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Xu W, Chan L, Danaei G, Lu Y, Wan EYF. Long-term statin use and risk of cancers: a target trial emulation study. J Clin Epidemiol 2024; 172:111425. [PMID: 38880437 DOI: 10.1016/j.jclinepi.2024.111425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 03/13/2024] [Accepted: 06/10/2024] [Indexed: 06/18/2024]
Abstract
BACKGROUND AND OBJECTIVES Controversy exists regarding potential cancer risks associated with long-term statin use. This study aimed to use real-world data to investigate the association between cancer incidence and sustained statin use over a 10-year period. METHODS Using territory-wide public electronic medical records in Hong Kong, we emulated a sequence of nested target trials on patients who met indications for statin initiation in each calendar month from January 2009 to December 2011. Statin initiators and noninitiators were matched in a 1:1 ratio to mimic the randomization of eligible person-trials at baseline. Pooled logistic regression was applied to obtain the hazard ratios for the cancer incidence of statin initiation in intention-to-treat analysis, with the adjustment of baseline confounders and the inverse probability weighting accounting for the postbaseline confounders in per-protocol analysis. RESULTS Among 8,560,051 eligible person-trials, 119,715 noninitiators were matched to 119,715 initiators for analysis. Over the 10-year study period, the estimated hazard ratio of overall cancer incidence was 0.96 (0.87, 1.05), and the standardized 10-year risk difference was -0.4% (-1.3%, 0.4%) in the per-protocol analysis. For the cancer subtypes of interest (ie, breast cancer, colorectal cancer, hematological cancer, pancreatic cancer, prostate cancer, urothelial carcinoma, and lung cancer), the 10-year risk differences ranged from -0.3% to 0.2% in the per-protocol analysis. No observable risk change for cancer was found in all patient subgroups with regards to their sex, age (<70/≥70 years), Charlson Comorbidity Index (≤4/>4), and statin indication. CONCLUSION Statin use has no impact on cancer incidence over a 10-year follow-up period, including all cancer subtypes of interest and patient subgroups with regards to sex, age, comorbidities, and statin indications.
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Affiliation(s)
- Wanchun Xu
- Department of Family Medicine and Primary Care, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Linda Chan
- Department of Family Medicine and Primary Care, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China; The Bau Institute of Medical and Health Sciences Education, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China; Department of Family Medicine and Primary Care, The University of Hong Kong - Shenzhen Hospital, Shenzhen, Guangdong, China
| | - Goodarz Danaei
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, MA, USA; Department of Epidemiology, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Yuan Lu
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University, New Haven, Connecticut, USA
| | - Eric Yuk Fai Wan
- Department of Family Medicine and Primary Care, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China; Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China; Laboratory of Data Discovery for Health (D24H), Hong Kong Science and Technology Park, Sha Tin, Hong Kong Special Administrative Region, China.
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Jin Q, Mei J, Wong YC, Lam CLK, Wan EYF. Associations and attributable burden between risk factors and all-cause and cause-specific mortality at different ages in patients with hypertension. Hypertens Res 2024; 47:2053-2063. [PMID: 38783145 DOI: 10.1038/s41440-024-01717-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 04/08/2024] [Accepted: 04/12/2024] [Indexed: 05/25/2024]
Abstract
It remains unclear the age-specific associations of risk factors with deaths and mortality burden attributable across age. In a territory-wide retrospective cohort, 1,012,228 adults with hypertension were identified. Comorbidities including diabetes, chronic kidney disease (CKD), cardiovascular disease (CVD), heart failure, and cancer, and risk factors including current smoking and suboptimal control of blood pressure (BP), glucose and low-density lipoprotein cholesterol were defined. Associations of comorbidities/risk factors with all-cause and cause-specific mortality across age groups (18-54, 55-64, 65-74, and ≥75 years) were assessed. Population attributable fractions were also quantified. During a median follow-up of 10.7 years, 244,268 (24.1%) patients died, with pneumonia (7.2%), cancer (5.1%), and CVD (4.2%) being the leading causes. Despite increasing deaths with age, relative risk of mortality related to comorbidities/risk factors decreased with age; similar patterns were found for cause-specific mortality. The assessed risk factors accounted for 24.0% (95% CI 22.5%, 25.4%) deaths, with highest proportion in the youngest group (33.5% [28.1%, 38.5%] in 18-54 years vs 19.4% [17.0%, 21.6%] in ≥75 years). For mortality burden, CKD was the overall leading risk factor (12.7% [12.4%, 12.9%]) with higher proportions in older patients (11.1-13.1% in ≥65 years), while diabetes was the leading risk factor in younger patients (15.9-13.5% in 18-54 years). The association of comorbidities or risk factors with mortality is stronger in younger patients with hypertension, despite lower absolute mortality in young patients than in the elderly. Leading risk factors differed across age, highlighting the importance of targeted and precise risk management.
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Affiliation(s)
- Qiao Jin
- Department of Family Medicine and Primary Care, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Jie Mei
- Department of Family Medicine and Primary Care, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Yu Chit Wong
- Department of Family Medicine and Primary Care, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Cindy Lo Kuen Lam
- Department of Family Medicine and Primary Care, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
- Department of Family Medicine, The University of Hong Kong - Shenzhen Hospital, Shenzhen, China
| | - Eric Yuk Fai Wan
- Department of Family Medicine and Primary Care, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China.
- Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China.
- Laboratory of Data Discovery for Health (D24H), Hong Kong SAR, China.
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Fava S, Reiff S. Association of body mass index and blood pressure variability with 10-year mortality and renal disease progression in type 2 diabetes. Acta Diabetol 2024; 61:747-754. [PMID: 38438789 PMCID: PMC11101579 DOI: 10.1007/s00592-024-02250-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 01/29/2024] [Indexed: 03/06/2024]
Abstract
BACKGROUND Variability in biological parameters may be associated with adverse outcomes. The aim of the study was to determine whether variability in body mass index (BMI) and blood pressure is associated with all-cause, cardiovascular mortality and cancer mortality or with renal disease progression in subjects with type 2 diabetes. METHODS The diabetes database was accessed, and all the information on patient visits (consultations) carried out in the study period (1 January 2008-31 December 2019) was extracted and linked to the laboratory database and the mortality register. RESULTS The total number of patients included in the study population was 26,261, of whom 54.4% were male. Median (interquartile range, IQR) age was 60.2 (51.8-68.3) years. The coefficient of variability of BMI was independently associated with increased all-cause and cardiovascular, but not cancer, mortality. Glycated haemoglobin (HbA1c) was associated with increased all-cause, cardiovascular, and cancer mortality as well as with renal progression. Variability in systolic blood pressure, diastolic blood pressure, and pulse pressure was associated with increased all-cause and cardiovascular mortality in bivariate, but not in multivariate, analyses. CONCLUSIONS Variability in BMI was associated with increased all-cause and cardiovascular, but not cancer, mortality in a large real-world contemporary population. Our results also confirm the association of HbA1c with increased all-cause, cardiovascular, and cancer mortality as well as with renal progression.
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Affiliation(s)
- Stephen Fava
- University of Malta Medical School, Msida, MSD 2090, Malta.
| | - Sascha Reiff
- Department for Policy in Health, Valletta, Malta
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Bao M, Song Y, Han X, Wu S, Li J. Comparison of BP variability, cumulative BP, and BP trajectory for predicting cardiovascular events in the general population. Hellenic J Cardiol 2024; 76:11-21. [PMID: 37532023 DOI: 10.1016/j.hjc.2023.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 07/08/2023] [Accepted: 07/15/2023] [Indexed: 08/04/2023] Open
Abstract
OBJECTIVE Systolic blood pressure variability (SBPV), cumulative systolic BP (cumSBP), and systolic blood pressure trajectory (trajSBP) are major indices describing characteristics of BP changes. The aim of this study was to compare their discrimination abilities for cardiovascular (CV) events. METHODS In 51698 subjects, associations were assessed using Cox regression in the overall cohort and Framingham risk score (FRS) stratified groups. Individuals with <10%, 10%-20%, and >20% 10-year CV risk were categorized into the low-, intermediate-, and high-risk group, respectively. Discrimination capabilities were evaluated using the area under curve (AUC), Harrell's C index, net reclassification index (NRI), and integrated discrimination index (IDI). RESULTS Within a mean follow-up of 6.83 ± 0.89 years, 2330 participants had CV events, and all three markers were significantly associated with CV events. TrajSBP provided the best additional discriminative value for CV events, with improvements of 1.54% in AUC%, 0.01 in Harrell's C, 37.52% in NRI%, and 0.59% in IDI%. CumSBP had good additional discriminative capability in the intermediate to high FRS groups, but the effect sizes were smaller than those of trajSBP. Although, SBPV improved the predictive capabilities in the low-to intermediate-risk groups, the effect sizes were much smaller than those of the other indices. Sensitivity analyses excluding patients who underwent antihypertensive therapy revealed similar patterns but higher effect sizes than in the overall population. CONCLUSION TrajSBP provides the best additional discrimination capabilities based on traditional risk profiles and may assist the risk stratification and individual prediction for future CV events.
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Affiliation(s)
- Minghui Bao
- Department of Cardiology, Peking University First Hospital, Peking University, Beijing, China.
| | - Yongjian Song
- Department of Cardiology, Zhangjiakou First Hospital, Hebei, China
| | - Xu Han
- Department of Cardiology, Kailuan Hospital, North China University of Science and Technology, Tangshan, China
| | - Shouling Wu
- Department of Cardiology, Kailuan Hospital, North China University of Science and Technology, Tangshan, China
| | - Jianping Li
- Department of Cardiology, Peking University First Hospital, Peking University, Beijing, China
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Erandathi MA, Wang WYC, Mayo M, Lee CC. Comprehensive Factors for Predicting the Complications of DiabetesMellitus: A Systematic Review. Curr Diabetes Rev 2024; 20:e040124225240. [PMID: 38178670 PMCID: PMC11327746 DOI: 10.2174/0115733998271863231116062601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 09/05/2023] [Accepted: 09/06/2023] [Indexed: 01/06/2024]
Abstract
BACKGROUND This article focuses on extracting a standard feature set for predicting the complications of diabetes mellitus by systematically reviewing the literature. It is conducted and reported by following the guidelines of PRISMA, a well-known systematic review and meta-analysis method. The research articles included in this study are extracted using the search engine "Web of Science" over eight years. The most common complications of diabetes, diabetic neuropathy, retinopathy, nephropathy, and cardiovascular diseases are considered in the study. METHOD The features used to predict the complications are identified and categorised by scrutinising the standards of electronic health records. RESULT Overall, 102 research articles have been reviewed, resulting in 59 frequent features being identified. Nineteen attributes are recognised as a standard in all four considered complications, which are age, gender, ethnicity, weight, height, BMI, smoking history, HbA1c, SBP, eGFR, DBP, HDL, LDL, total cholesterol, triglyceride, use of insulin, duration of diabetes, family history of CVD, and diabetes. The existence of a well-accepted and updated feature set for health analytics models to predict the complications of diabetes mellitus is a vital and contemporary requirement. A widely accepted feature set is beneficial for benchmarking the risk factors of complications of diabetes. CONCLUSION This study is a thorough literature review to provide a clear state of the art for academicians, clinicians, and other stakeholders regarding the risk factors and their importance.
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Affiliation(s)
| | | | | | - Ching-Chi Lee
- National Chen Kung University Hospital, Tainan, Taiwan
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Jin Q, Kuen Lam CL, Fai Wan EY. Association of eGFR slope with all-cause mortality, macrovascular and microvascular outcomes in people with type 2 diabetes and early-stage chronic kidney disease. Diabetes Res Clin Pract 2023; 205:110924. [PMID: 37778664 DOI: 10.1016/j.diabres.2023.110924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 09/12/2023] [Accepted: 09/27/2023] [Indexed: 10/03/2023]
Abstract
AIMS The association of estimated glomerular filtration rate (eGFR) slope with progression of complications in people with type 2 diabetes (T2D) and early-stage chronic kidney disease (CKD) is less clear. METHODS We identified 115,139 T2D participants without decreased eGFR (>60 mL/min/1.73 m2) between 2008 and 2015 from the electronic database of the Hong Kong Hospital Authority. eGFR slope calculated by linear-mixed effects model using 3-year eGFR measurements was categorized into quintiles. With Quintile 3 of eGFR slope as the reference group, we used Cox proportional or cause-specific models to investigate the association between eGFR slope and all-cause mortality, macrovascular and microvascular complications, as appropriate. RESULTS Over a median follow-up of 7.8 years, fastest eGFR declines (Quintile 1 with median eGFR slope: -4.32 mL/min/1.73 m2/year) were associated with increased risk of all adverse outcomes (adjusted hazard ratio [aHR] 1.36 to 2.97, all P < 0.0001), compared with less steep eGFR declines (Quintile 3: -1.08 mL/min/1.73 m2/year). Substantial eGFR increases (Quintile 5: 1.34 mL/min/1.73 m2/year) were associated with decreased risk of CKD and ≥ 40 % decline in eGFR (aHR [95 % CI] 0.65 [0.63, 0.67] and 0.85 [0.82, 0.89], respectively) and higher risk of death, CVD, DR and DN (aHR [95 % CI] 1.48 [1.40, 1.56], 1.19 [1.14, 1.25], 1.07 [1.004, 1.15] and 1.62 [1.37, 1.91], respectively). CONCLUSIONS In a cohort of T2D people without decreased eGFR, accelerated declines and increases in eGFR were associated with all-cause mortality, macrovascular and microvascular complications, supporting the potential prognostic utility of eGFR slope in T2D people with early-stage CKD.
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Affiliation(s)
- Qiao Jin
- Department of Family Medicine and Primary Care, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Cindy Lo Kuen Lam
- Department of Family Medicine and Primary Care, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China; Department of Family Medicine, The University of Hong Kong - Shenzhen Hospital, Shenzhen, China
| | - Eric Yuk Fai Wan
- Department of Family Medicine and Primary Care, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China; Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China; Laboratory of Data Discovery for Health (D24H), Hong Kong, China.
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Hong SN, Mak IL, Chin WY, Yu EYT, Tse ETY, Chen JY, Wong CKH, Chao DVK, Tsui WWS, Lam CLK, Wan EYF. Age-specific associations between the number of co-morbidities, all-cause mortality and public direct medical costs in patients with type 2 diabetes: A retrospective cohort study. Diabetes Obes Metab 2023; 25:454-467. [PMID: 36205484 DOI: 10.1111/dom.14889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 09/25/2022] [Accepted: 10/03/2022] [Indexed: 02/02/2023]
Abstract
AIM To evaluate the association between the number of co-morbidities, all-cause mortality and public health system expenditure in patients with type 2 diabetes (T2D) across different age groups. MATERIALS AND METHODS A retrospective observational study of T2D patients using electronic health records in Hong Kong was conducted. Patients were stratified by age (< 50, 50-64, 65-79, ≥ 80 years) and the number of co-morbidities (0, 1, 2, 3, ≥ 4), defined using the Charlson Comorbidity Index and prevalent chronic diseases identified in local surveys. The association between the number of co-morbidities, all-cause mortality and direct medical costs was examined using Cox proportional hazard regression and the gamma generalized linear model with log link function. RESULTS A total of 262 212 T2D patients with a median follow-up of 10 years were included. Hypertension and dyslipidaemia were the most common co-morbidities in all age groups. After age stratification, cardiovascular diseases dominated the top pair of co-morbidities in the older age groups (65-79 and ≥ 80 years), while inflammatory and liver disease were predominant among younger individuals. Compared with co-morbidity-free T2D patients, the hazard ratios (95% CI) of death for patients aged younger than 50 and 80 years or older with two co-morbidities were 1.31 (1.08-1.59) and 1.25 (1.15-1.36), respectively, and increased to 3.08 (2.25-4.21) and 1.98 (1.82-2.16), respectively, as the number of co-morbidities increased to four or more. Similar trends were observed for medical costs. CONCLUSIONS Age-specific co-morbidity patterns were observed for patients with T2D. A greater number of co-morbidities was associated with increased mortality and healthcare costs, with stronger relationships observed among younger patients.
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Affiliation(s)
- Sabrina Nan Hong
- Department of Family Medicine and Primary Care, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Ivy Lynn Mak
- Department of Family Medicine and Primary Care, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Weng Yee Chin
- Department of Family Medicine and Primary Care, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Esther Yee Tak Yu
- Department of Family Medicine and Primary Care, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Emily Tsui Yee Tse
- Department of Family Medicine and Primary Care, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Julie Yun Chen
- Department of Family Medicine and Primary Care, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Carlos King Ho Wong
- Department of Family Medicine and Primary Care, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
- Laboratory of Data Discovery for Health (D24H), Hong Kong Science Park, Hong Kong Science and Technology Park, Hong Kong, China
| | - David Vai Kiong Chao
- Department of Family Medicine & Primary Health Care, United Christian Hospital, Kowloon East Cluster, Hong Kong, China
| | - Wendy Wing Sze Tsui
- Department of Family Medicine and Primary Healthcare, Queen Mary Hospital, Hong Kong West Cluster, Hospital Authority, Hong Kong, China
| | - Cindy Lo Kuen Lam
- Department of Family Medicine and Primary Care, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
- Department of Family Medicine, The University of Hong Kong Shenzhen Hospital, Shenzhen, China
| | - Eric Yuk Fai Wan
- Department of Family Medicine and Primary Care, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
- Laboratory of Data Discovery for Health (D24H), Hong Kong Science Park, Hong Kong Science and Technology Park, Hong Kong, China
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Wan EYF, Yu EYT, Mak IL, Youn HM, Chan KS, Chan EWY, Wong ICK, Lam CLK. Diabetes with poor-control HbA1c is cardiovascular disease 'risk equivalent' for mortality: UK Biobank and Hong Kong population-based cohort study. BMJ Open Diabetes Res Care 2023; 11:e003075. [PMID: 36634978 PMCID: PMC9843200 DOI: 10.1136/bmjdrc-2022-003075] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 12/10/2022] [Indexed: 01/14/2023] Open
Abstract
INTRODUCTION Type 2 diabetes mellitus (T2DM) has traditionally been considered a coronary heart disease 'risk equivalent' for future mortality, but significant heterogeneity exists across people with T2DM. This study aims to determine the risk of all-cause mortality of patients with cardiovascular disease (CVD) and T2DM in UK and Hong Kong, with stratifications for hemoglobin A1 (HbA1c) concentrations, compared with those without CVD and diabetes mellitus. RESEARCH DESIGN AND METHODS This is a retrospective cohort study of 3 839 391 adults from Hong Kong and a prospective cohort study of 497 779 adults from the UK Biobank. Individuals were divided into seven disease groups: (1) no T2DM and CVD, (2) T2DM only with HbA1c <7%, (3) T2DM only with HbA1c 7%-7.9%, (4) T2DM only with HbA1c 8%-8.9%, (5) T2DM only with HbA1c ≥9%, (6) CVD only, and (7) T2DM and CVD. Differences in all-cause mortality between groups were examined using Cox regression. RESULTS After around 10 years of median follow-up, 423 818 and 19 844 deaths were identified in the Hong Kong cohort and UK Biobank, respectively. Compared with individuals without T2DM and CVD, the adjusted HR for all-cause mortality in the other six disease groups for the Hong Kong cohort was 1.25 (95% CI 1.23 to 1.27) for T2DM only with HbA1c <7%, 1.21 (95% CI 1.19 to 1.23) for T2DM only with HbA1c 7%-7.9%, 1.36 (95% CI 1.33 to 1.39) for T2DM only with HbA1c 8%-8.9%, 1.82 (95% CI 1.78 to 1.85) for T2DM only with HbA1c ≥9%, 1.37 (95% CI 1.36 to 1.38) for CVD only, and 1.83 (95% CI 1.81 to 1.85) for T2DM and CVD, and for the UK Biobank the HR was 1.45 (95% CI 1.33 to 1.58), 1.50 (95% CI 1.32 to 1.70), 1.72 (95% CI 1.43 to 2.08), 2.51 (95% CI 2.05 to 3.08), 1.67 (95% CI 1.59 to 1.75) and 2.62 (95% CI 2.42 to 2.83), respectively. This indicates that patients with T2DM had an increased risk of mortality compared with those without T2DM and CVD, and in those with HbA1c ≥9% an even higher risk than people with CVD. CONCLUSIONS Patients with T2DM with poor HbA1c control (8%-8.9% and ≥9%) were associated with similar and higher risk of mortality compared with patients with CVD, respectively. Optimal HbA1c, controlled for risk reduction and prevention of mortality and complications in diabetes management, remains important.
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Affiliation(s)
- Eric Yuk Fai Wan
- Department of Family Medicine and Primary Care, The University of Hong Kong, Hong Kong, Hong Kong
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, The University of Hong Kong, Hong Kong, Hong Kong
- Laboratory of Data Discovery for Health (D24H), Hong Kong, Hong Kong
| | - Esther Yee Tak Yu
- Department of Family Medicine and Primary Care, The University of Hong Kong, Hong Kong, Hong Kong
| | - Ivy Lynn Mak
- Department of Family Medicine and Primary Care, The University of Hong Kong, Hong Kong, Hong Kong
| | - Hin Moi Youn
- Department of Family Medicine and Primary Care, The University of Hong Kong, Hong Kong, Hong Kong
| | - Kam Suen Chan
- Department of Family Medicine and Primary Care, The University of Hong Kong, Hong Kong, Hong Kong
| | - Esther W Y Chan
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, The University of Hong Kong, Hong Kong, Hong Kong
- Laboratory of Data Discovery for Health (D24H), Hong Kong, Hong Kong
- Department of Pharmacy, The University of Hong Kong-Shenzhen Hospital, Shenzhen, People's Republic of China
- The University of Hong Kong Shenzhen Institute of Research and Innovation, Shenzhen, People's Republic of China
| | - Ian C K Wong
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, The University of Hong Kong, Hong Kong, Hong Kong
- Laboratory of Data Discovery for Health (D24H), Hong Kong, Hong Kong
- Department of Pharmacy, The University of Hong Kong-Shenzhen Hospital, Shenzhen, People's Republic of China
- Research Department of Practice and Policy, School of Pharmacy, University College London, London, UK
| | - Cindy Lo Kuen Lam
- Department of Family Medicine and Primary Care, The University of Hong Kong, Hong Kong, Hong Kong
- Department of Family Medicine, The University of Hong Kong Shenzhen Hospital, Shenzhen, People's Republic of China
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Wu D, Nam R, Leung KSK, Waraich H, Purnomo A, Chou OHI, Perone F, Pawar S, Faraz F, Liu H, Zhou J, Liu T, Chan JSK, Tse G. Population-Based Clinical Studies Using Routinely Collected Data in Hong Kong, China: A Systematic Review of Trends and Established Local Practices. CARDIOVASCULAR INNOVATIONS AND APPLICATIONS 2023; 8. [DOI: 10.15212/cvia.2023.0073] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2024] Open
Abstract
Background: Routinely collected health data are increasingly used in clinical research. No study has systematically reviewed the temporal trends in the number of publications and analyzed different aspects of local research practices and their variations in Hong Kong, China, with a specific focus on research ethics governance and approval.
Methods: PubMed was systematically searched from its inception to March 28, 2023, for studies using routinely collected healthcare data from Hong Kong.
Results: A total of 454 studies were included. Between 2000 and 2009, 32 studies were identified. The number of publications increased from 5 to 120 between 2010 and 2022. Of the investigator-led studies using the Hospital Authority (HA)’s cross-cluster data (n = 393), 327 (83.2%) reported receiving ethics approval from a single cluster/university-based REC, whereas 50 studies (12.7%) did not report approval from a REC. For use of the HA Data Collaboration Lab, approval by a single hospital-based or University-based REC is accepted. Repeated submission of identical ethics applications to different RECs is estimated to cost HK$4.2 million yearly.
Conclusions: Most studies reported gaining approval from a single cluster REC before retrieval of cross-cluster HA data. Substantial cost savings would result if repeated review of identical ethics applications were not required.
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Wan EYF, Yu EYT, Chan L, Mok AHY, Wang Y, Chan EWY, Wong ICK, Lam CLK. Comparative Risks of Nonsteroidal Anti-inflammatory Drugs on Cardiovascular Diseases: A Population-Based Cohort Study. J Clin Pharmacol 2023; 63:126-134. [PMID: 36063443 DOI: 10.1002/jcph.2142] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 08/16/2022] [Indexed: 12/15/2022]
Abstract
Through examining the incidence of cardiovascular diseases (CVDs) among nonsteroidal anti-inflammatory drug (NSAID) users and nonusers, this study aims to compare the risks contributed by different NSAIDs in a Chinese population. The retrospective cohort including 4 298 368 adults without CVD from electronic health records between 2008 and 2017 in Hong Kong was adopted. A total of 4.5% of individuals received NSAIDs including celecoxib, etoricoxib, diclofenac, ibuprofen, indomethacin, mefenamic acid, or naproxen for ≥4 consecutive weeks at baseline. Cox regression, including NSAID use as a time-dependent covariate and adjusted with patient's characteristics, was conducted to examine the association between NSAID exposure and incident CVD. After a median follow-up of 6.9 years (30 million person-years), a total of 258 601 cases of incident CVD was recorded. NSAID use was shown to be associated with a significantly higher risk of CVD (hazard ratio [HR], 1.32 [95%CI, 1.28-1.37]) compared to non-NSAID use. Similar results in coronary heart disease (HR, 1.37 [95%CI, 1.31-1.43]), stroke (HR, 1.27 [95%CI, 1.21-1.33]), and heart failure (HR, 1.25 [95%CI, 1.16-1.34]) were obtained. Overall, similar CVD risk was observed across users of NSAIDs except for etoricoxib, which showed a higher risk (HR, 2.01 [95%CI, 1.63-2.48]). Considering that a higher CVD risk was consistently displayed among NSAID users, NSAIDs should be used cautiously, and the usage of etoricoxib in the Chinese population should be reviewed.
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Affiliation(s)
- Eric Yuk Fai Wan
- Department of Family Medicine and Primary Care, The University of Hong Kong, Ap Lei Chau, Hong Kong, China.,Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, The University of Hong Kong, Ap Lei Chau, Hong Kong, China.,Laboratory of Data Discovery for Health (D24H), Hong Kong Science and Technology Park, Sha Tin, Hong Kong, China
| | - Esther Yee Tak Yu
- Department of Family Medicine and Primary Care, The University of Hong Kong, Ap Lei Chau, Hong Kong, China
| | - Linda Chan
- Department of Family Medicine and Primary Care, The University of Hong Kong, Ap Lei Chau, Hong Kong, China
| | - Anna Hoi Ying Mok
- Department of Family Medicine and Primary Care, The University of Hong Kong, Ap Lei Chau, Hong Kong, China
| | - Yuan Wang
- Department of Family Medicine and Primary Care, The University of Hong Kong, Ap Lei Chau, Hong Kong, China
| | - Esther Wai Yin Chan
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, The University of Hong Kong, Ap Lei Chau, Hong Kong, China.,Laboratory of Data Discovery for Health (D24H), Hong Kong Science and Technology Park, Sha Tin, Hong Kong, China.,Department of Pharmacy, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China.,The University of Hong Kong Shenzhen Institute of Research and Innovation, Shenzhen, China
| | - Ian Chi Kei Wong
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, The University of Hong Kong, Ap Lei Chau, Hong Kong, China.,Laboratory of Data Discovery for Health (D24H), Hong Kong Science and Technology Park, Sha Tin, Hong Kong, China.,Research Department of Practice and Policy, School of Pharmacy, University College London, London, UK.,Aston Pharmacy School, Aston University, Birmingham, UK.,Department of Pharmacy, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Cindy Lo Kuen Lam
- Department of Family Medicine and Primary Care, The University of Hong Kong, Ap Lei Chau, Hong Kong, China.,Department of Family Medicine, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
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11
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Xu Z, Arnold M, Sun L, Stevens D, Chung R, Ip S, Barrett J, Kaptoge S, Pennells L, Di Angelantonio E, Wood AM. Incremental value of risk factor variability for cardiovascular risk prediction in individuals with type 2 diabetes: results from UK primary care electronic health records. Int J Epidemiol 2022; 51:1813-1823. [PMID: 35776101 PMCID: PMC9749723 DOI: 10.1093/ije/dyac140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 06/17/2022] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Cardiovascular disease (CVD) risk prediction models for individuals with type 2 diabetes are important tools to guide intensification of interventions for CVD prevention. We aimed to assess the added value of incorporating risk factors variability in CVD risk prediction for people with type 2 diabetes. METHODS We used electronic health records (EHRs) data from 83 910 adults with type 2 diabetes but without pre-existing CVD from the UK Clinical Practice Research Datalink for 2004-2017. Using a landmark-modelling approach, we developed and validated sex-specific Cox models, incorporating conventional predictors and trajectories plus variability of systolic blood pressure (SBP), total and high-density lipoprotein (HDL) cholesterol, and glycated haemoglobin (HbA1c). Such models were compared against simpler models using single last observed values or means. RESULTS The standard deviations (SDs) of SBP, HDL cholesterol and HbA1c were associated with higher CVD risk (P < 0.05). Models incorporating trajectories and variability of continuous predictors demonstrated improvement in risk discrimination (C-index = 0.659, 95% CI: 0.654-0.663) as compared with using last observed values (C-index = 0.651, 95% CI: 0.646-0.656) or means (C-index = 0.650, 95% CI: 0.645-0.655). Inclusion of SDs of SBP yielded the greatest improvement in discrimination (C-index increase = 0.005, 95% CI: 0.004-0.007) in comparison to incorporating SDs of total cholesterol (C-index increase = 0.002, 95% CI: 0.000-0.003), HbA1c (C-index increase = 0.002, 95% CI: 0.000-0.003) or HDL cholesterol (C-index increase= 0.003, 95% CI: 0.002-0.005). CONCLUSION Incorporating variability of predictors from EHRs provides a modest improvement in CVD risk discrimination for individuals with type 2 diabetes. Given that repeat measures are readily available in EHRs especially for regularly monitored patients with diabetes, this improvement could easily be achieved.
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Affiliation(s)
- Zhe Xu
- British Heart Foundation Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Matthew Arnold
- British Heart Foundation Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Luanluan Sun
- British Heart Foundation Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - David Stevens
- British Heart Foundation Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Ryan Chung
- British Heart Foundation Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Samantha Ip
- British Heart Foundation Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Jessica Barrett
- Medical Research Council Biostatistics Unit, Cambridge Institute of Public Health, University of Cambridge, Cambridge, UK
| | - Stephen Kaptoge
- British Heart Foundation Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
- National Institute for Health Research Blood and Transplant Research Unit in Donor Health and Genomics, University of Cambridge, Cambridge, UK
| | - Lisa Pennells
- British Heart Foundation Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Emanuele Di Angelantonio
- British Heart Foundation Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
- National Institute for Health Research Blood and Transplant Research Unit in Donor Health and Genomics, University of Cambridge, Cambridge, UK
- British Heart Foundation Centre of Research Excellence, University of Cambridge, Cambridge, UK
- Health Data Research UK Cambridge, Wellcome Genome Campus and University of Cambridge, Cambridge, UK
| | - Angela M Wood
- British Heart Foundation Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
- Medical Research Council Biostatistics Unit, Cambridge Institute of Public Health, University of Cambridge, Cambridge, UK
- National Institute for Health Research Blood and Transplant Research Unit in Donor Health and Genomics, University of Cambridge, Cambridge, UK
- British Heart Foundation Centre of Research Excellence, University of Cambridge, Cambridge, UK
- Health Data Research UK Cambridge, Wellcome Genome Campus and University of Cambridge, Cambridge, UK
- The Alan Turing Institute, London, UK
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12
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Deng Y, Liu Y, Zhang S, Yu H, Zeng X, An R, Chen Z, Sun N, Yin X, Dong Y. Visit-to-visit variability of blood pressure and risk of macrovascular and microvascular complications in patients with type 2 diabetes: A Chinese primary-care cohort study. J Diabetes 2022; 14:767-779. [PMID: 36443961 PMCID: PMC9705806 DOI: 10.1111/1753-0407.13331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 09/22/2022] [Accepted: 10/25/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND We evaluated the effects of visit-to-visit variability of systolic blood pressure (SBP) and diastolic blood pressure (DBP) on macrovascular and microvascular complications among patients with type 2 diabetes. METHODS A total of 11 043 patients with type 2 diabetes from primary healthcare institutions between January 2010 and June 2020 were included. The visit-to-visit blood pressure variability was calculated using three metrics: SD, coefficient of variation (CV), and average real variability (ARV), obtained over a 12-month measurement period. The associations of visit-to-visit blood pressure variability with macrovascular and microvascular complications were evaluated using multivariate-adjusted Cox proportional hazards models, and hazard ratio (HR) with 95% confidence interval (CI) were reported. RESULTS There were 330 macrovascular events and 542 microvascular events. Compared to those for participants with the lowest quartile of SD of SBP and DBP, increased risks were observed in patients with the highest quartile of SD of SBP and DBP for macrovascular complications (SD-SBP: HR = 1.78, 95% CI: 1.24-2.57; SD-DBP: HR = 2.20, 95% CI: 1.50-3.25) and microvascular complications (SD-SBP: HR = 1.85, 95% CI: 1.39-2.46; SD-DBP: HR = 1.82, 95% CI: 1.36-2.44). CV and ARV of SBP and DBP also had statistically significant associations with macrovascular and microvascular complications. The optimal variability of blood pressure target was SD of SBP <6.45 mm Hg and SD of DBP <4.81 mm Hg. CONCLUSIONS Visit-to-visit blood pressure variability may be a potential predictor for macrovascular and microvascular complications in patients with type 2 diabetes.
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Affiliation(s)
- Ying Deng
- Department of Community Health ManagementBaoan District Central HospitalShenzhenPeople's Republic of China
| | - Yin Liu
- Department of Community Health ManagementBaoan District Central HospitalShenzhenPeople's Republic of China
| | - Shengchao Zhang
- Department of Community Health ManagementBaoan District Central HospitalShenzhenPeople's Republic of China
| | - Hanbing Yu
- Department of Community Health ManagementBaoan District Central HospitalShenzhenPeople's Republic of China
| | - Xiaozhou Zeng
- Department of Community Health ManagementBaoan District Central HospitalShenzhenPeople's Republic of China
| | - Rongrong An
- Department of Social Medicine and Health Management, School of Public Health, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanPeople's Republic of China
| | - Zhenyuan Chen
- Department of Social Medicine and Health Management, School of Public Health, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanPeople's Republic of China
| | - Na Sun
- Department of Social Medicine and Health Management, School of Public Health, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanPeople's Republic of China
| | - Xiaoxv Yin
- Department of Social Medicine and Health Management, School of Public Health, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanPeople's Republic of China
| | - Yue Dong
- Department of Social Medicine and Health Management, School of Public Health, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanPeople's Republic of China
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13
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Lin CC, Li CI, Juan YL, Liu CS, Lin CH, Yang SY, Li TC. Joint effect of blood pressure and glycemic variation on the risk of cardiovascular morbidity and mortality in persons with type 2 diabetes. Metabolism 2022; 136:155308. [PMID: 36058287 DOI: 10.1016/j.metabol.2022.155308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 08/16/2022] [Accepted: 08/29/2022] [Indexed: 10/31/2022]
Abstract
OBJECTIVE Few studies have explored the association of visit-to-visit variation in blood pressure (BP) and glycemic factors with cardiovascular disease (CVD) morbidity and mortality. This study aimed to examine the independent and joint effect of visit-to-visit BP and glycemic variation on CVD morbidity and mortality in persons with T2DM. METHODS The present study consisted of two retrospective cohort studies. The Taiwan Diabetes Study was based on a database of the National Diabetes Care Management Program (DCMP) and linked with cardiovascular morbidity incidence. The Taichung Diabetes Study was based on the DCMP database of a medical center, which can be linked with the National Death Registry dataset. The outcomes were analyzed by using Cox's proportional hazard models. RESULTS A total of 13,280 and 10,894 persons with T2DM in Taiwan and Taichung Diabetes Study, respectively, were included. SBP-CV, FPG-CV, and HbA1c-CV were significant predictors of stroke, CVD event or death, all-cause mortality, and expanded CVD mortality, whereas DBP-CV was a significant predictor of all-cause mortality and expanded and non-expanded CVD mortality. The joint effect of SBP, FPG, and HbA1c predicted the incidence of stroke and CVD event or death with increased risks of 16 %-35 %. In addition, the joint effect of SBP, DBP, FPG, and HbA1c was associated with all-cause and expanded CVD mortality with increased risks of 29 %-81 %. CONCLUSIONS The joint effect of BP and glucose variation improved the prediction of cardiovascular morbidity and mortality. Moreover, simultaneous measurement of visit-to-visit BP and glycemic variation may stratify persons with cardiovascular risks and may be regarded as important therapeutic goals in the care of T2DM.
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Affiliation(s)
- Cheng-Chieh Lin
- School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan; Department of Family Medicine, China Medical University Hospital, Taichung, Taiwan; Department of Medical Research, China Medical University Hospital, Taichung, Taiwan
| | - Chia-Ing Li
- School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan; Department of Medical Research, China Medical University Hospital, Taichung, Taiwan
| | - Ya-Ling Juan
- Department of Public Health, College of Public Health, China Medical University, Taichung, Taiwan
| | - Chiu-Shong Liu
- School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan; Department of Family Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Chih-Hsueh Lin
- School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan; Department of Family Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Shing-Yu Yang
- Department of Public Health, College of Public Health, China Medical University, Taichung, Taiwan
| | - Tsai-Chung Li
- Department of Public Health, College of Public Health, China Medical University, Taichung, Taiwan; Department of Healthcare Administration, College of Medical and Health Science, Asia University, Taichung, Taiwan.
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14
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Zarife AS, Fraga-Maia H, Mill JG, Lotufo P, Griep RH, Fonseca MDJMD, Brito LL, Almeida MDC, Aras R, Matos SMA. Variabilidade da Pressão Arterial em Única Visita e Risco Cardiovascular em Participantes do ELSA-Brasil. Arq Bras Cardiol 2022; 119:505-511. [PMID: 36074482 PMCID: PMC9563895 DOI: 10.36660/abc.20210804] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Accepted: 04/06/2022] [Indexed: 11/18/2022] Open
Abstract
Fundamento A variabilidade da pressão arterial (VPA) tem valor prognóstico para desfechos cardiovasculares fatais e não fatais. Objetivos Este estudo teve como objetivo avaliar a associação entre a VPA em uma única visita e o risco cardiovascular em participantes do Estudo Longitudinal de Saúde do Adulto (ELSA-Brasil). Métodos O presente estudo transversal foi conduzido com dados basais (2008-2010) de 14.357 participantes do ELSA-Brasil, sem história de doença cardiovascular. A VPA foi quantificada pelo coeficiente de variação de três medidas padronizadas da pressão arterial sistólica (PAS) realizadas com um oscilômetro. Medidas antropométricas e exames laboratoriais também foram realizados. O risco cardiovascular foi avaliado pelo estimador de risco de doença cardiovascular aterosclerótica (ASCVD), e se empregou a análise de regressão logística multivariada com nível de significância de 5%. Resultados Um risco cardiovascular significativamente maior foi determinado por uma VPA elevada para ambos os sexos. Uma prevalência significativamente maior de alto risco foi observada mais em homens que em mulheres em todos os quartis, com a maior diferença observada no quarto quartil de variabilidade (48,3% vs. 17,1%). Comparações entre quartis por sexo revelaram um risco significativamente mais alto para homens no terceiro (OR=1,20; IC95%: 1,02 - 1,40) e no quarto quartis OR=1,46; IC95%: 1,25 -1,71), e para mulheres no quarto quartil (OR=1,27; IC95%: 1,03 - 1,57). Conclusão Análises de dados basais de participantes do ELSA-Brasil revelaram que a variabilidade da pressão arterial se associou com risco cardiovascular aumentado, especialmente nos homens.
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15
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Evaluation of Persistent Efficacy of Diabetes Remission and Decline of Cardiovascular Risk After Laparoscopic Sleeve Gastrectomy: a Preliminary 1-Year Study. Obes Surg 2022; 32:3289-3297. [DOI: 10.1007/s11695-022-06201-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 07/03/2022] [Accepted: 07/04/2022] [Indexed: 02/05/2023]
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16
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Zhu W, Xu L, Chen X, Lee YJ, Zhang Z, Lou Q. Effects of different blood pressures and their long-term variability on the development of diabetic kidney disease in patients with type 2 diabetes mellitus. Clin Exp Hypertens 2022; 44:464-469. [PMID: 35531897 DOI: 10.1080/10641963.2022.2071917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Weiyan Zhu
- Department of Nephrology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, ZJ, China
| | - Lichen Xu
- Department of Nephrology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, ZJ, China
| | - Xue Chen
- Nursing College, Nanjing University of Chinese Medicine, Nanjing, JS, China
| | - Yau-Jiunn Lee
- Division of Cardiology, Department of Internal Medicine, E-Da Hospital, Kaohsiung, Taiwan
| | - Zongjun Zhang
- Affiliated Hospital of Integrated Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, Department of Radiology, Nanjing, JS, China
| | - Qingqing Lou
- eDepartment of Endocrinology,The First Affiliated Hospital of Hainan Medical University, HI, China
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17
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Lin CH, Lai YC, Chang TJ, Jiang YD, Chang YC, Chuang LM. Visit-to-visit variability in albuminuria predicts renal function deterioration in patients with type 2 diabetes. J Diabetes Investig 2022; 13:1021-1029. [PMID: 35100497 PMCID: PMC9153848 DOI: 10.1111/jdi.13761] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 01/10/2022] [Accepted: 01/25/2022] [Indexed: 11/28/2022] Open
Abstract
Aims/Introduction We aimed to study the predictive ability of visit‐to‐visit variability in albuminuria for changes in renal function in patients with type 2 diabetes mellitus. Materials and Methods The cohort study was carried out in a single medical center. In the model development cohort of 1008 subjects, we developed the albuminuria variability score (AVS) to evaluate the visit‐to‐visit variability in albuminuria, which was the percentage of the number of changes in the urine albumin : creatinine ratio ≥3.39 mg/mmol among all visit‐to‐visit urine albumin : creatinine ratio differences within an individual. Multivariate logistic regression was applied to predict the influence of AVS levels on the occurrence of study end‐points. In another independent validation cohort of 310 participants, survival analysis was carried out to evaluate the ability of AVS in predicting the study end‐point. Results In the model development cohort, a higher AVS was associated with higher adjusted odds of having a declined or rapidly declined estimated glomerular filtration rate (eGFR) trajectory (1.84, 95% confidence interval 1.23–2.76 and 5.70, 95% confidence interval 2.28–14.25, respectively), a resultant eGFR <60 mL/min/1.73 m2 (2.61, 95% confidence interval 1.63–4.16) and a >40% decline in eGFR from baseline (6.44, 95% confidence interval 2.15–19.26). In the validation cohort, a higher AVS independently predicted a 5‐year decrease of >40% in eGFR to <60 mL/min/1.73 m2 (adjusted hazard ratio 3.33, 95% confidence interval 1.10–10.05). Integrated discrimination index and concordance statistics showed that AVS significantly improved the predictive ability of the models. Conclusions Visit‐to‐visit variability in albuminuria can independently predict long‐term renal function deterioration in patients with type 2 diabetes mellitus. Further investigations are warranted to elucidate the potential clinical applications.
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Affiliation(s)
- Chih-Hung Lin
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, 100, Taiwan.,Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, 100, Taiwan
| | - Ying-Chuen Lai
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, 100, Taiwan.,Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, 100, Taiwan
| | - Tien-Jyun Chang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, 100, Taiwan
| | - Yi-Der Jiang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, 100, Taiwan
| | - Yi-Cheng Chang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, 100, Taiwan.,Graduate Institute of Genomics and Proteomics, College of Medicine, National Taiwan University, Taipei, 100, Taiwan.,Institute of Biomedical Sciences, Academia Sinica, Taipei, 115, Taiwan
| | - Lee-Ming Chuang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, 100, Taiwan.,Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, 100, Taiwan.,Institute of Preventive Medicine, College of Public Health, National Taiwan University, Taipei, 100, Taiwan
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18
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Silva AFRD, Cruz RC, Albuquerque NLSD, Silva VMD, Araujo TLD. Blood pressure variability in individuals with diabetes mellitus: a scoping review. Rev Bras Enferm 2022; 75:e20210804. [DOI: 10.1590/0034-7167-2021-0804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 02/07/2022] [Indexed: 11/22/2022] Open
Abstract
ABSTRACT Objectives: to map methods and devices used to assess very short-, short-, medium-, and long-term pressure variability in adults with type 1 or 2 diabetes mellitus. Methods: scoping review conducted in January and February 2021 in MEDLINE, Web of Science, CINAHL, LILACS, PubMed, and Embase databases. Studies conducted within the last ten years analyzing pressure variability in adult and older patients with diabetes mellitus type 1 or 2 were included. Studies that used discontinued devices were excluded. Results: the sample was composed of 25 articles published since 2017, with the majority developed in Japan (n=11); with the predominance of the oscillometric method (n=22); the most used devices were from the Omron® brand (n=14); the most detected type was long-term variability (n=10). Conclusions: we observed the increasing application of the oscillometric method for pressure variability analysis with various brands and models of automatic devices.
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19
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Chen F, Pan Y, Liu Z, Huang R, Wang J, Shao J, Gong Y, Sun X, Jiang X, Wang W, Li Z, Zhong S, Pan Q, Zhou K. Impact of Visit-to-Visit Triglyceride-Glucose Index Variability on the Risk of Cardiovascular Disease in the Elderly. Int J Endocrinol 2022; 2022:5125884. [PMID: 36159087 PMCID: PMC9507760 DOI: 10.1155/2022/5125884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 08/14/2022] [Accepted: 08/23/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND The aging population is increasingly susceptible to cardiovascular disease (CVD). Visit-to-visit variability in glucose and lipid levels both contributed to CVD risk independent of their mean values. However, whether variability in the triglyceride-glucose (TyG) index is a risk factor for CVD remains unknown. Research Design and Methods. In this retrospective study of electronic health records, 27,520 participants aged over 60 years were enrolled. The visit-to-visit variability of TyG index was calculated from annual health examination data and defined as average real variability (ARV), standard deviation (SD), or the coefficient of variability (CV). CVD events were identified from the chronic disease registry or follow-up database and included myocardial infarction, angina, coronary, and stroke. Multivariate Cox regression was used to examine the correlation between TyG variability and incident CVD. RESULTS Over a median follow-up of 6.2 years, there were 2,178 CVD events. When participants were divided into four quartiles according to their TyG variability, after adjusting for established CVD risk factors, subjects in the top quartile had (HR = 1.18, 95% CI 1.05-1.34, P=0.005) significantly higher CVD risk than those in the bottom quartile. The association remained significant in overweight individuals or those without diabetes (P < 0.005 and P < 0.01, respectively). CONCLUSIONS High variability in TyG was significantly associated with elevated CVD risk in the elderly, independent of average TyG and other risk factors. Close monitoring variability in TyG might be informative to identify old individuals at high risk of CVD.
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Affiliation(s)
- Fei Chen
- College of Life Sciences, University of Chinese Academy of Sciences, China
| | - Ying Pan
- Department of Endocrinology, Kunshan Hospital Affiliated to Jiangsu University, Kunshan, Jiangsu, China
| | - Ziqing Liu
- College of Life Sciences, University of Chinese Academy of Sciences, China
| | - Rong Huang
- Guangzhou Laboratory, Guangzhou, Guangdong, China
| | - Jing Wang
- College of Life Sciences, University of Chinese Academy of Sciences, China
| | - Jian Shao
- College of Life Sciences, University of Chinese Academy of Sciences, China
| | - Yaqin Gong
- Department of Medical Informatics, Kunshan Hospital Affiliated to Jiangsu University, Kunshan, Jiangsu, China
| | - Xiyi Sun
- Department of Medical Informatics, Kunshan Hospital Affiliated to Jiangsu University, Kunshan, Jiangsu, China
| | - Xiaobo Jiang
- ZhenChuan Community Health Service Center, Kunshan, Jiangsu, China
| | - Weihao Wang
- Department of Endocrinology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Zhaoqiang Li
- Guangzhou Laboratory, Guangzhou, Guangdong, China
| | - Shao Zhong
- Department of Endocrinology, Kunshan Hospital Affiliated to Jiangsu University, Kunshan, Jiangsu, China
| | - Qi Pan
- Department of Endocrinology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Kaixin Zhou
- College of Life Sciences, University of Chinese Academy of Sciences, China
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Wan EYF, Yu EYT, Chin WY, Barrett JK, Wong ICK, Chan EWY, Chui CSL, Chen S, Lam CLK. Age-Specific Associations of Usual Blood Pressure Variability With Cardiovascular Disease and Mortality: 10-Year Diabetes Mellitus Cohort Study. J Am Heart Assoc 2021; 10:e019026. [PMID: 34398678 PMCID: PMC8649287 DOI: 10.1161/jaha.120.019026] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
Background The detrimental effects of increased variability in systolic blood pressure (SBP) on cardiovascular disease (CVD) and mortality risk in patients with diabetes mellitus remains unclear. This study evaluated age‐specific association of usual SBP visit‐to‐visit variability with CVD and mortality in patients with type 2 diabetes mellitus. Methods and Results A retrospective cohort study investigated 155 982 patients with diabetes mellitus aged 45 to 84 years without CVD at baseline (2008–2010). Usual SBP variability was estimated using SBP SD obtained from a mixed‐effects model. Age‐specific associations (45–54, 55–64, 65–74, 75–84 years) between usual SBP variability, CVD, and mortality risk were assessed by Cox regression adjusted for patient characteristics. After a median follow‐up of 9.7 years, 49 816 events (including 34 039 CVD events and 29 211 mortalities) were identified. Elevated SBP variability was independently, positively, and log‐linearly associated with higher CVD and mortality risk among all age groups, with no evidence of any threshold effects. The excess CVD and mortality risk per 5 mm Hg increase in SBP variability within the 45 to 54 age group is >3 times higher than the 70 to 79 age group (hazard ratio, 1.66; 95% CI, 1.49–1.85 versus hazard ratio, 1.19; 95% CI, 1.15–1.23). The significant associations remained consistent among all subgroups. Patients with younger age had a higher association of SBP variability with event outcomes. Conclusions The findings suggest that SBP visit‐to‐visit variability was strongly associated with CVD and mortality with no evidence of a threshold effect in a population with diabetes mellitus. As well as controlling overall blood pressure levels, SBP visit‐to‐visit variability should be monitored and evaluated in routine practice, in particular for younger patients.
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Affiliation(s)
- Eric Yuk Fai Wan
- Department of Family Medicine and Primary Care The University of Hong Kong Hong Kong SAR China.,Centre for Safe Medication Practice and Research Department of Pharmacology and Pharmacy The University of Hong Kong Hong Kong SAR China.,Laboratory of Data Discovery for Health (D24H) Hong Kong Science and Technology Park Sha Tin Hong Kong, China
| | - Esther Yee Tak Yu
- Department of Family Medicine and Primary Care The University of Hong Kong Hong Kong SAR China.,Department of Family Medicine and Primary Care The University of Hong Kong Shenzhen Hospital Shenzhen China
| | - Weng Yee Chin
- Department of Family Medicine and Primary Care The University of Hong Kong Hong Kong SAR China
| | - Jessica K Barrett
- Medical Research Council (MRC) Biostatistics Unit University of Cambridge Cambridge United Kingdom
| | - Ian Chi Kei Wong
- Centre for Safe Medication Practice and Research Department of Pharmacology and Pharmacy The University of Hong Kong Hong Kong SAR China.,Laboratory of Data Discovery for Health (D24H) Hong Kong Science and Technology Park Sha Tin Hong Kong, China.,Research Department of Practice and Policy School of Pharmacy University College London London United Kingdom
| | - Esther Wai Yin Chan
- Centre for Safe Medication Practice and Research Department of Pharmacology and Pharmacy The University of Hong Kong Hong Kong SAR China.,Laboratory of Data Discovery for Health (D24H) Hong Kong Science and Technology Park Sha Tin Hong Kong, China
| | - Celine Sze Ling Chui
- Centre for Safe Medication Practice and Research Department of Pharmacology and Pharmacy The University of Hong Kong Hong Kong SAR China.,Laboratory of Data Discovery for Health (D24H) Hong Kong Science and Technology Park Sha Tin Hong Kong, China
| | - Shiqi Chen
- Department of Family Medicine and Primary Care The University of Hong Kong Hong Kong SAR China
| | - Cindy Lo Kuen Lam
- Department of Family Medicine and Primary Care The University of Hong Kong Hong Kong SAR China
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21
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Kaze AD, Santhanam P, Erqou S, Yuyun M, Bertoni AG, Ahima RS, Echouffo-Tcheugui JB. Long-Term Variability of Blood Pressure, Cardiovascular Outcomes, and Mortality: The Look AHEAD Study. Am J Hypertens 2021; 34:689-697. [PMID: 33825813 DOI: 10.1093/ajh/hpaa210] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 11/09/2020] [Accepted: 03/31/2021] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND We evaluated the associations of visit-to-visit blood pressure (BP) variability with incident cardiovascular disease (CVD) and deaths in adults with type 2 diabetes. METHODS We analyzed 4,152 participants in Look AHEAD (Action for Health in Diabetes) free of CVD events and deaths during the first 36 months of follow-up. Variability of systolic BP (SBP) and diastolic BP (DBP) across 4 annual visits was assessed using the intraindividual SD, variation independent of the mean, and coefficient of variation. Cox regression was used to generate the adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs) for CVD (myocardial infarction [MI], stroke, or CVD-related deaths) and mortality. RESULTS Over a median of 6.6 years, there were 220 MIs, 105 stroke cases, 62 CVD-related deaths, and 236 deaths. After adjustment for confounders including average BP, the aHRs for the highest (vs. lowest) tertile of SD of SBP were 1.98 (95% CI 1.01-3.92), 1.25 (95% CI 0.90-1.72), 1.26 (95% CI 0.96-1.64), 1.05 (95% CI 0.75-1.46), and 1.64 (95% CI 0.99-2.72) for CVD mortality, all-cause mortality, CVD, MI, and stroke, respectively. The equivalent aHRs for SD of DBP were 1.84 (95% CI 0.98-3.48), 1.43 (95% CI 1.03-1.98), 1.19 (95% CI 0.91-1.56), 1.14 (95% CI 0.82-1.58), and 0.97 (95% CI 0.58-1.60), respectively. CONCLUSIONS In a large sample of individuals with type 2 diabetes, a greater variability in SBP was associated with higher cardiovascular mortality and CVD events; a higher variability in DBP was linked to increased overall and cardiovascular mortality.
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Affiliation(s)
- Arnaud D Kaze
- Department of Medicine, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Prasanna Santhanam
- Department of Medicine, Division of Endocrinology, Diabetes & Metabolism, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Sebhat Erqou
- Department of Medicine, Providence Veterans Affairs Medical Center and Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Matthew Yuyun
- Department of Medicine, Veterans Affairs Boston Healthcare System, Boston, Massachusetts, USA
| | - Alain G Bertoni
- Department of Epidemiology and Prevention, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Rexford S Ahima
- Department of Medicine, Division of Endocrinology, Diabetes & Metabolism, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Justin B Echouffo-Tcheugui
- Department of Medicine, Division of Endocrinology, Diabetes & Metabolism, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
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22
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Ceriello A, Prattichizzo F. Variability of risk factors and diabetes complications. Cardiovasc Diabetol 2021; 20:101. [PMID: 33962641 PMCID: PMC8106175 DOI: 10.1186/s12933-021-01289-4] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 04/27/2021] [Indexed: 12/15/2022] Open
Abstract
Several studies suggest that, together with glucose variability, the variability of other risk factors, as blood pressure, plasma lipids, heart rate, body weight, and serum uric acid, might play a role in the development of diabetes complications. Moreover, the variability of each risk factor, when contemporarily present, may have additive effects. However, the question is whether variability is causal or a marker. Evidence shows that the quality of care and the attainment of the target impact on the variability of all risk factors. On the other hand, for some of them causality may be considered. Although specific studies are still lacking, it should be useful checking the variability of a risk factor, together with its magnitude out of the normal range, in clinical practice. This can lead to an improvement of the quality of care, which, in turn, could further hesitate in an improvement of risk factors variability.
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Affiliation(s)
- Antonio Ceriello
- IRCCS MultiMedica, Via Gaudenzio Fantoli, 16/15, 20138, Milan, Italy.
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23
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Rotbain Curovic V, Theilade S, Winther SA, Tofte N, Tarnow L, Jorsal A, Parving HH, Persson F, Hansen TW, Rossing P. Visit-to-visit variability of clinical risk markers in relation to long-term complications in type 1 diabetes. Diabet Med 2021; 38:e14459. [PMID: 33179275 DOI: 10.1111/dme.14459] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 10/16/2020] [Accepted: 11/09/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Clinical characteristics such as HbA1c , systolic blood pressure (SBP), albuminuria and estimated glomerular filtration rate (eGFR) are important when treating type 1 diabetes. We investigated the variability in these measures as risk markers for micro- and macrovascular complications. METHODS This prospective study included 1062 individuals with type 1 diabetes. Visit-to-visit variability of HbA1c , SBP, albuminuria and eGFR was calculated as the SD of the residuals in individual linear regression models using all available measures in a specified period of 3 years (VV). Endpoints included were as follows: cardiovascular events (CVE) defined as myocardial infarction, non-fatal stroke, or coronary or peripheral arterial intervention; end-stage kidney disease (ESKD) defined as eGFR <15 ml/min/1.73 m2 , chronic dialysis or kidney transplantation; eGFR decline ≥30%; and mortality. Adjustment included age, sex, cholesterol, HbA1c , SBP, body mass index, smoking, albuminuria, eGFR, and mean, intercept, slope of respective exposure variables and regression models. RESULTS SBP VV was significantly associated with CVE (adjusted hazard ratio per 50% increase, (CI 95%); p: 1.21 [1.05-1.39]; p = 0.008), ESKD (1.51 [1.16-1.96]; p = 0.002) and mortality (1.25 [1.09-1.44]; p = 0.002). HbA1c VV was significantly associated with mortality (1.51 [1.30-1.75]; p < 0.001); albuminuria VV with eGFR decline (1.14 [1.08-1.20]; p = 0.024) and ESKD (1.14 [1.02-1.27]; p < 0.001), but neither CVE nor mortality. Adjusted eGFR VV was not associated with endpoints. CONCLUSION In type 1 diabetes, higher variability of basic clinical risk markers adds important risk stratification information for the development of micro- and macrovascular complications.
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Affiliation(s)
| | - Simone Theilade
- Steno Diabetes Center Copenhagen, Gentofte, Denmark
- Department of Medicine, Herlev-Gentofte Hospital, Herlev, Denmark
| | | | - Nete Tofte
- Steno Diabetes Center Copenhagen, Gentofte, Denmark
| | - Lise Tarnow
- Steno Diabetes Center Sjaelland, Holbaek, Denmark
| | - Anders Jorsal
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | | | | | | | - Peter Rossing
- Steno Diabetes Center Copenhagen, Gentofte, Denmark
- University of Copenhagen, Copenhagen, Denmark
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24
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Wong YK, Chan YH, Hai JSH, Lau KK, Tse HF. Predictive value of visit-to-visit blood pressure variability for cardiovascular events in patients with coronary artery disease with and without diabetes mellitus. Cardiovasc Diabetol 2021; 20:88. [PMID: 33894788 PMCID: PMC8070286 DOI: 10.1186/s12933-021-01280-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 04/15/2021] [Indexed: 12/26/2022] Open
Abstract
Background High blood pressure is a major risk factor for cardiovascular disease. Visit-to-visit blood pressure variability (BPV) has recently been shown to predict cardiovascular outcomes. We investigated the predictive value of BPV for major adverse cardiovascular events (MACE) among patients with coronary artery disease (CAD), with and without type 2 diabetes mellitus (T2DM). Methods Patients with stable CAD were enrolled and monitored for new MACE. Visit-to-visit BPV was defined as the coefficient of variation (CV) of systolic and diastolic BP across clinic visits. Multivariable logistic regression analysis was performed to evaluate the association of BPV with MACE. Area under the receiver operating characteristic curve (AUC) was used to assess its predictive ability. Results Among 1140 Chinese patients with stable CAD, 192 (17%) experienced a new MACE. In multivariable analyses, the risk of MACE was significantly associated with CV of systolic BP (odds ratio [OR] for highest versus lowest quartile, 3.30; 95% CI 1.97–5.54), and diastolic BP (OR for highest versus lowest quartile, 2.39; 95% CI 1.39–4.11), after adjustment for variables of the risk factor model (age, gender, T2DM, hypertension, antihypertensive agents, number of BP measurements) and mean BP. The risk factor model had an AUC of 0.70 for prediction of MACE. Adding systolic/diastolic CV into the risk factor model with mean BP significantly increased the AUC to 0.73/0.72 (P = 0.002/0.007). In subgroup analyses, higher CV of systolic BP remained significantly associated with an increased risk for MACE in patients with and without T2DM, whereas the association of CV of diastolic BP with MACE was observed only in those without T2DM. Conclusions Visit-to-visit variability of systolic BP and of diastolic BP was an independent predictor of new MACE and provided incremental prognostic value beyond mean BP and conventional risk factors in patients with stable CAD. The association of BPV in CAD patients without T2DM with subsequent risk for MACE was stronger than in those with T2DM. Supplementary Information The online version contains supplementary material available at 10.1186/s12933-021-01280-z.
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Affiliation(s)
- Yuen-Kwun Wong
- Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong, China
| | - Yap-Hang Chan
- Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong, China
| | - JoJo S H Hai
- Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong, China
| | - Kui-Kai Lau
- Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong, China
| | - Hung-Fat Tse
- Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong, China. .,Department of Medicine, Shenzhen Hong Kong University Hospital, Shenzhen, China. .,Hong Kong-Guangdong Joint Laboratory On Stem Cell and Regenerative Medicine, The University of Hong Kong, Hong Kong, China. .,Shenzhen Institutes of Research and Innovation, The University of Hong Kong, Hong Kong SAR, China.
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25
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Dong W, Wan EYF, Fong DYT, Kwok RLP, Chao DVK, Tan KCB, Hui EMT, Tsui WWS, Chan KH, Fung CSC, Lam CLK. Prediction models and nomograms for 10-year risk of end-stage renal disease in Chinese type 2 diabetes mellitus patients in primary care. Diabetes Obes Metab 2021; 23:897-909. [PMID: 33319467 DOI: 10.1111/dom.14292] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Revised: 11/28/2020] [Accepted: 12/07/2020] [Indexed: 12/30/2022]
Abstract
AIMS To develop and validate 10-year risk prediction models, nomograms and charts for end-stage renal disease (ESRD) in Chinese patients with type 2 diabetes mellitus (T2DM) in primary care, in order to guide individualized treatment. MATERIALS AND METHODS This was a 10-year population-based observational cohort study. A total of 141 516 Chinese T2DM patients without history of cardiovascular disease or ESRD who were managed in public primary care clinics in 2008 were included and followed up until December 2017. Two-thirds of these patients were randomly selected to develop sex-specific ESRD risk prediction models using Cox regressions. The validity and accuracy of the models were tested on the remaining third of patients using Harrell's C-index. We selected variables based on their clinical and statistical importance to construct the nomograms and charts. RESULTS The median follow-up period was 9.75 years. The cumulative incidence of ESRD was 6.0% (men: 6.1%, women: 5.9%). Age, diabetes duration, systolic blood pressure (SBP), SBP variability, diastolic blood pressure, triglycerides, glycated haemoglobin (HbA1c), HbA1c variability, urine albumin to creatinine ratio (UACR), and estimated glomerular filtration rate (eGFR) were significant predictors for both sexes. Smoking and total cholesterol to HDL cholesterol ratio were additional significant predictors for men and women, respectively. The models showed Harrell's C-statistics of 0.889/0.889 (women/men). Age, eGFR, UACR, SBP and HbA1c were selected for both sexes to develop nomograms and charts. CONCLUSIONS Using routinely available variables, the 10-year ESRD risk of Chinese T2DM patients in primary care can be predicted with approximately 90% accuracy. We have developed different tools to facilitate routine ESRD risk prediction in primary care, so that individualized care can be provided to prevent or delay ESRD in T2DM patients.
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Affiliation(s)
- Weinan Dong
- Department of Family Medicine and Primary Care, University of Hong Kong, Hong Kong
| | - Eric Yuk Fai Wan
- Department of Family Medicine and Primary Care, University of Hong Kong, Hong Kong
- Department of Pharmacology and Pharmacy, University of Hong Kong, Hong Kong
| | | | - Ruby Lai Ping Kwok
- Department of Primary and Community Services, Hospital Authority, Hong Kong
| | - David Vai Kiong Chao
- Department of Family Medicine and Primary Health Care, Kowloon East Cluster, Hospital Authority, Hong Kong
| | | | - Eric Ming Tung Hui
- Department of Family Medicine, New Territories East Cluster, Hospital Authority, Hong Kong
| | - Wendy Wing Sze Tsui
- Family Medicine and Primary Healthcare, QMH, Hong Kong West Cluster, Hospital Authority, Hong Kong
| | | | | | - Cindy Lo Kuen Lam
- Department of Family Medicine and Primary Care, University of Hong Kong, Hong Kong
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26
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Association of visit-to-visit variability of systolic blood pressure with cardiovascular disease, chronic kidney disease and mortality in patients with hypertension. J Hypertens 2021; 38:943-953. [PMID: 31904623 DOI: 10.1097/hjh.0000000000002347] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE This study aimed to evaluate the association between visit-to-visit variability of systolic blood pressure (SBP) and cardiovascular disease, chronic kidney disease, and mortality among hypertensive patients. METHODS A population-based cohort included 225 759 Chinese hypertensive adults without diabetes, cardiovascular disease, and chronic kidney disease during 2011-2012. SBP variability was determined based on standard deviations of SBP over the previous 5 years before baseline. Cox regressions adjusted with patients' baseline characteristics, mean, and temporal trend of SBP was applied to the associations between variability and incident cardiovascular disease, chronic kidney disease and all-cause mortality. RESULTS In all, 25 714 patients with cardiovascular disease, 27 603 with chronic kidney disease, and 16 778 deaths have occurred during the median follow-up of 70.5 months (1.2 million person-years). SBP variability was continuously and positively associated with higher cardiovascular disease, chronic kidney disease and mortality risk among hypertensive patients without evidence of a threshold. Each 10-mmHg increase in SD of SBP was associated with 35% [hazard ratio 1.35, 95% confidence interval (CI) 1.30-1.39], 39% (HR 1.39, 95% CI 1.35-1.43), and 40% (HR 1.40, 95% CI 1.34-1.45) higher risk of cardiovascular disease, chronic kidney disease and mortality, respectively. HRs were attenuated with increased age, mean SBP, and Charlson index, and decreased temporal trend of systolic blood pressure, but it remained significant and consistent in most of the different subgroups. CONCLUSIONS Findings suggested that SBP variability is a significant prognostic value, in addition to baseline or mean of SBP for the risk of cardiovascular disease and mortality.
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Seng JJB, Monteiro AY, Kwan YH, Zainudin SB, Tan CS, Thumboo J, Low LL. Population segmentation of type 2 diabetes mellitus patients and its clinical applications - a scoping review. BMC Med Res Methodol 2021; 21:49. [PMID: 33706717 PMCID: PMC7953703 DOI: 10.1186/s12874-021-01209-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 01/13/2021] [Indexed: 12/25/2022] Open
Abstract
Background Population segmentation permits the division of a heterogeneous population into relatively homogenous subgroups. This scoping review aims to summarize the clinical applications of data driven and expert driven population segmentation among Type 2 diabetes mellitus (T2DM) patients. Methods The literature search was conducted in Medline®, Embase®, Scopus® and PsycInfo®. Articles which utilized expert-based or data-driven population segmentation methodologies for evaluation of outcomes among T2DM patients were included. Population segmentation variables were grouped into five domains (socio-demographic, diabetes related, non-diabetes medical related, psychiatric / psychological and health system related variables). A framework for PopulAtion Segmentation Study design for T2DM patients (PASS-T2DM) was proposed. Results Of 155,124 articles screened, 148 articles were included. Expert driven population segmentation approach was most commonly used, of which judgemental splitting was the main strategy employed (n = 111, 75.0%). Cluster based analyses (n = 37, 25.0%) was the main data driven population segmentation strategies utilized. Socio-demographic (n = 66, 44.6%), diabetes related (n = 54, 36.5%) and non-diabetes medical related (n = 18, 12.2%) were the most used domains. Specifically, patients’ race, age, Hba1c related parameters and depression / anxiety related variables were most frequently used. Health grouping/profiling (n = 71, 48%), assessment of diabetes related complications (n = 57, 38.5%) and non-diabetes metabolic derangements (n = 42, 28.4%) were the most frequent population segmentation objectives of the studies. Conclusions Population segmentation has a wide range of clinical applications for evaluating clinical outcomes among T2DM patients. More studies are required to identify the optimal set of population segmentation framework for T2DM patients. Supplementary Information The online version contains supplementary material available at 10.1186/s12874-021-01209-w.
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Affiliation(s)
- Jun Jie Benjamin Seng
- Duke-NUS Medical School, 8 College Road, Singapore, 169857, Singapore.,SingHealth Regional Health System PULSES Centre, Singapore Health Services, Outram Rd, Singapore, 169608, Singapore
| | | | - Yu Heng Kwan
- SingHealth Regional Health System PULSES Centre, Singapore Health Services, Outram Rd, Singapore, 169608, Singapore.,Program in Health Services and Systems Research, Duke-NUS Medical School, 8 College Road, Singapore, 169857, Singapore.,Department of Pharmacy, Faculty of Science, National University of Singapore, Singapore, Singapore
| | - Sueziani Binte Zainudin
- Department of General Medicine (Endocrinology), Sengkang General Hospital, Singapore, Singapore
| | - Chuen Seng Tan
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore, Republic of Singapore
| | - Julian Thumboo
- SingHealth Regional Health System PULSES Centre, Singapore Health Services, Outram Rd, Singapore, 169608, Singapore.,Department of Rheumatology and Immunology, Singapore General Hospital, Singapore, Singapore.,SingHealth Regional Health System, Singapore Health Services, Singapore, Singapore
| | - Lian Leng Low
- SingHealth Regional Health System PULSES Centre, Singapore Health Services, Outram Rd, Singapore, 169608, Singapore. .,SingHealth Regional Health System, Singapore Health Services, Singapore, Singapore. .,Department of Family Medicine and Continuing Care, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore. .,SingHealth Duke-NUS Family Medicine Academic Clinical Program, Singapore, Singapore. .,Outram Community Hospital, SingHealth Community Hospitals, 10 Hospital Boulevard, Singapore, 168582, Singapore.
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Abstract
OBJECTIVE In addition to high blood pressure variability (BPV), low BPV was associated with adverse cardiovascular prognosis in selected high-risk patients. We explored this issue in the Systolic Blood Pressure Intervention Trial (SPRINT) using a nonlinear approach with BPV as a continuous variable. METHODS Long-term systolic BPV (SBPV) (coefficient of variation, CoV %) was calculated on quarterly visits until a fatal/nonfatal cardiovascular event or all-cause mortality, excluding titration period and patients with missing visits. We used Cox proportional hazard models with penalized smoothing splines to shape the risk of outcomes against the continuum of SBPV (independent variable). Adjusted hazard ratios (aHR, 95% CI) were calculated using the reference range derived from the nonlinear model. Sensitivity analysis based on propensity score matching (PSM) was performed. RESULTS The association of SBPV with fatal/nonfatal cardiovascular events was J-shaped, whereas that with all-cause mortality was linear. After multivariate adjustment, however, the only significant associations remained that of low SBPV (CoV <5%) with cardiovascular events (hazard ratio 1.85, 95% CI 1.24-2.75, P = 0.003), and of high SBPV (CoV >10%) with the composite of cardiovascular events and all-cause mortality (hazard ratio 1.35, 95% CI 1.02-1.80; P = 0.037). Low SBPV was associated with ischemic heart disease (hazard ratio 2.76, 95% CI 1.55-4.91; P < 0.001). There was a significant U-shaped association of SBPV with cardiovascular events in the PSM cohort. CONCLUSION Nonlinear modeling indicates that low and high long-term SBPV have prognostic relevance in high-risk hypertensive individuals from SPRINT. Randomized trials are needed to test these findings and their potential therapeutic implications.
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Wan EYF, Yu EYT, Chin WY, Barrett JK, Mok AHY, Lau CST, Wang Y, Wong ICK, Chan EWY, Lam CLK. Greater variability in lipid measurements associated with cardiovascular disease and mortality: A 10-year diabetes cohort study. Diabetes Obes Metab 2020; 22:1777-1788. [PMID: 32452623 PMCID: PMC7540339 DOI: 10.1111/dom.14093] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 05/17/2020] [Accepted: 05/17/2020] [Indexed: 12/24/2022]
Abstract
AIM To examine the associations between variability in lipids and the risk of cardiovascular disease (CVD) and mortality in patients with type 2 diabetes based on low-density lipoprotein-cholesterol (LDL-C), the total cholesterol (TC) to high-density lipoprotein-cholesterol (HDL-C) ratio and triglycerides (TG). MATERIALS AND METHODS A retrospective cohort study included 125 047 primary care patients with type 2 diabetes aged 45-84 years without CVD during 2008-2012. The variability of LDL-C, TC to HDL-C and TG was determined using the standard deviation of variables in a mixed effects model to minimize regression dilution bias. The associations between variability in lipids and CVD and mortality risk were assessed by Cox regression. Subgroup analyses based on patients' baseline characteristics were also conducted. RESULTS A total of 19 913 CVD events and 15 329 mortalities were recorded after a median follow-up period of 77.5 months (0.8 million person-years), suggesting a positive linear relationship between variability in lipids and the risk of CVD and mortality. Each unit increase in the variability of LDL-C (mmol/L), the TC to HDL-C ratio and TG (mmol/L) was associated with a 27% (HR: 1.27 [95% CI: 1.20-1.34]), 31% (HR:1.31 [95% CI: 1.25-1.38]) and 9% (HR: 1.09 [95% CI: 1.04-1.15]) increase in the risk of composite endpoint of CVD and mortality, respectively. Age-specific effects were also found when comparing LDL-C variability, with patients aged 45-54 years (HR: 1.70 [95% CI: 1.42-2.02]) exhibiting a 53% increased risk for the composite endpoints than those aged 75-84 years (HR: 1.11 [95% CI: 1.01-1.23]). Similar age effects were observed for both the TC to HDL-C ratio and TG variability. Significant associations remained consistent among most of the subgroups. CONCLUSIONS Variability in respective lipids are significant factors in predicting CVD and mortality in primary care patients with type 2 diabetes, with the strongest effects related to LDL-C and the TC to HDL-C ratio and most significant in the younger age group of patients aged 45-54 years. Further study is warranted to confirm these findings.
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Affiliation(s)
- Eric Y. F. Wan
- Department of Family Medicine and Primary CareThe University of Hong KongHong Kong
- Department of Pharmacology and PharmacyThe University of Hong KongHong Kong
| | - Esther Y. T. Yu
- Department of Family Medicine and Primary CareThe University of Hong KongHong Kong
| | - Weng Y. Chin
- Department of Family Medicine and Primary CareThe University of Hong KongHong Kong
| | - Jessica K. Barrett
- Medical Research Council (MRC) Biostatistics UnitUniversity of CambridgeCambridgeUK
| | - Anna H. Y. Mok
- Department of Family Medicine and Primary CareThe University of Hong KongHong Kong
| | - Christie S. T. Lau
- Department of Family Medicine and Primary CareThe University of Hong KongHong Kong
| | - Yuan Wang
- Department of Family Medicine and Primary CareThe University of Hong KongHong Kong
| | - Ian C. K. Wong
- Department of Pharmacology and PharmacyThe University of Hong KongHong Kong
- Research Department of Practice and Policy, School of PharmacyUniversity College LondonLondonUK
| | - Esther W. Y. Chan
- Centre for Safe Medication Practice and Research, Department of Pharmacology and PharmacyThe University of Hong KongHong Kong
| | - Cindy L. K. Lam
- Department of Family Medicine and Primary CareThe University of Hong KongHong Kong
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Dong W, Wan EYF, Bedford LE, Wu T, Wong CKH, Tang EHM, Lam CLK. Prediction models for the risk of cardiovascular diseases in Chinese patients with type 2 diabetes mellitus: a systematic review. Public Health 2020; 186:144-156. [PMID: 32836004 DOI: 10.1016/j.puhe.2020.06.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 05/23/2020] [Accepted: 06/07/2020] [Indexed: 12/27/2022]
Abstract
OBJECTIVES Diabetes mellitus (DM) is a serious public health issue worldwide, and DM patients have higher risk of cardiovascular diseases (CVDs), which is the leading cause of DM-related deaths. China has the largest DM population, yet a robust model to predict CVDs in Chinese DM patients is still lacking. This systematic review is carried out to summarize existing models and identify potentially important predictors for CVDs in Chinese DM patients. STUDY DESIGN Systematic review. METHODS Medline and Embase were searched for data from April 1st, 2011 to May 31st, 2018. A study was eligible if it developed CVD (defined as total CVD or any major cardiovascular component) risk prediction models or explored potential predictors of CVD specifically for Chinese people with type 2 DM. Standardized forms were utilized to extract information, appraise applicability, risk of bias, and availabilities. RESULTS Five models and 29 studies focusing on potential predictors were identified. Models for a primary care setting, or to predict total CVD, are rare. A number of common predictors (e.g. age, sex, diabetes duration, smoking status, glycated hemoglobin (HbA1c), blood pressure, lipid profile, and treatment modalities) were observed in existing models, in which urine albumin:creatinine ratio (ACR) and estimated glomerular filtration rate (eGFR) are highly recommended for the Chinese population. Variability of blood pressure (BP) and HbA1c should be included in prediction model development as novel factors. Meanwhile, interactions between age, sex, and risk factors should also be considered. CONCLUSIONS A 10-year prediction model for CVD risk in Chinese type 2 DM patients is lacking and urgently needed. There is insufficient evidence to support the inclusion of other novel predictors in CVDs risk prediction functions for routine clinical use.
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Affiliation(s)
- W Dong
- Department of Family Medicine and Primary Care, The University of Hong Kong, 3/F, Ap Lei Chau Clinic, 161 Main Street, Ap Lei Chau, Hong Kong, China
| | - E Y F Wan
- Department of Family Medicine and Primary Care, The University of Hong Kong, 3/F, Ap Lei Chau Clinic, 161 Main Street, Ap Lei Chau, Hong Kong, China; Department of Pharmacology and Pharmacy, The University of Hong Kong, L02-56, 2/F, Laboratory Block, 21 Sassoon Road, Pokfulam, Hong Kong, China.
| | - L E Bedford
- Department of Family Medicine and Primary Care, The University of Hong Kong, 3/F, Ap Lei Chau Clinic, 161 Main Street, Ap Lei Chau, Hong Kong, China
| | - T Wu
- Department of Family Medicine and Primary Care, The University of Hong Kong, 3/F, Ap Lei Chau Clinic, 161 Main Street, Ap Lei Chau, Hong Kong, China
| | - C K H Wong
- Department of Family Medicine and Primary Care, The University of Hong Kong, 3/F, Ap Lei Chau Clinic, 161 Main Street, Ap Lei Chau, Hong Kong, China
| | - E H M Tang
- Department of Family Medicine and Primary Care, The University of Hong Kong, 3/F, Ap Lei Chau Clinic, 161 Main Street, Ap Lei Chau, Hong Kong, China
| | - C L K Lam
- Department of Family Medicine and Primary Care, The University of Hong Kong, 3/F, Ap Lei Chau Clinic, 161 Main Street, Ap Lei Chau, Hong Kong, China
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Wan EYF, Yu EYT, Chin WY, Ng FTY, Chia SMC, Wong ICK, Chan EWY, Lam CLK. Age-specific associations of glycated haemoglobin variability with cardiovascular disease and mortality in patients with type 2 diabetes mellitus: A 10- year cohort study. Diabetes Obes Metab 2020; 22:1316-1327. [PMID: 32196917 DOI: 10.1111/dom.14034] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 03/05/2020] [Accepted: 03/15/2020] [Indexed: 01/01/2023]
Abstract
AIMS To investigate the associations of increased variability in glycated haemoglobin (HbA1c) with cardiovascular disease (CVD) and mortality risk in patients with diabetes. MATERIALS AND METHODS This prospective cohort study included 147 811 patients aged 45 to 84 years with type 2 diabetes mellitus, without CVD and with at least three HbA1c values recorded before baseline in the period 2008 to 2010. HbA1c variability was evaluated using a mixed effects model to reduce regression dilution bias. Age-specific associations (45- 54, 55- 64, 65- 74 and 75- 84 years) between HbA1c variability and risk of CVD and mortality were assessed by Cox regression, adjusted for patient characteristics and usual HbA1c. RESULTS After a median follow-up of 7.4 years(1.02 million person-years), an overall incidence of 40 785 events including CVD (incidence 27 793) and all-cause mortalities (incidence 23 175) were identified. Positive log-linear associations between HbA1c variability and CVD and mortality were identified in all age groups. The hazard ratios (HRs) for the composite of CVD and all-cause mortality showed that age was inversely associated with HbA1c variability, with a 28% higher risk per 1% increase in HbA1c variability in the age group 45 to 54 years (all composite outcomes: HR 1.28, 95% confidence interval [CI] 1.21, 1.35), whereas only a 14% higher risk in the 75- 84 age group (all composite outcomes: HR 1.14, 95% CI 1.11, 1.17). Subgroup analysis showed the risk in patients with usual HbA1c <53mmol/mol was about eight times higher than in those with usual HbA1c ≥64mmol/mol. CONCLUSIONS HbA1c variability was strongly related to CVD and mortality in patients with diabetes across all age groups. Whilst pursuing optimal HbA1c targets, attention should be given to patients with high HbA1c variability, especially younger patients with good HbA1c control.
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Affiliation(s)
- Eric Yuk Fai Wan
- Department of Family Medicine and Primary Care, University of Hong Kong, Ap Lei Chau, Hong Kong
- Department of Pharmacology and Pharmacy, University of Hong Kong, Ap Lei Chau, Hong Kong
| | - Esther Yee Tak Yu
- Department of Family Medicine and Primary Care, University of Hong Kong, Ap Lei Chau, Hong Kong
| | - Weng Yee Chin
- Department of Family Medicine and Primary Care, University of Hong Kong, Ap Lei Chau, Hong Kong
| | - Florence Ting Yan Ng
- Department of Family Medicine and Primary Care, University of Hong Kong, Ap Lei Chau, Hong Kong
| | - Shu Ming Cheryl Chia
- Department of Family Medicine and Primary Care, University of Hong Kong, Ap Lei Chau, Hong Kong
| | - Ian Chi Kei Wong
- Department of Pharmacology and Pharmacy, University of Hong Kong, Ap Lei Chau, Hong Kong
| | - Esther Wai Yin Chan
- Department of Pharmacology and Pharmacy, University of Hong Kong, Ap Lei Chau, Hong Kong
| | - Cindy Lo Kuen Lam
- Department of Family Medicine and Primary Care, University of Hong Kong, Ap Lei Chau, Hong Kong
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Cardoso CRL, Leite NC, Salles GF. Prognostic importance of visit-to-visit blood pressure variability for micro- and macrovascular outcomes in patients with type 2 diabetes: The Rio de Janeiro Type 2 Diabetes Cohort Study. Cardiovasc Diabetol 2020; 19:50. [PMID: 32359350 PMCID: PMC7196231 DOI: 10.1186/s12933-020-01030-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 04/25/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND The prognostic importance of an increased visit-to-visit blood pressure variability (BP-VVV) for the future development of micro- and macrovascular complications in type 2 diabetes has been scarcely investigated and is largely unsettled. We aimed to evaluate it in a prospective long-term follow-up study with 632 individuals with type 2 diabetes. METHODS BP-VVV parameters (systolic and diastolic standard deviations [SD] and variation coefficients) were measured during the first 24-months. Multivariate Cox analysis, adjusted for risk factors and mean BP levels, examined the associations between BP-VVV and the occurrence of microvascular (retinopathy, microalbuminuria, renal function deterioration, peripheral neuropathy) and macrovascular complications (total cardiovascular events [CVEs], major adverse CVEs [MACE] and cardiovascular and all-cause mortality). Improvement in risk discrimination was assessed by the C-statistic and integrated discrimination improvement (IDI) index. RESULTS Over a median follow-up of 11.3 years, 162 patients had a CVE (132 MACE), and 212 patients died (95 from cardiovascular diseases); 153 newly-developed or worsened diabetic retinopathy, 193 achieved the renal composite outcome (121 newly-developed microalbuminuria and 95 deteriorated renal function), and 171 newly-developed or worsened peripheral neuropathy. Systolic BP-VVV was an independent predictor of MACE (hazard ratio: 1.25, 95% CI 1.03-1.51 for a 1-SD increase in 24-month SD), but not of total CVEs, cardiovascular and all-cause mortality, and of any microvascular outcome. However, no BP-VVV parameter significantly improved cardiovascular risk discrimination (increase in C-statistic 0.001, relative IDI 0.9%). CONCLUSIONS Systolic BP-VVV was an independent predictor of MACE, but it did not improve cardiovascular risk stratification. The goal of anti-hypertensive treatment in patients with type 2 diabetes shall remain in controlling mean BP levels, not on decreasing their visit-to-visit variability.
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Affiliation(s)
- Claudia R L Cardoso
- Department of Internal Medicine, University Hospital Clementino Fraga Filho, School of Medicine, Universidade Federal do Rio de Janeiro, Rua Croton, 72, Jacarepagua, Rio de Janeiro, RJ, CEP 22750-240, Brazil
| | - Nathalie C Leite
- Department of Internal Medicine, University Hospital Clementino Fraga Filho, School of Medicine, Universidade Federal do Rio de Janeiro, Rua Croton, 72, Jacarepagua, Rio de Janeiro, RJ, CEP 22750-240, Brazil
| | - Gil F Salles
- Department of Internal Medicine, University Hospital Clementino Fraga Filho, School of Medicine, Universidade Federal do Rio de Janeiro, Rua Croton, 72, Jacarepagua, Rio de Janeiro, RJ, CEP 22750-240, Brazil.
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Tseng JY, Chen HH, Huang KC, Hsu SP, Chen CC. Effect of mean HbA1c on the association of HbA1c variability and all-cause mortality in patients with type 2 diabetes. Diabetes Obes Metab 2020; 22:680-687. [PMID: 31903705 DOI: 10.1111/dom.13951] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 12/20/2019] [Accepted: 12/28/2019] [Indexed: 02/01/2023]
Abstract
AIM To evaluate the effect of mean HbA1c on the correlation between HbA1c variability and all-cause mortality, and the risks associated with different levels of HbA1c and glycaemic control status in patients with type 2 diabetes. MATERIALS AND METHODS Patients with type 2 diabetes and at least three HbA1c measurements within 12-24 months were included. HbA1c variability score, coefficient of variation (CV) and standard deviation (SD) were used to evaluate variability. A variability score of 50 was set as a cutoff to define low and high variability. RESULTS A total of 4216 patients were included, of whom 1196 died during the observation period (11.1 ± 3.2 years). All-cause mortality increased with HbA1c variability score and the quartiles of HbA1c CV and SD. The strength of this association was attenuated after adjustment for mean HbA1c, and the risks associated with HbA1c variability and glycaemic control status were similar. The highest associated risk was observed with an HbA1c variability score of >50 and mean HbA1c of ≥7.5%. Mortality risk was significantly higher with a mean HbA1c of ≤6.0% and >8.5% and of ≤6.0% and >8.0% for low and high HbA1c variability, respectively. CONCLUSIONS Mean HbA1c contributed to the correlation between HbA1c variability and all-cause mortality. The risks associated with HbA1c variability and glycaemic control status were similar. The relationship between mean HbA1c and mortality presented a J-shaped distribution for both low and high HbA1c variability.
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Affiliation(s)
- Juei-Yu Tseng
- Division of Endocrinology and Metabolism, Department of Medicine, China Medical University Hospital, Taichung, Taiwan
- Department of Medicine, China Medical University, Taichung, Taiwan
| | - Hsin-Hung Chen
- Intelligent Diabetes Metabolism and Exercise Center, China Medical University Hospital, Taichung, Taiwan
- School of Medicine, Chung Shan Medical University, Taichung, Taiwan
- Institute of Public Health, Chung Shan Medical University, Taichung, Taiwan
| | - Kuo-Chin Huang
- Integration of Traditional Chinese-Western Medicine, Department of Chinese Medicine, China Medical University Hospital, Taichung, Taiwan
- School of Chinese Medicine, China Medical University, Taichung, Taiwan
| | - Sheng-Pang Hsu
- Division of Endocrinology and Metabolism, Department of Medicine, China Medical University Hospital, Taichung, Taiwan
- Department of Medicine, China Medical University, Taichung, Taiwan
| | - Ching-Chu Chen
- Division of Endocrinology and Metabolism, Department of Medicine, China Medical University Hospital, Taichung, Taiwan
- School of Chinese Medicine, China Medical University, Taichung, Taiwan
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Factors Associated with Visit-to-Visit Variability of Blood Pressure Measured as Part of Routine Clinical Care among Patients Attending Cardiology Outpatient Department of a Tertiary Care Centre in Northern Sri Lanka. Int J Hypertens 2019; 2019:6450281. [PMID: 31885898 PMCID: PMC6915156 DOI: 10.1155/2019/6450281] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 11/01/2019] [Accepted: 11/11/2019] [Indexed: 11/18/2022] Open
Abstract
Visit-to-visit variability (VVV) is a relatively new concept in the hypertensive arena. Data regarding VVV are lacking in our region, and factors associated with VVV are rarely examined in previous studies. This study was conducted among 406 patients attended to the cardiology outpatient department of Teaching Hospital, Jaffna, Sri Lanka, in 2018 to assess the long-term variability of blood pressure (BP) by reviewing last six consecutive BP readings from the records retrospectively. Data regarding sociodemographic variables and behavioural factors such as medication adherence, physical activity, smoking, alcohol consumption, and relevant comorbidities were taken through an interviewer-administered questionnaire. Data were analysed by using SPSS version 25 and VVV of systolic blood pressure (SBP) matrix expressed as mean of SD and association were examined with various factors and VVV of SBP. SBP showed high VVV among the participants as expressed by mean of SD which was 13.06 ± 5.64. When comparing mean SD among the categories of different variables, female sex (P=0.023) and comorbidities such as diabetes mellitus (DM) (P=0.013), chronic kidney disease (CKD) (P=0.007), and risk of developing obstructive sleep apnoea (OSA) (P=0.04) showed significant variation. Medication adherence to prescribed hypertensive medication was a major issue even though significant association was not found with high VVV (P=0.536). The SD of SBP was then classified into high and low VVV groups by means of a cutoff point at the 50th percentile. Bivariate analysis by using Chi-squared test revealed comorbidities such as DM, CKD, and physical activity (P=0.044) were significantly associated with high VVV. Further multivariate regression analysis revealed that comorbidities such as DM and CKD have 1.561 times and 5.999 times more risk to show high variability, respectively. In conclusion, we recommend simple practical measures to achieve sustainable BP control among hypertensive patients with DM and CKD to minimize the VVV and improve their cardiovascular outcome.
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Chiriacò M, Pateras K, Virdis A, Charakida M, Kyriakopoulou D, Nannipieri M, Emdin M, Tsioufis K, Taddei S, Masi S, Georgiopoulos G. Association between blood pressure variability, cardiovascular disease and mortality in type 2 diabetes: A systematic review and meta-analysis. Diabetes Obes Metab 2019; 21:2587-2598. [PMID: 31282073 DOI: 10.1111/dom.13828] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 06/20/2019] [Accepted: 07/01/2019] [Indexed: 12/17/2022]
Abstract
AIM To investigate the associations of blood pressure variability (BPV), expressed as long-term (visit-to-visit) and short-term (ambulatory blood pressure monitoring [ABPM] and home blood pressure monitoring [HBPM]) and all-cause mortality, major adverse cardiovascular events (MACEs), extended MACEs, microvascular complications (MiCs) and hypertension-mediated organ damage (HMOD) in adult patients with type 2 diabetes. MATERIALS AND METHODS PubMed, Medline, Embase, Cinahl, Web of Science, ClinicalTrials.gov and grey literature databases were searched for studies including patients with type 2 diabetes, at least one variable of BPV (visit-to-visit, HBPM, ABPM) and evaluation of the incidence of at least one of the following outcomes: all-cause mortality, MACEs, extended MACEs and/or MiCs and/or HMOD. The extracted information was analyzed using random effects meta-analysis and meta-regression. RESULTS Data from a total of 377 305 patients were analyzed. Systolic blood pressure (SBP) variability was associated with a significantly increased risk of all-cause mortality (HR 1.12, 95% CI 1.04-1.21), MACEs (HR 1.01, 95% CI 1.04-1.17), extended MACEs (HR 1.07, 95% CI 1.03-1.11) and MiCs (HR 1. 12, 95% CI 1.01-1.24), while diastolic blood pressure was not. Associations were mainly driven from studies on long-term SBP variability. Qualitative analysis showed that BPV was associated with the presence of HMOD expressed as carotid intima-media thickness, pulse wave velocity and left ventricular hypertrophy. Results were independent of mean blood pressure, glycaemic control and serum creatinine levels. CONCLUSIONS Our results suggest that BPV might provide additional information rather than mean blood pressure on the risk of cardiovascular disease in patients with type 2 diabetes.
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Affiliation(s)
- Martina Chiriacò
- Department of Clinical and Experimental Medicine, Università degli Studi di Pisa, Pisa, Italy
- Department of Medicine, Sant'Anna School of Advanced Studies, Pisa, Italy
| | - Konstantinos Pateras
- Department of Biostatistics and Research Support, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Agostino Virdis
- Department of Clinical and Experimental Medicine, Università degli Studi di Pisa, Pisa, Italy
| | - Marietta Charakida
- Institute of Cardiovascular Science, University College London, London, UK
| | - Despoina Kyriakopoulou
- First Department of Cardiology, Hippocration Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Monica Nannipieri
- Department of Clinical and Experimental Medicine, Università degli Studi di Pisa, Pisa, Italy
| | - Michele Emdin
- Department of Medicine, Sant'Anna School of Advanced Studies, Pisa, Italy
| | - Konstantinos Tsioufis
- First Department of Cardiology, Hippocration Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Stefano Taddei
- Department of Clinical and Experimental Medicine, Università degli Studi di Pisa, Pisa, Italy
| | - Stefano Masi
- Department of Clinical and Experimental Medicine, Università degli Studi di Pisa, Pisa, Italy
- Institute of Cardiovascular Science, University College London, London, UK
- Department of Twin Research & Genetic Epidemiology, King's College London, London, UK
| | - Georgios Georgiopoulos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece
- Department of Cardiovascular Imaging, King's College London, London, UK
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Yu ZB, Li D, Chen XY, Zheng PW, Lin HB, Tang ML, Jin MJ, Wang JB, Chen K. Association of Visit-to-Visit Variability of Blood Pressure with Cardiovascular Disease among Type 2 Diabetes Mellitus Patients: A Cohort Study. Diabetes Metab J 2019; 43:350-367. [PMID: 30877712 PMCID: PMC6581546 DOI: 10.4093/dmj.2018.0108] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 10/08/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Increasing evidence has shown that visit-to-visit variability (VVV) of blood pressure (BP) is associated with an increased risk of cardiovascular disease (CVD). The objective of this study was to evaluate the impact of VVV of systolic blood pressure (SBP) and diastolic blood pressure (DBP) on the risk of CVD among patients with type 2 diabetes mellitus (T2DM) in China. METHODS We conducted a retrospective cohort study of 10,163 T2DM patients who were not previously diagnosed with CVD from January 2008 to December 2012 in Ningbo, China. The VVV of BP was calculated using five metrics, including standard deviation (SD), coefficient of variation (CV), variation independent of mean, average real variability, and successive variability (SV) of measurements, obtained over a 24-month measurement period. Hazard ratios and 95% confidence intervals (CIs) were estimated by Cox proportional hazards regression models for the associations of variability in BP with risk of CVD. RESULTS A total of 894 CVD events were observed during a median follow-up of 49.5 months. The hazard ratio in the highest quintile of SD of SBP was 1.24 (95% CI, 1.01 to 1.52) compared with patients in the lowest quintile. The association between higher VVV of DBP and risk of CVD was not consistent across different metrics and sensitivity analyses. CONCLUSION Higher VVV of SBP was associated with an increased risk of CVD, irrespective of the mean SBP level. Future studies are needed to confirm these findings.
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Affiliation(s)
- Zhe Bin Yu
- Department of Epidemiology and Health Statistics, Zhejiang University School of Public Health, Hangzhou, China
| | - Die Li
- Department of Epidemiology and Health Statistics, Zhejiang University School of Public Health, Hangzhou, China
| | - Xue Yu Chen
- Department of Epidemiology and Health Statistics, Zhejiang University School of Public Health, Hangzhou, China
| | - Pei Wen Zheng
- Department of Epidemiology and Health Statistics, Zhejiang University School of Public Health, Hangzhou, China
| | - Hong Bo Lin
- Center for Disease Control and Prevention of Yinzhou District, Ningbo, China
| | - Meng Ling Tang
- Department of Epidemiology and Health Statistics, Zhejiang University School of Public Health, Hangzhou, China
| | - Ming Juan Jin
- Department of Epidemiology and Health Statistics, Zhejiang University School of Public Health, Hangzhou, China
| | - Jian Bing Wang
- Department of Epidemiology and Health Statistics, Zhejiang University School of Public Health, Hangzhou, China
- Research Center for Air Pollution and Health, Zhejiang University, Hangzhou, China.
| | - Kun Chen
- Department of Epidemiology and Health Statistics, Zhejiang University School of Public Health, Hangzhou, China
- Research Center for Air Pollution and Health, Zhejiang University, Hangzhou, China.
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Wan EYF, Yu EYT, Chin WY, Fung CSC, Kwok RLP, Chao DVK, Chan KH, Hui EMT, Tsui WWS, Tan KCB, Fong DYT, Lam CLK. Ten-year risk prediction models of complications and mortality of Chinese patients with diabetes mellitus in primary care in Hong Kong: a study protocol. BMJ Open 2018; 8:e023070. [PMID: 30327405 PMCID: PMC6194459 DOI: 10.1136/bmjopen-2018-023070] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
INTRODUCTION Diabetes mellitus (DM) is a major disease burden worldwide because it is associated with disabling and lethal complications. DM complication risk assessment and stratification is key to cost-effective management and tertiary prevention for patients with diabetes in primary care. Existing risk prediction functions were found to be inaccurate in Chinese patients with diabetes in primary care. This study aims to develop 10-year risk prediction models for total cardiovascular diseases (CVD) and all-cause mortality among Chinese patients with DM in primary care. METHODS AND ANALYSIS A 10-year cohort study on a population-based primary care cohort of Chinese patients with diabetes, who were receiving care in the Hospital Authority General Outpatient Clinic on or before 1 January 2008, were identified from the clinical management system database of the Hospital Authority. All patients with complete baseline risk factors will be included and followed from 1 January 2008 to 31 December 2017 for the development and validation of prediction models. The analyses will be carried out separately for men and women. Two-thirds of subjects will be randomly selected as the training sample for model development. Cox regressions will be used to develop 10-year risk prediction models of total CVD and all-cause mortality. The validity of models will be tested on the remaining one-third of subjects by Harrell's C-statistics and calibration plot. Risk prediction models for diabetic complications specific to Chinese patients in primary care will enable accurate risk stratification, prioritisation of resources and more cost-effective interventions for patients with DM in primary care. ETHICS AND DISSEMINATION The study was approved by the Institutional Review Board of the University of Hong Kong-the Hospital Authority Hong Kong West Cluster (reference number: UW 15-258). TRIAL REGISTRATION NUMBER NCT03299010; Pre-results.
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Affiliation(s)
- Eric Yuk Fai Wan
- Department of Family Medicine and Primary Care, The University of Hong Kong, Hong Kong
| | - Esther Yee Tak Yu
- Department of Family Medicine and Primary Care, The University of Hong Kong, Hong Kong
| | - Weng Yee Chin
- Department of Family Medicine and Primary Care, The University of Hong Kong, Hong Kong
| | | | - Ruby Lai Ping Kwok
- Department of Primary and Community Services, Hospital Authority Head Office, Hospital Authority, Hong Kong
| | - David Vai Kiong Chao
- Department of Family Medicine and Primary Healthcare, Kowloon East Cluster, Hospital Authority, Hong Kong
| | - King Hong Chan
- Department of Family Medicine & Primary Healthcare, Kowloon Central Cluster, Hospital Authority, Hong Kong
| | - Eric Ming-Tung Hui
- Department of Family Medicine, New Territories East Cluster, Hospital Authority, Hong Kong
| | - Wendy Wing Sze Tsui
- Department of Family Medicine and Primary Healthcare, Hong Kong West Cluster, Hospital Authority, Hong Kong
| | | | | | - Cindy Lo Kuen Lam
- Department of Family Medicine and Primary Care, The University of Hong Kong, Hong Kong
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Tedla YG, Yano Y, Thyagarajan B, Kalhan R, Viera AJ, Rosenberg S, Greenland P, Carnethon MR. Peak lung function during young adulthood and future long-term blood pressure variability: The Coronary Artery Risk Development in Young Adults (CARDIA) study. Atherosclerosis 2018; 275:225-231. [PMID: 29957459 PMCID: PMC7702294 DOI: 10.1016/j.atherosclerosis.2018.06.816] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Revised: 06/05/2018] [Accepted: 06/13/2018] [Indexed: 01/08/2023]
Abstract
BACKGROUND AND AIMS Long-term blood pressure variability (BPV) is associated with cardiovascular events independent of mean blood pressure (BP); however, little is known about its predictors. METHODS Using data from the CARDIA study, we investigated the association between peak lung-function and long-term BPV in 2917 individuals (mean age 24.8 years, 45.3% males, 58.6% whites) who were not taking antihypertensive medications. Lung-function was measured using forced vital capacity (FVC) and forced expiratory volume in 1-s (FEV1) at years 0, 2, 5, 10 and 20 and the maximum score attained was considered as peak lung-function. Variability independent of the mean (VIM) and coefficient of variation (CV) of BP were calculated to quantify BPV since achieving peak lung-function across 9 visits over 30 years. RESULTS In a multivariate linear regression models, individuals in the 2nd (-0.64 mmHg; 95% CI: -1.06, -0.19), 3rd (-0.96; -1.47, -0.45), and 4th (-0.85: -1.53, -0.17) quartiles of FVC had lower VIM of systolic BP than the those in quartile 1 (p-trend = 0.005). CV of systolic BP was also lower by -0.58 (-0.98, -0.19), -0.92 (-1.42, -0.43), and -0.74 (-1.40, -0.08) percentage points, in the three progressively higher quartiles of FVC compared to quartile 1 (p-trend = 0.008). Similar findings were observed when the outcome was diastolic BPV. There was no association of FEV1 and FEV1-to-FVC ratio with BPV. CONCLUSIONS These findings suggest that smaller lung volume or restrictive lung disease during young adulthood, which result in lower peak FVC, may independently increase the risk of higher long-term BPV during middle adulthood.
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Affiliation(s)
- Yacob G Tedla
- Center for Health Information Partnership, Feinberg School of Medicine, Northwestern University, USA.
| | - Yuichiro Yano
- University of Mississippi Medical Center, University of Mississippi, USA
| | - Bharat Thyagarajan
- Department of Laboratory Medicine and Pathology, School of Medicine, University of Minnesota, USA
| | - Ravi Kalhan
- Pulmonary and Critical Care Medicine, Feinberg School of Medicine, Northwestern University, USA
| | - Anthony J Viera
- Department of Epidemiology, University of North Carolina at Chapel Hill, USA; Department of Family Medicine, University of North Carolina at Chapel Hill, USA
| | - Sharon Rosenberg
- Pulmonary and Critical Care Medicine, Feinberg School of Medicine, Northwestern University, USA
| | - Philip Greenland
- Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, USA
| | - Mercedes R Carnethon
- Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, USA
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Bell KJL, Azizi L, Nilsson PM, Hayen A, Irwig L, Östgren CJ, Sundröm J. Prognostic impact of systolic blood pressure variability in people with diabetes. PLoS One 2018; 13:e0194084. [PMID: 29641538 PMCID: PMC5894975 DOI: 10.1371/journal.pone.0194084] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Accepted: 02/24/2018] [Indexed: 11/19/2022] Open
Abstract
Objective Blood pressure variability (BPV) has been associated with risk of cardiovascular events in observational studies, independently of mean BP levels. In states with higher autonomic imbalance, such as in diabetes, the importance of BP variability may theoretically be even greater. We aimed to investigate the incremental value of BPV for prediction of cardiovascular and all-cause mortality in patients with type 2 diabetes. Methods We identified 9,855 patients without pre-existing cardiovascular disease who did not change BP-lowering treatment during the observation period from a Swedish primary health care cohort of patients with type 2 diabetes. BPV was summarized as the standard deviation (SD), coefficient of variation (CV), or variation independent of mean (VIM). Patients were followed for a median of 4 years and associations with cardiovascular and all-cause mortality were investigated using Cox proportional hazards models. Results BPV was not associated with cardiovascular specific or all-cause mortality in the total sample. In patients who were not on BP-lowering drugs during the observation period (n = 2,949), variability measures were associated with all-cause mortality: hazard ratios were 1.05, 1.04 and 1.05 for 50% increases in SD, CV and VIM, respectively, adjusted for Framingham risk score risk factors, including mean BP. However, the addition of the variability measures in this subgroup only led to very minimal improvement in discrimination, indicating they may have limited clinical usefulness (change in C-statistic ranged from 0.000–0.003 in all models). Conclusions Although BPV was independently associated with all-cause mortality in diabetes patients in primary care who did not have pre-existing cardiovascular disease or BP-lowering drugs, it may be of minimal clinical usefulness above and beyond that of other routinely measured predictors, including mean BP.
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Affiliation(s)
- Katy J. L. Bell
- Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia
- * E-mail:
| | - Lamiae Azizi
- School of Mathematics and Statistics, University of Sydney, Sydney, New South Wales, Australia
| | - Peter M. Nilsson
- Department of Clinical Sciences, Lund University, Malmo, University Hospital, Malmo, Sweden
| | - Andrew Hayen
- Australian Centre for Public and Population Health Research University of Technology Sydney (UTS), Sydney, New South Wales, Australia
| | - Les Irwig
- Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia
| | - Carl J. Östgren
- Department of Medical and Health Sciences, Linkoping University, Linkoping, Sweden
| | - Johan Sundröm
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
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Wightman SS, Sainsbury CAR, Jones GC. Visit-to-visit HbA1c variability and systolic blood pressure (SBP) variability are significantly and additively associated with mortality in individuals with type 1 diabetes: An observational study. Diabetes Obes Metab 2018; 20:1014-1017. [PMID: 29266630 DOI: 10.1111/dom.13193] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Revised: 12/06/2017] [Accepted: 12/17/2017] [Indexed: 11/26/2022]
Abstract
AIM To investigate the relationship between variability in both visit-to-visit HbA1c and SBP and mortality in individuals with type 1 diabetes. METHODS The Scottish Care Information (SCI) Diabetes dataset was used to identify 5952 individuals with type 1 diabetes for inclusion in this observational study. The SCI-Diabetes dataset allowed access to blood pressure values, HbA1c readings, demographic information and mortality rates for all study participants. Participants were dichotomized to above and below median values for both HbA1c coefficient of variation (CV) and SBP CV, thus dividing participants into 4 cohorts for survival analysis. Survival analysis was carried out over 1430 days. A Cox proportional hazard model was used to allow comparison of mortality between the 4 cohorts. RESULTS Of the 5952 patients, death occurred in 416. CV for both HbA1c and SBP were significantly associated with mortality. The median values for HbA1c CV and SBP CV were 8.0 and 8.1, respectively. The hazard ratio for high HbA1c CV only (P = .0015) was 1.78 ± 0.36. The hazard ratio for high SBP CV only (P = .0018) was 1.69 ± 0.33. The hazard ratio for both high HbA1c CV and high SBP CV (P < .00001) was 2.37 ± 0.32. CONCLUSIONS Our findings demonstrate that variability of both HbA1c and SBP is significantly and additively associated with mortality in individuals with type 1 diabetes. The variability of these parameters might be useful for risk stratification and is a potential target for future interventional studies.
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Affiliation(s)
- Stuart S Wightman
- Department of Diabetes and Endocrinology, Gartnavel General Hospital, Glasgow, Scotland, UK
| | | | - Gregory C Jones
- Department of Diabetes and Endocrinology, Gartnavel General Hospital, Glasgow, Scotland, UK
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Tanaka A, Node K. Amelioration of arterial pressure lability: an unmissable target for diabetes management. Hypertens Res 2017; 40:629-631. [PMID: 28298651 DOI: 10.1038/hr.2017.35] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Atsushi Tanaka
- Department of Cardiovascular Medicine, Saga University, Saga, Japan
| | - Koichi Node
- Department of Cardiovascular Medicine, Saga University, Saga, Japan
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