messenger RNA for PCSK9, which acts by reducing hepatic production of PCSK9, is also under investigation. These agents may only need to be given by subcutaneous injection once every 4-6 months. Ongoing trials will determine whether anti-PCSK9 antibody therapy safely reduces cardiovascular risk, although high cost may limit its use. Development of PCSK9-lowering technologies cheaper than monoclonal antibodies will be necessary for large numbers of individuals to benefit from this approach to lowering cholesterol.

MicroRNAs and Cardiovascular Disease in Diabetes Mellitus

Cardiovascular disease (CVD) is the major macrovascular complication of diabetes mellitus. Recently, although CVD morbidity and mortality have decreased as a result of comprehensive control of CVD risk factors, CVD remains the leading cause of death of patients with diabetes in many countries, indicating the potential underlying pathophysiological mechanisms. MicroRNAs are a class of noncoding, single-stranded RNA molecules that are involved in β-cell function, insulin secretion, insulin resistance, skeletal muscle, and adipose tissue and which play an important role in glucose homeostasis and the pathogenesis of diabetic complications. Here, we review recent progress in research on microRNAs in endothelial cell and vascular smooth muscle cell dysfunction, macrophage and platelet activation, lipid metabolism abnormality, and cardiomyocyte repolarization in diabetes mellitus. We also review the progress of microRNAs as potential biomarkers and therapeutic targets of CVD in patients with diabetes.

Cardiovagal modulation and efficacy of aerobic exercise training in obese individuals

Type 2 diabetes (T2D) is associated with poor exercise tolerance and peak aerobic capacity (V˙O2peak) even when compared to obese nondiabetic peers. Exercise training studies have demonstrated improvements in V˙O2peak among patients with T2D, yet there is a large amount of variability in this response. Recent evidence suggests that cardiac autonomic modulation may be an important factor when considering improvements in aerobic capacity.

PURPOSE

This study aimed to determine the effects of a 16-wk aerobic exercise program on V˙O2peak in obese individuals, with and without T2D, who were classified as having either high or low cardiovagal modulation (HCVM or LCVM) at baseline.

METHODS

Obese individuals (38 women and 19 men; body mass index = 36.1 kg·m(-2)) were studied in the fasted state. ECG recordings were obtained while seated for 3 min, before and after 4 months of exercise training (4 d·wk(-1), 65% V˙O(2peak)). The ECG recording was analyzed for HR variability in the spectral domain. Groups were split on a marker of CVM (normalized high frequency (HFnu)) at the 50th percentile, as either HCVM or LCVM.

RESULTS

V˙O(2peak) only increased with exercise training among those classified as having HCVM, regardless of diabetes status (T2D: HCVM = 20.3-22.5 mL·kg(-1)min(-1), LCVM = 24.3-25.0 mL·kg(-1)min(-1); obese nondiabetics: HCVM = 24.5-26.3 mL·kg(-1)min(-1), LCVM = 23.1-23.7 mL·kg(-1)min(-1)) (P < 0.05). No change in V˙O(2peak) was observed for the LCVM group. Changes in weight do not explain the change in V˙O(2peak) among the HCVM group. Glucose tolerance only improved among the LCVM group with T2D.

CONCLUSIONS

Obese individuals, with or without T2D, when classified as having relatively HCVM before exercise training, have a greater propensity to improve V˙O(2peak) after a 16-wk aerobic training program.

Improved trends in cardiovascular complications among subjects with type 2 diabetes in Korea: a nationwide study (2006-2013)

Background

Representative data on the secular trends in cardiovascular disease (CVD) are limited in Asian populations with diabetes. We aimed to estimate the temporal trends in cardiovascular complications using Korean nationwide whole population-based claims data in subjects with and without diabetes.

Methods

Type 2 diabetes was defined as a current medication history of anti-diabetic drugs and the presence of International Classification of Diseases (ICD)-10 codes (E11–E14) as diagnosis. We compared the 8-year rates of six cardiovascular complications [i.e., ischemic heart disease, acute myocardial infarction (AMI), ischemic stroke, hemorrhagic stroke, percutaneous coronary intervention (PCI), and coronary artery bypass graft (CABG)] in Korean adults aged 30 years and older using data from four consecutive nationwide databases (2006–2007, 2008–2009, 2010–2011, and 2012–2013) of Korean national health insurance service.

Results

A total of 1,645,348, 1,971,559, 2,291,247, and 2,562,612 subjects with type 2 diabetes were found in the year of 2006–2007, 2008–2009, 2010–2011, and 2012–2013, respectively. Age and gender standardized rates of the six predefined cardiovascular complications decreased in Korean adults with type 2 diabetes during the study period. The greatest relative reductions were observed for hospitalization due to AMI (−37.28%), followed by hospitalizations due to ischemic stroke (−36.98%). In the overall population without type 2 diabetes, the greatest relative reductions were observed for hospitalization for hemorrhagic stroke (−29.47%), followed by hospitalization due to ischemic stroke (−28.92%). Relative decreases in all six predefined cardiovascular complications were generally more profound in adults with diabetes than in those without diabetes, which led to significant decrease in the relative risks of all six cardiovascular complications in subjects with diabetes over the past 8 years. However, people with diabetes still had a two- to sixfold higher risk of hospitalization for major CVD events and interventions than people without diabetes.

Conclusions

Our findings suggest a significant reduction in the rate of people affected by CVD within the diabetic population. However, as the number of people with diabetes rises, the absolute burden of CVD will still be high in Korea.

Electronic supplementary material

The online version of this article (doi:10.1186/s12933-016-0482-6) contains supplementary material, which is available to authorized users.

Using Large Diabetes Databases for Research

There are an increasing number of clinical, administrative and trial databases that can be used for research. These are particularly valuable if there are opportunities for linkage to other databases. This paper describes examples of the use of large diabetes databases for research. It reviews the advantages and disadvantages of using large diabetes databases for research and suggests solutions for some challenges. Large, high-quality databases offer potential sources of information for research at relatively low cost. Fundamental issues for using databases for research are the completeness of capture of cases within the population and time period of interest and accuracy of the diagnosis of diabetes and outcomes of interest. The extent to which people included in the database are representative should be considered if the database is not population based and there is the intention to extrapolate findings to the wider diabetes population. Information on key variables such as date of diagnosis or duration of diabetes may not be available at all, may be inaccurate or may contain a large amount of missing data. Information on key confounding factors is rarely available for the nondiabetic or general population limiting comparisons with the population of people with diabetes. However comparisons that allow for differences in distribution of important demographic factors may be feasible using data for the whole population or a matched cohort study design. In summary, diabetes databases can be used to address important research questions. Understanding the strengths and limitations of this approach is crucial to interpret the findings appropriately.

In-Hospital Outcomes and Complications of Coronary Artery Bypass Grafting in the United States Between 2008 and 2012

OBJECTIVE

To investigate the frequency and predictors of in-hospital complications among patients undergoing coronary artery bypass grafting (CABG) in the United States.

DESIGN

Retrospective national database analysis SETTINGS: United States hospitals.

PARTICIPANTS

A weighted sample of 1,910,236 patients undergoing CABG surgery identified from the National (Nationwide) Inpatient Sample from 2008 to 2012.

INTERVENTIONS

CABG surgery MEASUREMENTS AND MAIN RESULTS: The number of CABG surgeries decreased from 436,275 in 2008 to 339,749 in 2012. The Deyo comorbidity index showed a steady increase from 2008 to 2012. The rate of in-hospital mortality decreased from 2.7% in 2008 to 2.2% in 2012 (p<0.001). The most common in-hospital complication was postoperative hemorrhage (30.4%), followed by cardiac (11.34%) and respiratory complications (2.3%). During the 5-year period, the rates of in-hospital cardiac, respiratory and infectious complications decreased (p<0.001), while the rate of postoperative hemorrhage showed a 35.8% relative increase in 2012 compared to 2008.

CONCLUSION

The annual number of CABG surgeries is declining in the United States. While the burden of comorbidities is increasing, the rates of mortality and most in-hospital complications are improving. The increasing rate of postoperative bleeding necessitates the need to develop strategies to improve the risk of bleeding in this patient population.

Trends in hospital admissions for hypoglycaemia in England: a retrospective, observational study

BACKGROUND

Studies in the USA and Canada have reported increasing or stable rates of hospital admissions for hypoglycaemia. Some data from small studies are available for other countries. We aimed to gather information about long-term trends in hospital admission for hypoglycaemia and subsequent outcomes in England to help widen understanding for the global burden of hospitalisation for hypoglycaemia.

METHODS

We collected data for all hospital admissions listing hypoglycaemia as primary reason of admission between Jan 1, 2005, and Dec 31, 2014, using the Hospital Episode Statistics database, which contains details of all admissions to English National Health Service (NHS) hospital trusts. We calculated trends in crude and adjusted (for age, sex, ethnic group, social deprivation, and Charlson comorbidity score) admissions for hypoglycaemia; in admissions for hypoglycaemia per total hospital admissions and per diabetes prevalence in England; and in length of stay, in-hospital mortality, and 1 month readmissions for hypoglycaemia.

FINDINGS

79 172 people had 101 475 admissions for hypoglycaemia between 2005 and 2014, of which 72 568 (72%) occurred in people aged 60 years or older. 13 924 (18%) people had more than one admission for hypoglycaemia during the study period. The number of admissions increased steadily from 7868 in 2005, to 11 756 in 2010 (49% increase) and then remained more stable until 2014 (10 977; 39% increase from baseline, range across English regions 11-89%); the trend was similar after adjustment for risk factors, with a rate ratio of 1·53 (95% CI 1·29-1·81) for 2014 versus 2005. Admissions for hypoglycaemia per 100 000 total hospital admissions increased from 63·6 to 78·9 between 2005-06 and 2010-11 (24% increase), and then fell to 72·3 per 100 000 in 2013-14 (14% overall increase). Accounting for diabetes prevalence data, rates declined from 4·64 to 3·86 admissions per 1000 person-years with diabetes between 2010-11 and 2013-14. We were unable to compare prevalence rates with data prior to 2010, as the populations were not comparable; data were available for all individuals prior to 2010 but only for those aged 17 years or older after 2010. With some differences across regions, from 2005 to 2014, the adjusted proportion of admissions to receive same-day discharge increased by 43·8% (from 18·9 to 27·1 same-day discharges per 100 admissions); in-hospital mortality decreased by 46·3% (from 4·2 to 2·3 deaths per 100 admissions); and 1 month readmissions decreased by 63·0% (from 48·1 to 17·8 per 100 readmissions).

INTERPRETATION

Over 10 years, hospital admissions in England for hypoglycaemia increased by 39% in absolute terms and by 14% considering the general increase in hospitalisation; however, accounting for diabetes prevalence, there was a reduction of admission rates. Hospital length of stay, mortality, and 1 month readmissions decreased progressively and consistently during the study period. Given the continuous rise of diabetes prevalence, ageing population, and costs associated with hypoglycaemia, individual and national initiatives should be implemented to reduce the burden of hospital admissions for hypoglycaemia.

FUNDING

None.

The changing face of diabetes complications

The global increase in type 2 diabetes prevalence is well documented, but international trends in complications of type 2 diabetes are less clear. The available data suggest large reductions in classic complications of type 2 diabetes in high-income countries over the past 20 years, predominantly reductions in myocardial infarction, stroke, amputations, and mortality. These trends might be accompanied by less obvious, but still important, changes in the character of morbidity in people with diabetes. In the USA, for example, substantial reductions in macrovascular complications in adults aged 65 years or older mean that a large proportion of total complications now occur among adults aged 45-64 years instead, rates of renal disease could persist more than other complications, and obesity-related type 2 diabetes could have increasing effect in youth and adults under 45 years of age. Additionally, the combination of decreasing mortality and increasing diabetes prevalence has increased the overall mean years lived with diabetes and could lead to a diversification of diabetes morbidity, including continued high rates of renal disease, ageing-related disability, and cancers. Unfortunately, data on trends in diabetes-related complications are limited to only about a dozen countries, most of which are high income, leaving the changing character for countries of low and middle income ambiguous.

Initiation and persistence with dual antiplatelet therapy after acute myocardial infarction: a Danish nationwide population-based cohort study

OBJECTIVES

The study investigated dual antiplatelet therapy (DAPT) patterns over time and patient characteristics associated with the various treatments in a myocardial infarction (MI) population.

DESIGN

A registry-based observational cohort study was performed using antecedent data.

SETTING

This study linked morbidity, mortality and medication data from Danish national registries.

PARTICIPANTS

All 28 449 patients admitted to a Danish hospital with a first-time MI and alive at discharge from 2009 through 2012 were included.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcome was initiation of DAPT and secondary outcomes comprised persistence in DAPT treatment and switches between DAPT treatments.

RESULTS

The overall proportion of patients prescribed DAPT increased from 68% (CL 95% 67-69%) to 73% (CL 95% 72-74%) from 2009 to 2012. For treatment of patients with and without percutaneous coronary intervention (PCI), the corresponding numbers were from 87% (CL 95% 86-88%) to 91% (CL 95% 90-92%) and from 49% (CL 95% 47-50%) to 52% (CL 95% 51-54%), respectively. Non-PCI patients had a higher cardiovascular risk compared with PCI patients. Among PCI patients, age>75 years, atrial fibrillation, diabetes and peripheral arterial disease were associated with a higher risk of treatment breaks for DAPT. Among patients without PCI, ticagrelor treatment was associated with an increased risk of treatment breaks during the first 12 months compared with clopidogrel treatment.

CONCLUSIONS

From 2009 to 2012, there was an increase in the proportion of patients with MI receiving DAPT, and a longer duration of DAPT. Still, a large proportion of patients without PCI are discharged either without DAPT or with a short DAPT duration. These findings may indicate the need for more careful attention to DAPT for patients with MI not undergoing PCI in Denmark.

Time trends in coronary revascularization procedures among people with COPD: analysis of the Spanish national hospital discharge data (2001-2011)

Background

People with COPD suffering from coronary artery disease are frequently treated with revascularization procedures. We aim to compare trends in the use and outcomes of these procedures in COPD and non-COPD patients in Spain between 2001 and 2011.

Methods

We identified all patients who had undergone percutaneous coronary interventions (PCIs) and coronary artery bypass graft (CABG) surgeries, using national hospital discharge data. Discharges were grouped into: COPD and no COPD.

Results

From 2001 to 2011, 428,516 PCIs and 79,619 CABGs were performed. The sex and age-adjusted use of PCI increased by 21.27% per year from 2001 to 2004 and by 5.47% per year from 2004 to 2011 in patients with COPD. In-hospital mortality (IHM) among patients with COPD who underwent a PCI increased significantly from 2001 to 2011 (odds ratio 1.11; 95% confidence interval 1.03–1.20). Among patients with COPD who underwent a CABG, the sex and age-adjusted CABG incidence rate increased by 9.77% per year from 2001 to 2003, and then decreased by 3.15% through 2011. The probability of dying during hospitalization in patients who underwent a CABG did not change significantly in patients with and without COPD (odds ratio, 1.06; 95% confidence interval 0.96–1.17).

Conclusion

The annual percent change in PCI procedures increased in COPD and non-COPD patients. We found a decrease in the use of CABG procedures in both groups. IHM was higher in patients with COPD who underwent a PCI than in those without COPD. However, COPD did not increase the probability of dying during hospitalization in patients who underwent a CABG.

Improving 30-day case fatality after incident myocardial infarction in people with diabetes between 1998 and 2010

OBJECTIVE

To compare population-level trends in 30-day case fatality following incident myocardial infarction (MI) in people with diabetes and those without diabetes.

METHODS

We identified all hospitalised incident MIs in 35-84 year olds from the Western Australian Data Linkage System for 1998-2010, stratified by diabetes status. Crude and age- and sex-standardised 30-day case fatality were estimated, and age- and sex-adjusted trends were calculated from logistic regression. We calculated the trend in risk of 30-day death associated with diabetes from multivariable logistic regression, adjusting for demographics, comorbidities and MI type.

RESULTS

26 610 hospitalised incident MI cases were identified, 24.8% of whom had diabetes. The prevalence of heart failure fell in people with diabetes, concurrent with increasing chronic kidney disease and prior coronary heart disease and increasing levels of evidence-based therapies. Case fatality in people with diabetes fell from 11.65%, in 1998-2001, to 3.96% by 2008-2010. Age- and sex-standardised case fatality declined at a greater rate in those with diabetes (-10.6%/year, 95% CI -12.8% to -8.2%) compared to non-diabetics (-6.9%/year, 95% CI -8.3% to -5.3%; interaction p=0.005). The adjusted risk of 30-day death after incident MI was 1.23 times higher in diabetics than non-diabetics in 1998-2001 (95% CI 1.01 to 1.50), but was lower by 2008-2010 (OR 0.64, 95% CI 0.46 to 0.88).

CONCLUSIONS

Greater improvements in 30-day case fatality following incident MI in people with diabetes during the 13-year study period has led to diabetes no longer being an independent predictor of early death following incident MI by 2008-2010.

Targeting mitochondria to restore failed adaptation to exercise in diabetes

Our translational research group focuses on addressing the problem of exercise defects in diabetes with basic research efforts in cell and rodent models and clinical research efforts in subjects with diabetes mellitus. CREB (cAMP-response-element-binding protein) regulates cellular differentiation of neurons, β-cells, adipocytes and smooth muscle cells; it is also a potent survival factor and an upstream regulator of mitochondrial biogenesis. In diabetes and cardiovascular disease, CREB protein content is decreased in the vascular media, and its regulation in aberrant in β-cells, neurons and cardiomyocytes. Loss of CREB content and function leads to decreased vascular target tissue resilience when exposed to stressors such as metabolic, oxidative or sheer stress. This basic research programme set the stage for our central hypothesis that diabetes-mediated CREB dysfunction predisposes the diabetes disease progression and cardiovascular complications. Our clinical research programme revealed that diabetes mellitus leads to defects in functional exercise capacity. Our group has determined that the defects in exercise correlate with insulin resistance, endothelial dysfunction, decreased cardiac perfusion and diastolic dysfunction, slowed muscle perfusion kinetics, decreased muscle perfusion and slowed oxidative phosphorylation. Combined basic and clinical research has defined the relationship between exercise and vascular function with particular emphasis on how the signalling to CREB and eNOS [endothelial NOS (nitric oxide synthase)] regulates tissue perfusion, mitochondrial dynamics, vascular function and exercise capacity. The present review summarizes our current working hypothesis that restoration of eNOS/NOS dysfunction will restore cellular homoeostasis and permit an optimal tissue response to an exercise training intervention.

Declines in coronary heart disease incidence and mortality among middle-aged adults with and without diabetes

PURPOSE

The purpose of the study was to investigate secular changes in coronary heart disease (CHD) incidence and mortality among adults with and without diabetes and to determine the effect of increased lipid-lowering medication use and reductions in low-density lipoprotein cholesterol (LDL-C) levels on these changes.

METHODS

We analyzed data on participants aged 45 to 64 years from the Atherosclerosis Risk in Communities Study in 1987-1996 (early period) and the Reasons for Geographic and Racial Differences in Stroke Study in 2003-2009 (late period). Hazard ratios (HRs) for the association of diabetes and period with incident CHD and CHD mortality were obtained after adjustment for sociodemographics cardiovascular risk factors, lipid-lowering medication use, and LDL-C.

RESULTS

After multivariable adjustment, diabetes was associated with an increased CHD risk during the early (HR = 1.99, 95% confidence interval = 1.59-2.49) and late (HR = 2.39, 95% confidence interval = 1.69-3.35) periods. CHD incidence and mortality declined between the early and late periods for individuals with and without diabetes. Increased use of lipid-lowering medication and lower LDL-C explained 33.6% and 27.2% of the decline in CHD incidence and CHD mortality, respectively, for those with diabetes.

CONCLUSIONS

Although rates have declined, diabetes remains associated with an increased risk of CHD incidence and mortality, highlighting the need for continuing diabetes prevention and cardiovascular risk factor management.

Shifts in the age distribution and from acute to chronic coronary heart disease hospitalizations

BACKGROUND

Shifts in the burden of coronary heart disease (CHD) from an acute to chronic illness have important public health consequences.

OBJECTIVE

To assess age-sex-specific time trends in rates and characteristics of acute and chronic forms of CHD hospital admissions in the Netherlands.

METHODS

Using nationwide Dutch registers, we assessed time trends between 1998 and 2007 in hospitalization rates of 188,266 acute myocardial infarction (AMI, ICD-9 410), 294,374 unstable angina (ICD-9 411, 413) and 205,649 chronic forms of CHD (ICD-9 412, 414) admissions.

RESULTS

Between 1998 and 2007, the age-standardized CHD hospitalization rate declined from 688 to 545 per 100,000 in men and from 281 to 229 per 100,000 in women. Overall, hospitalization rates decreased at younger age (<75 years) but increased in very old age (≥85 years). The annual percentage change in hospitalization rates was larger for AMI (men:-5.1%, women:-4.4%) than for unstable angina patients (men:-2.0%, women:-2.0%). For chronic CHD, the average annual percentage change was +0.7% in men and +2.1% in women. The proportion of chronic CHD in the total of CHD admissions increased between 1998 and 2007 from 29% to 36% in men and from 23% to 30% in women. The proportion of AMI decreased from 30% to 24% in men and from 27% to 22% in women.

CONCLUSIONS

An increasing proportion of Dutch CHD hospital admissions was for chronic forms of CHD. The age at hospitalization was pushed towards older age: premature CHD admission declined over time and admission rates at very old age increased.

Pre-diabetes and capturing opportunities to raise awareness

This article explores the high risk of diabetes and cardiovascular diseases in adults over 18 years of age and recognises, through the literature, the potential role for nurses in engagement with diabetes prevention strategies in their everyday practice. It considers the latest international projections for diabetes, a critical review of evidence of how diabetes can be prevented and how effective methods of detection of pre-diabetes can be employed with every clinical encounter with adults who perhaps previously were not considered to be 'at risk' of developing type 2 diabetes. Effective consultation approaches to raise diabetes awareness within populations and to enable tailored approaches to public health lifestyle advice are explored, to encourage each practitioner to 'think diabetes' in every clinical encounter.

National trends over one decade in hospitalization for acute myocardial infarction among Spanish adults with type 2 diabetes: cumulative incidence, outcomes and use of percutaneous coronary intervention

BACKGROUND

This study aims to describe trends in the rate of acute myocardial infarction (AMI) and use of percutaneous coronary interventions (PCI) in patients with and without type 2 diabetes in Spain, 2001-2010.

METHODS

We selected all patients with a discharge of AMI using national hospital discharge data. Discharges were grouped by diabetes status: type 2 diabetes and no diabetes. In both groups PCIs were identified. The cumulative incidence of discharges attributed to AMI were calculated overall and stratified by diabetes status and year. We calculated length of stay and in-hospital mortality (IHM). Use of PCI was calculated stratified by diabetes status. Multivariate analysis was adjusted by age, sex, year and comorbidity.

RESULTS

From 2001 to 2010, 513,517 discharges with AMI were identified (30.3% with type 2 diabetes). The cumulative incidence of discharges due to AMI in diabetics patients increased (56.3 in 2001 to 71 cases per 100,000 in 2004), then decreased to 61.9 in 2010. Diabetic patients had significantly higher IHM (OR, 1.14; 95%CI, 1.05-1.17). The proportion of diabetic patients that underwent PCI increased from 11.9% in 2001 to 41.6% in 2010. Adjusted incidence of discharge in patients with diabetes who underwent PCI increased significantly (IRR, 3.49; 95%CI, 3.30-3.69). The IHM among diabetics patients who underwent a PCI did not change significantly over time.

CONCLUSIONS

AMI hospitalization rates increased initially but declining slowly. From 2001 to 2010 the proportion of diabetic patients who undergo a PCI increased almost four-fold. Older age and more comorbidity may explain why IHM did not improve after a PCI.

National trends in utilization and outcomes of coronary revascularization procedures among people with and without type 2 diabetes in Spain (2001-2011)

BACKGROUND

Diabetes is associated with a high risk of death due to coronary artery disease (CAD). People with diabetes suffering from CAD are frequently treated with revascularization procedures. We aim to compare trends in the use and outcomes of coronary revascularization procedures in diabetic and non-diabetic patients in Spain between 2001 and 2011.

METHODS

We identified all patients who had undergone coronary revascularization procedures, percutaneous coronary interventions (PCI) and coronary artery bypass graft (CABG) surgeries, using national hospital discharge data. Discharges were grouped by diabetes status: type 2 diabetes and no diabetes. The incidence of discharges attributed to coronary revascularization procedures were calculated stratified by diabetes status. We calculated length of stay and in-hospital mortality (IHM). We apply joinpoint log-linear regression to identify the years in which changes in tendency occurred in the use of PCI and CABG in diabetic and non-diabetic patients. Multivariate analysis was adjusted by age, sex, year and comorbidity (Charlson comorbidity index).

RESULTS

From 2001 to 2011, 434,108 PCIs and 79,986 CABGs were performed. According to the results of the joinpoint analysis, we found that sex and age-adjusted use of PCI increased by 31.4% per year from 2001 to 2003, by 15.9% per year from 2003 to 2006 and by 3.8% per year from 2006 to 2011 in patients with diabetes. IHM among patients with diabetes who underwent a PCI did not change significantly over the entire study period (OR 0.99; 95% CI 0.97-1.00).Among patients with diabetes who underwent a CABG, the sex and age-adjusted CABG incidence rate increased by 10.4% per year from 2001 to 2003, and then decreased by 1.1% through 2011. Diabetic patients who underwent a CABG had a 0.67 (95% CI 0.63-0.71) times lower probability of dying during hospitalization than those without diabetes.

CONCLUSIONS

The annual percent change in PCI procedures increased in diabetic and non-diabetic patients. Higher comorbidity and the female gender are associated with a higher IHM in PCI procedures. In diabetic and non-diabetic patients, we found a decrease in the use of CABG procedures. IHM was higher in patients without diabetes than in those with diabetes.

The growing prevalence of type 2 diabetes: increased incidence or improved survival?

Approximately 347 million persons were estimated to have diabetes worldwide in 2008, an increase of 194 million cases from 1980. Diabetes now affects both high- and low-income countries, with low-income countries bearing the majority of the burden. The epidemiologic transition from traditional health risks, such as poor hygiene, to modern health risks, such as sedentary lifestyle, has facilitated the increase in incidence in diabetes, especially in developing countries. The effect of these risk factors may be especially pronounced in some racial and ethnic populations. Increased surveillance for diabetes has contributed to increased diabetes prevalence in higher-income countries. Survival with and some risk factors for diabetes have improved in developed countries, but global diabetes mortality has increased by 20 % since 1990. Population growth and aging will only increase the burden of diabetes, and public health interventions are needed to address diabetes risk factors to stem the tide of this epidemic.

Relationship between HbA1c and risk of all-cause hospital admissions among people with Type 2 diabetes

AIM

To investigate the relationship between HbA(1c) and the 2-year risk of hospitalization among people with Type 2 diabetes.

METHODS

In total, 4704 patients from 18 general practices in Cambridgeshire were included. Glycaemic exposure was assessed in 2008-2009. The primary outcome was all-cause hospital admissions in 2010-2011. Adjusted relative risks for each HbA(1c) quintile were estimated using Cox models. Further relationships between HbA(1c) and risks were explored using spline models.

RESULTS

There was a non-linear relationship between HbA(1c) and the risk of all-cause, diabetes and vascular admissions (all P < 0.001 for linearity test) with an HbA(1c) threshold of 61 (95% CI 55-66) mmol/mol [7.7 (95% CI 7.2-8.2)%]. For every 11 mmol/mol (1%) HbA(1c) above the threshold, the risks increased by 6.3% for all-cause admission, 6.4% for a diabetes admission and 15.9% for a cardiovascular admission (all P < 0.001). The overall hospitalization risks of having an HbA(1c) above, rather than at, the threshold, were 19.1 16.3 and 54.3% greater, respectively. There were non-significantly greater risks of hospital admission below the threshold.

CONCLUSION

In people with Type 2 diabetes, a non-linear relationship exists between HbA(1c) and the risk of hospitalization. A threshold of 61 mmol/mol (7.7%) was associated with the lowest rate of all-cause hospital admissions. Further research should investigate the causes of admissions below and above this threshold, with a view to developing strategies to reduce the excess hospitalization among patients with diabetes.

Left ventricular dysfunction and outcome at two-year follow-up in patients with type 2 diabetes: The DYDA study

AIMS

Left ventricular dysfunction (LVD) in type 2 diabetes mellitus (DM) (DYDA) study is a prospective investigation enrolling 960 with DM without overt cardiac disease. At baseline, a high prevalence of LVD was detected by analysing midwall shortening. We report here the incidence of clinical events in DYDA patients after 2-year follow-up and the frequency of LVD detected at baseline and 2-year evaluation.

METHODS

Systolic LVD was defined as midwall shortening ≤15%, diastolic LVD as any condition different from "normal diastolic function" identified as E/A ratio on Doppler mitral flow between 0.75 and 1.5 and deceleration time of E wave >140 ms. Major outcome was a composite of major events, including all-causes death and hospital admissions.

RESULTS

During the study period, any systolic/diastolic LVD was found in 616 of 699 patients (88.1%) in whom LVD function could be measured at baseline or at 2 years. Older age and high HbA1c predicted the occurrence of LVD. During the follow-up 15 patients died (1.6%), 3 for cardiovascular causes, 139 were hospitalized (14.5%, 43 of them for cardiovascular causes, 20 for a new cancer).

CONCLUSIONS

During a 2-year follow-up any LVD is detectable in a large majority of patients with DM without overt cardiac disease. Older age and higher HbA1c predict LVD. All-cause death or hospitalization occurred in 15% of patients, cardiovascular cause was uncommon. Independent predictors of events were older age, pathologic lipid profile, high HbA1c, claudicatio and repaglinide therapy. Echo-assessed LVD at baseline was not prognosticator of events.

Did hospital mortality in England change from 2005 to 2010? A retrospective cohort analysis

BACKGROUND

There is some evidence that hospital performance in England measured by the Dr Foster Hospital Standardised Mortality Ratio (HSMR) has improved substantially over the last 10 years. This study explores mortality in-hospital and up to 30 days post-discharge over a five year period to determine whether there have been improvements in case-mix adjusted mortality, to examine if any changes are due to changes in case-mix adjustment variables such as age, sex, method of admission and comorbidity, and to compare changes between hospital trusts.

METHODS

Using Hospital Episode Statistics linked to mortality data from the Office for National Statistics the Summary Hospital-Level Mortality Index (SHMI) was calculated for all patients who were discharged or died in general acute hospital trusts in England for the period 01/04/2005 to 30/09/2010.

RESULTS

During this five year period the number of admissions rose by 8% but deaths fell by 5%. The SHMI fell by 24% from 112 to 85 over the period, partly due to fewer deaths but partly due to increasing numbers predicted by the SHMI model. Excluding comorbidities from the model the SHMI fell by 18% from 108 to 89 over this period. The reduction was similar in emergency and elective admissions and in all other sub-groups examined. The average quarterly change in SHMI varied considerably between trusts (range: -4.4 to -0.2).

CONCLUSIONS

As measured by the SHMI there has been a 24% improvement in mortality in acute general trusts in England over a period of five and a half years. Part of this improvement is an artificial effect caused by changes in the depth of coding of comorbidities and other effects due to change in case-mix or non-constant risk.

Type 2 diabetes mellitus and exercise impairment

Limitations in physical fitness, a consistent finding in individuals with both type I and type 2 diabetes mellitus, correlate strongly with cardiovascular and all-cause mortality. These limitations may significantly contribute to the persistent excess cardiovascular mortality affecting this group. Exercise impairments in VO2 peak and VO2 kinetics manifest early on in diabetes, even with good glycemic control and in the absence of clinically apparent complications. Subclinical cardiac dysfunction is often present but does not fully explain the observed defect in exercise capacity in persons with diabetes. In part, the cardiac limitations are secondary to decreased perfusion with exercise challenge. This is a reversible defect. Similarly, in the skeletal muscle, impairments in nutritive blood flow correlate with slowed (or inefficient) exercise kinetics and decreased exercise capacity. Several correlations highlight the likelihood of endothelial-specific impairments as mediators of exercise dysfunction in diabetes, including insulin resistance, endothelial dysfunction, decreased myocardial perfusion, slowed tissue hemoglobin oxygen saturation, and impairment in mitochondrial function. Both exercise training and therapies targeted at improving insulin sensitivity and endothelial function improve physical fitness in subjects with type 2 diabetes. Optimization of exercise functions in people with diabetes has implications for diabetes prevention and reductions in mortality risk. Understanding the molecular details of endothelial dysfunction in diabetes may provide specific therapeutic targets for the remediation of this defect. Rat models to test this hypothesis are under study.